Nerve fiber analysis of the lingual branch of the glossopharyngeal nerve in human adult subjects.

PURPOSE: Fibers of the glossopharyngeal part of the superior constrictor muscle are connected with fibers of the transverse lingual muscle, forming a ring of muscle at the base of the tongue. This group of muscles constrict the midpharyngeal cavity during retrusive movement of the tongue. The purpose of this study is to identify the contribution of the lingual branch of the glossopharyngeal nerve to the neuro-motor control of three muscles: the glossopharyngeal part of the superior pharyngeal constrictor muscle, the palatopharyngeal and the palatoglossus muscles. METHODS: Six en bloc samples (9 sides), including the tissue from the skull base to the hyoid bone were obtained from adult human cadavers. Nerve fiber of the lingual branch of the glossopharyngeal nerve (main root of the glossopharyngeal nerve) was examined by the use of a binocular stereomicroscope. RESULTS: We observed that, after branching to the stylopharyngeal muscle, the lingual branch of the glossopharyngeal nerve branched to the glossopharyngeal part of the superior pharyngeal constrictor muscle, the palatopharyngeal and the palatoglossus muscles before inserting into the space between the muscle layers of the superior and middle pharyngeal constrictors. CONCLUSION: These neuromuscular arrangements may suggest the presence of specialized constrictive movements of the midpharygeal cavity at the level of the base of the tongue with the retrusive movement of the tongue. The simultaneous contraction of the palatopharyngeal and palatoglossus muscles on the pharyngeal stage of deglutition may aid in the passage of bolus from the oral cavity to the midpharyngeal cavity by increasing pharyngeal pressure.

Patients' perceptions of vocal problems: results from a survey in the Tokyo area.

Laryngoscopy in cases of sulcus vocalis reveals bowed vocal folds, resulting in a spindle-shaped chink with glottal incompetence. The anatomic and functional problems and resulting incomplete glottal closure during phonation lead to the presenting symptoms of breathy hoarseness, decrease in maximum phonation time (MPT), and vocal fatigue. These symptoms, however, have been reported from the physician's viewpoint, not the patient's. Furthermore, no standardized guidelines for the treatment of sulcus vocalis have been established. Because the general attitude toward sulcus vocalis appears to have become 'It is only a vocal problem and does not significantly affect the patient's well-being,' knowledge of sulcus vocalis has decreased and knowledge about choices of therapy remain limited. We therefore conducted an epidemiological questionnaire survey on this pathological condition in voice clinics in seven hospitals in the Tokyo area to establish preliminary guidelines for the management of sulcus vocalis, in reference to the opinion of the patients. Here we report the summary of our preliminary study 'a survey for sulcus vocalis' and suggest guidelines for the management of such pathological conditions. Although these management guidelines may result in improvement in the symptoms of sulcus vocalis, patients and physicians should be aware that treatment of this condition is difficult and improvement is not guaranteed.

Surgical improvement of speech disorder caused by amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a progressive debilitating neurological disease. ALS disturbs the quality of life by affecting speech, swallowing and free mobility of the arms without affecting intellectual function. It is therefore of significance to improve intelligibility and quality of speech sounds, especially for ALS patients with slowly progressive courses. Currently, however, there is no effective or established approach to improve speech disorder caused by ALS. We investigated a surgical procedure to improve speech disorder for some patients with neuromuscular diseases with velopharyngeal closure incompetence. In this study, we performed the surgical procedure for two patients suffering from severe speech disorder caused by slowly progressing ALS. The patients suffered from speech disorder with hypernasality and imprecise and weak articulation during a 6-year course (patient 1) and a 3-year course (patient 2) of slowly progressing ALS. We narrowed bilateral lateral palatopharyngeal wall at velopharyngeal port, and performed this surgery under general anesthesia without muscle relaxant for the two patients. Postoperatively, intelligibility and quality of their speech sounds were greatly improved within one month without any speech therapy. The patients were also able to generate longer speech phrases after the surgery. Importantly, there was no serious complication during or after the surgery. In summary, we performed bilateral narrowing of lateral palatopharyngeal wall as a speech surgery for two patients suffering from severe speech disorder associated with ALS. With this technique, improved intelligibility and quality of speech can be maintained for longer duration for the patients with slowly progressing ALS.

Fiber arrangements of the vertical lingual muscle in human adult subjects

This study identified the anatomy of the vertical lingual muscle and functional relationships between the vertical lingual and the other lingual muscles in the human tongue. Three whole tongues were obtained from adult human cadavers and were used for histological study by the serial section method. At the tip of the tongue, the fibers of the vertical lingual muscle cross with the transverse lingual muscle, and extend inferiorly to the fibers of the inferior longitudinal lingual muscle. At the body of the tongue, the fibers of the vertical lingual muscle are located between the fibers of the superior longitudinal lingual and inferior longitudinal lingual muscle, crossing the fibers of the transverse lingual muscle, instead of crossing the fibers of the extrinsic lingual muscles. At the base of the tongue, the fibers of the vertical lingual muscle start by the fibers of the superior longitudinal lingual muscle, and connect with the fibers of the posterior muscle bundle of the styloglossus muscle. The average diameters of the vertical lingual muscle fibers increased gradually as they approached the base of the tongue. These findings suggest that posterosuperior movement of the tongue body may be accomplished with downward movement of the tip of the tongue by contractions of both the vertical lingual and the styloglossus muscle. The inferior longitudinal lingual muscle may also play a supporting role for the vertical lingual muscle at the tip of the tongue (AU)

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Vocal acoustic characteristics of patients with Parkinson's disease.

Speech samples obtained from 39 idiopathic Parkinson's disease (PD) patients with vocal pathologies were compared with those from 62 age-matched vocally normal non-PD controls. Voice samples collected from sustained vowel phonation and passage reading were acoustically analyzed using Computer Speech Lab and Multi-Dimensional Voice Program software. Noise-to-harmonic ratio, voice turbulence index (VTI) and soft phonation index (SPI) were incorporated as noise-related measurements, fundamental frequency-tremor intensity index (FTRI), amplitude tremor intensity, fundamental frequency-tremor frequency (Fftr), and amplitude-tremor frequency as tremor-related measurements. Compared with controls, the following results were noted: (1) male and female PD patients exhibited significant differences in acoustic parameters of all frequency and amplitude perturbation measurements and noise-related measurements (except VTI in males); (2) speaking fundamental frequency was significantly higher only in male PD patients; (3) FTRI and Fftr in male (only FTRI in female) PD patients were significantly higher, and (4) disease severity and MDVP analysis showed significant correlations between SPI and the Unified Parkinson's Disease Rating Scale Part I (mentation, behavior, mood) and Part II (activities of daily living) in male PD patients; however, this was not the case in female PD patients.

Changes in speaking fundamental frequency characteristics with aging.

Changes in speaking fundamental frequency (SFF) associated with aging were studied in a total of 374 healthy normal speakers (187 males and 187 females) from adolescent to older age groups. Participants were asked to read a sample passage aloud, and acoustic analysis was performed. The main results were as follows: (1) Males exhibited no significant trend for SFF changes in aging. However, a slight increase was observed in participants aged 70 years or older. (2) Females in their 30s and 40s showed obviously lower frequencies than those in their 20s. Across all age groups, including the 80s, SFF tended to decrease markedly in association with aging. (3) The degree of SFF change in association with aging was much larger in females than in males. In addition, reference intervals (mean +/- 1.96 SD) obtained for males and females in each age group are considered useful for clinical detection of abnormalities of SFF, as well as for detection of laryngeal diseases causing SFF abnormality.

Clinical experience with collagen injection of the vocal fold: a study of 155 patients.

OBJECTIVE: This study evaluated the results of laryngeal collagen injection. STUDY DESIGN: Retrospective study of patients who had undergone laryngeal collagen injection. MATERIALS AND METHODS: A retrospective review of 275 patients treated with collagen injection and a review of the relevant literature on the results of treatment were presented. Follow-up studies were performed for at least 3 months on 155 patients. The patients' voice quality was assessed by perceptual voice analysis using the GRBAS scale, and their vocal function was assessed by acoustic and aerodynamic measures (maximal phonation time and mean flow rate). Assessments were performed before and after collagen injection. RESULTS: Mean objective measures and clinician's perceptual ratings demonstrated measurable improvement in vocal function and voice quality after collagen injection. There were no major complications and no hypersensitivity reactions. CONCLUSION: As an outpatient office procedure, collagen injection offers a simple, efficient and effective treatment for dysphonia. Various aspects of the procedure for anesthesia, injection techniques, and patient selection are discussed.

Nerve fiber analysis for the lingual nerve of the human adult subjects.

The neuro-motor control of the human tongue musculature had not been investigated in detail. This study identified first that the lingual nerve should play the neuro-motor control of some lingual muscles. Six en bloc samples (12 sides), including the tissues from the skull base to the hyoid bone, and three whole tongues were obtained from adult human cadavers. The former samples were used for the study of nerve fiber analysis of the lingual nerve with the aid of binocular stereomicroscope, and the latter samples were used for histological study by serial section method. On nerve fiber analysis of the lingual nerve from the trigeminal ganglion to the tongue musculature, we found that the motor- root of the trigeminal nerve gave off its supply to the lingual nerve and traveled into the lingual nerve, and branched to the superior and the inferior longitudinal muscles. On histological study, it was revealed that in the anterior part of the tongue the superior and the inferior longitudinal muscles surrounded the other lingual musculature and combined with the sub-mucosal connective tissues closely like the cutaneous muscle, for example, the facial muscles. The lingual nerve entered the inner side of the space between the genioglossus and the inferior longitudinal muscles with the lingual artery. These findings suggested that the superior and the inferior longitudinal muscles should be innervated by the motor fibers traveled into the lingual nerve from the motor root of the trigeminal nerve, and do not originate from the myotome originating in occipital somites but branchial muscles.

Comparison of speaking rate, articulation rate and alternating motion rate in dysarthric speakers.

Despite recent indications that speaking rate, articulation rate and alternating motion rate (AMR) are sensitive to the influence of neurological disease on speech production in dysarthric speakers, the relationship among these parameters remains largely questionable. In the current study, speech samples were collected from 62 dysarthric speakers and 34 controls while reading a passage. Acoustic analysis investigated speaking rate, articulation rate and AMR and compared these parameters between the dysarthric and control groups and within the control and dysarthric group. The major findings were: (1) Speaking rate, articulation rate and AMR were all markedly lower in dysarthric speakers than in controls. (2) Marked correlations were recognized between speaking rate, articulation rate and AMR in the dysarthric group. (3) Compared with the speaking rate and articulation rate, AMR is characterized as follows: (i) variation was more limited in controls, and (ii) the control group was clearly distinguishable from the dysarthric group. (4) Unlike in controls, AMR in the dysarthric speakers was notably lower than their articulation rate. We therefore conclude that AMR is a more easily detected sign of abnormal articulation than speaking rate and articulation rate.

M-mode color Doppler ultrasonic imaging of vertical tongue movement during articulatory movement.

To observe and estimate the movement of the tongue, ultrasonic investigation is the most harmless real-time monitoring procedure for analyzing articulatory movements. Color Doppler ultrasonic imaging is special in that it can only sample a moving target, and it can indicate the velocity and direction of the target by color and brightness in real time. This study assessed and demonstrated the validity of M-mode color Doppler ultrasonic imaging to observe the movements of the tongue during syllable repetition tasks performed by normal subjects and dysarthric patients, those affected by amyotrophic lateral sclerosis, cerebellar ataxia, Parkinsonism, and polymyopathy. When the transducer was set below the jaw, upward movement was indicated by a blue signal and downward movement was indicated by a red one on the screen of the ultrasound machine. We also measured the velocity of the tongue by contrast scale classified by 15 degrees. Thus, we could observe vertical tongue movement by a color-coded pattern after quantitative analysis. The Doppler signal patterns of normal subjects were verified by simultaneous video x-ray fluorography recordings. The findings for dysarthric patients corresponded well with previously reported features analyzed by other methods. Therefore, color Doppler ultrasonic imaging of the tongue is a useful procedure to researchers for clinical speech and voice studies.

Clinical course of hearing and language development in GJB2 and non-GJB2 deafness following habilitation with hearing aids.

Mutations in the GJB2 gene (connexin 26) are the most common cause of nonsyndromic autosomal recessive sensorineural hearing loss. Genetic testing of GJB2 may offer opportunities to predict the features of hearing loss and prognostication of speech-language development in children with hearing loss. The present study assessed the clinical features of hearing and some aspects of language development in congenital deafness due either to GJB2 mutations or to other factors in Japanese patients who had been habilitated with hearing aids. Thirty-five unrelated subjects with nonsyndromic, congenital, bilateral sensorineural hearing loss were enrolled in the study. Among them, 16 had biallelic GJB2 mutations related to hearing loss and 17 lacked such mutations. As has been reported in populations of European ancestry, the present Japanese subjects with GJB2 mutations had a relatively high incidence of the flat pattern audiogram and nonprogressive pure tone thresholds compared with subjects without GJB2 mutations. Subjects with GJB2 mutations and those without GJB2 mutations both showed a similar tendency in speech perception, some aspects of language development, and communication methods. In both groups, development of reading ability tended to be normal, but vocabulary development tended to be delayed. The present results establish the basis for future studies to aid in the evaluation and follow-up of patients with congenital hearing loss associated with GJB2 mutations who are habilitated with hearing aids.

Physiological studies of retrusive movements of the human tongue.

SUMMARY: This study identified that physiologically the superior pharyngeal constrictor muscle at the level of the base of the tongue contributes to retrusive movement of the tongue with constriction of the mid-pharyngeal cavity and possesses unique properties in terms of motor speech control along with the genioglossus muscle. From a kinematic study involving trans-nasal fiberscopy and lateral X-ray fluorography, retrusive movement of the tongue was highly correlated with constrictive movement of the mid-pharyngeal cavity. An electromyographic study revealed that the superior pharyngeal constrictor muscle at the level of the base of the tongue contributes to retrusive movement of the tongue and that the genioglossus muscle contributes to protrusive movement. We also noted that this relationship between the activities of these two muscles were in response to postural changes during vowel productions without changes in the acoustic features. These findings suggest that these two muscles act not only antagonistically to produce retrusive and protrusive movement of the tongue, but also they complement each other to conserve the shape of the vocal tract for speech production. The functional relationship between these two muscles could contribute the consecutive movement of human speech production under various conditions and might be useful when applying rehabilitation approaches for the patients with neurological speech and swallowing disorders.

Autologous transplantation of fascia into the vocal fold: long-term result of type-1 transplantation and the future.

OBJECTIVES: Since 1997, we have performed the autologous transplantation of fascia into the vocal fold (ATFV) procedure on cases of sulcus vocalis. In what follows, we report the long-term results of our new surgical approach and discuss the role of these transplantations. We also review and report some complications that can be caused by ATFV. Finally, we discuss the ATFV technique as a contribution to the phonosurgery of the future. STUDY DESIGN: Prospective study. METHODS: We were able to obtain long-term results from 10 volunteer cases (2 female and 8 male, age: 15-71, mean 46.5 years old) who could be followed up for at least 3 years after transplantation. All were cases of pathologic sulcus vocalis.We measured maximum phonation time (MPT) and carried out pre- and postsurgical clinical observation and laryngeal stroboscopy in all cases. These measurements and observations were made before the ATFV and at 6 months, 1 year, 2 years, and 3 years after surgery. RESULTS: In stroboscopic observation 1 year after the ATFV, satisfactory glottal closure and excellent mucosal wave were observed for all cases, and there was no case with hyperadduction of the false vocal folds. MPT measures remained at an improved level 2 years and 3 years after the transplantations. Paired-sample t tests showed that the improvement relative to preATFV levels was significant for all postsurgical measurements up to 3 years. CONCLUSIONS: We conclude that ATFV is a successful surgical procedure for sulcus vocalis and scarred vocal folds. Other phonosurgical clinical applications may also be envisioned.

Autologous replacement of the vocal fold: a new surgical approach for adduction-type spasmodic dysphonia.

Many surgical approaches have been developed for the treatment of adduction-type spasmodic dysphonia (SPD). We developed and performed a new type of surgical approach (autologous replacement of the vocal fold). Our new surgical technique increases the advantages and decreases the disadvantages of previous surgical procedures in three ways: (1) It has similar effects to the previous procedures in that it prevents contraction of the thyroarytenoid muscle. (2) It decreases vocal-fold tension, as in framework surgery. (3) It reduces glottal incompetence, as does fibrinogen-glue injection, but it is more suitable because it is autologous. Furthermore, it produces increases in the mass and volume of the vocal-fold body and is also safe because the replacement tissue is autologous. The short-term results appear encouraging in preventing spastic voice while also avoiding vocal-fold atrophy. Long-term follow up will be necessary to determine the actual efficacy. However, this is clearly a possible choice as a surgical approach for treating adduction-type SPD.

Relationship between speech and swallowing disorders in patients with neuromuscular disease.

The intelligibility of monosyllabic speech, word speech, and conversational speech was evaluated in 113 dysarthric speakers, and the presence and severity of swallowing disorders were evaluated using videofluoroscopic and bedside examinations. The results revealed a high correlation between swallowing function and all levels of speech intelligibility. Furthermore, the prevalence of concomitant dysphagia in dysarthric patients was quite high regardless of the primary etiology and time elapsed since the onset. However, the relationship between the two functions is more complex than is initially apparent. The prevalence and severity of dysphagia vary markedly according to the type of dysarthria. Patients in the flaccid, spastic, and mixed categories encompass a broad range of severity levels with many individuals being severely impaired, while patients in the ataxic, hypokinetic, and unilateral upper motor neuron categories seldom have severe concomitant swallowing problems. Furthermore, the correlation coefficient between conversational intelligibility and swallowing function varies considerably according to the type of dysarthria. The correlation was not significant in the flaccid, hypokinetic, and UUMN dysarthria groups. Based on these findings, we discuss herein the clinical management of dysarthric patients with dysphagia.

Morphological studies for retrusive movement of the human adult tongue.

This study identified the anatomical and close functional relationship between the transverse lingual and superior pharyngeal constrictor muscle. Two en bloc samples (including the tongue and mid-pharyngeal wall) and four whole tongues were obtained from adult human cadavers. We found that fibers of the superior pharyngeal constrictor muscle connected with fibers of the transverse lingual muscle, forming a ring of muscle at the base of the tongue. The average diameters of the transverse muscle fibers increased in size gradually as they approached the base of the tongue. Distribution of the muscle spindles in the transverse lingual muscle and the genioglossus muscle also increased as they reached posteriorly near the base of the tongue. These findings suggest that a ring of muscle formed by the postero-inferior portion of the transverse lingual muscle and the superior pharyngeal constrictor may be largely responsible for the retrusive movement of the tongue and the constrictive movement of the pharyngeal cavity as an antagonist of the genioglossus muscle.

A comparison of voice quality ratings made by Japanese and American listeners using the GRBAS scale.

The GRBAS scale is a widely used method for perceptual evaluation of voice quality. Two linguistically diverse groups of listeners (Japanese and American) rated 35 voice samples using the GRBAS scale. The ratings obtained from the two groups were compared to determine if the different linguistic background affected the use of the GRBAS scale. Results show that there are no significant differences between the Japanese and American listeners in the use of the Grade, Roughness and Breathiness scales. Ratings on the Asthenia and Strain scales, however, were different between the two groups of listeners. Despite these discrepancies, the GRBAS scale may be an excellent tool for perceptual evaluation of voice quality by linguistically diverse groups.

Laryngeal gestures during stop production using high-speed digital images.

On acoustic and fiberscopic studies of stop consonants, voice onset time and glottal width have been shown to be greatest in heavily aspirated stops, next greater for slightly aspirated stops, and least for unaspirated stops. Integrated activity of the thyroarytenoid and posterior cricoarytenoid muscles has been reported to be involved in differentiating aspirate characteristics of the stops. However, the fine movement of mucosal edges of vocal folds during the production of stops has not been well documented. In recent years, a new method for high-speed digital recording of laryngeal dynamics has made this possible. In the current study, the movements of vocal fold edges were documented during the period of stop production using a fiberscopic system of high-speed digital images. By observing the glottal width and the visual vibratory movements of vocal folds before voice onset, the heavily aspirated stop was characterized as being more prominent and dynamic than the slightly aspirated and unaspirated stops.

Vocal cord paralysis after surgery for thoracic aortic aneurysm.

OBJECTIVE: To determine the incidence, etiology, prognosis, and treatment of vocal cord paralysis (VCP) after surgery for thoracic aortic aneurysm (TAA). STUDY DESIGN: Retrospective study performed between 1989 and 1995. SETTING: Academic, tertiary care, referral medical center. PATIENTS: Seventy-one TAA patients underwent surgery at the Kameda Medical Center between 1989 and 1995. RESULTS: Sixty-two of 71 patients were examined postoperatively for voice quality. Twenty patients (32%) had hoarseness develop caused by VCP, as confirmed by laryngoscopy. The left recurrent laryngeal nerve had been sacrificed in 1 patient during surgery, but it was preserved in the remaining 19 patients. Unilateral left VCP was noted in 19 patients, and bilateral VCP occurred in 1 patient. The incidence of VCP was higher in those patients who underwent surgery for type I aneurysms (9 of 14 patients, 64%). In 16 of the 19 patients (84%) who received follow-up for > 6 months, vocal cord movement did not return to normal. Surgery to improve voice quality, arytenoid adduction in five patients and intracordal injection in two patients, was performed with success. CONCLUSIONS: Our results indicate that surgery for TAA is associated with a relatively high incidence of VCP. VCP occurred despite preservation of the recurrent laryngeal nerve, and the paralysis did not show a spontaneous recovery even 6 months after surgery.