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-- Neurological Problems of the Voice Care of the Professional Voice ASSOCIATE EDITOR: Robert T. Sataloff, MD, DMA Neurological Problems of the Voice - -- Blake Simpson, MD Gayle Woodson, MD What are neurological voice box, throat, palate, jaw, tongue, is usually accompanied by other symp- problems of the voice? or lips, resulting in a variety of voice toms, such as speech distortion, swal- Normal speech production requires and/or speech problems. When neu- lowing problems, choking when precise control and coordination of rological voice disorders lead to weak- drinking liquids, or neurological prob- the muscles of the voice box, throat, ness of the vocal fold muscles, the lems elsewhere in the body (i.e., arm palate, jaw, tongue, and lips. When voice maybe very weak, breathy, and or leg weakness or tremor). Acquired the vocal fold muscles are dysfunc- subject to fatigue. At other times a speech impairment (difficulty form- tional, we generally refer to this symp- harsh and strained voice may be pres- ing words) in adults virtually always tom as a i'oice abnormality. On the ent due to vocal fold spasms from an indicates a neurologic problem. Poor other hand, when the tongue and lip underlying neurological condition. control of the muscles that shape muscles malfunction, the articulation The voice may also sound too nasal words is called dysarthria. This may of words becomes altered (typically (from weakness of the palate mus- range from slurring of speech to "slurred"), resulting in a speech dis- cles), or speech patterns may be slur- imprecise consonants, or completely order. Difficulty forming words is a red or monotonous from tongue/jaw/ incomprehensible speech. Dysfiuent neurological problem of speech and lip involvement. The type of problem speech, such as stuttering or stam- is called dysarthria, a condition com- varies with the underlying disease mering, also indicates a neurological monly seen after a stroke process and the specific muscles and problem. Some patients know what Neurological voice disorders are actions that are affected. they want to say, but cannot get the due to abnormalities of the brain words out (aphasia). Other patients and/or the nerves of the body that What are the symptoms of cannot remember words. These prob- impair control of the muscles of the neurological voice disorders? lems are usually the result of a stroke. Isolated hoarseness is usually due A change in resonance, such as an Journal of Singing, March/April 2003 to a problem within the larynx, but overly nasal sounding voices often indi- Volume 59, No. 4, pp. 321-327 cates impaired control of throat or Copyright 2003 could be a sign of neurologic disease National Association of Teachers of Singing in some cases. Neurologic hoarseness palate muscles. A shaking, tremulous MARCH/APRIl. 2003 321 Blake Simpson, M.D. and Gayle Woodson, M.D. voice indicates a tremor, which is seen coughing/choking (especially when general, the older the patient the in a variety of neurological disorders. drinking liquids) that can be quite worse the prognosis for recovery Abrupt voice spasms are also signs of severe and debilitating. The com- of function. Vocal and swallow- neurological dysfunction, although bination of a paralyzed vocal fold, ing difficulties often persist, and sometimes patients with emotional poor airway protection, weakened can be so severe that the patient problems could have similar changes swallowing muscles, and loss of is dependant on a feeding tube for in the sound of the voice. feeling/sensation in the throat nutrition and is unable to com- Difficulty breathing can be a sign of probably explains the severe nature municate. Speech and swallowing an underlying neurological disease of swallowing problems in some therapy with a Speech/Language and may be due to weakness/paraly- stroke patients. Occasionally, a Pathologist is essential in the reha- sis of both vocal folds resulting in a weak palate will cause a hyper- bilitation process for many stroke narrow, compromised airway. nasal voice as well. patients. Vocal symptoms with cerebral What are some of the more cortex strokes more often are 2. Parkinson's Disease common neurological diseases related to articulation disorders • What are the symptoms? that affect the voice? (slurred speech, or dysarthria), Vocal symptoms consist of low Because of the complex and diverse rather than hoarseness. Some volume voice with a monotone nature of neurological voice disor- patients may have loss of speaking (expressionless) quality. The ders, the more common conditions ability (aphasia) when the domi- speech pattern is often produced will be covered individually, address- nant brain hemisphere is affected. in short bursts with inappropri- ing the following areas: It is very important to note, how- ate silences between words, and What is the cause of the disease and ever, that voice and speech distur- long pauses before initiating who is at risk? bances are not the dominant speech. The speech maybe slurred What are the symptoms? symptoms in stroke initially. Other as well. A small percentage of How is the disease diagnosed? symptoms typically dominate in patients (about fifteen percent) What are the pitfalls of diagnosis/ stroke patients, and can include may also have a tremulous voice. common misdiagnoses? weakness or paralysis of the arms As with most neurological disor- How is the disease treated and what and/or legs, incoordination (ataxia), ders, voice and speech disturbance is the overall prognosis? numbness in the arms or legs, par- are merely a small part of the tial or total loss of vision, and loss symptoms in Parkinson's. Tremor 1. Stroke (Cerebrovascular of consciousness or coma. in the hands, and slow, shuffling Accident or CVA) • How is stroke diagnosed? gait, and other movement distur- • What is the cause of the disease Generally, a specialist in nerve bances dominate, and often pres- and who is at risk? and brain disorders (neurologist) ent long before vocal difficulties Stroke results from interrupted is the most appropriate physician enter the picture. blood flow to the brain or brain- in the diagnosis and treatment of • What is the cause of the disease stem, and is generally seen in males stroke. An MRI or CAT scan is and who is at risk? above the age of fifty. The risk fac- generally ordered to locate the area The cause is not fully under- tors for stroke include high blood of the brain affected, but a good stood, but loss of nerve cells in pressure, high cholesterol level, history and physical examination select areas of the brainstem occurs and vascular disease. often pinpoints the diagnosis. through an unknown mechanism. • What are the symptoms? • How is stroke treated and what The disease is more common in Vocal symptoms typically con- is the prognosis? men (3:2 male to female ratio), and sist of a hoarse, breathy voice when New clot-dissolving drugs, if the age of onset is usually above the brainstem is involved in stroke, given early during the emergence the age of fifty. No risk factors are and is due to paralysis of the vocal of stroke symptoms, can make a known. fold muscles on one side. Often, huge difference in the prognosis • How is it diagnosed? the patient also will experience of stroke. The overall prognosis of The diagnosis is made clinically swallowing difficulties as well as stroke varies considerably, but in (history and physical examination) 322 JOURNAL OF SINGING Care of the Professional Voice by a neurologist, although MRI or used to treat Parkinson's disease; dystonia. Dystonia can also occur CAT scans are often obtained to however, voice symptoms may not to a region of the body (head and help rule out other conditions. improve, and may actually worsen neck or arm) or to all the muscles • What are possible misdiagnoses? with this treatment. of the body. The latter is very rare. Exposure to certain toxic sub- Spasmodic dysphonia also has been stances, such as carbon monoxide, Spasmodic Dysphonia called spastic dysphonia in the and side effects from certain neu- • What are the symptoms? past. This condition is caused by roleptic medications can cause The symptoms of this neuro- an abnormality in the part of the symptoms similar to Parkinson's logical disorder are unique in that brain (basal ganglia) responsible disease. voice problems are most often the for control of laryngeal muscle • How is Parkinson's disease only symptom of the disorder. contraction. treated? There are two different types of According to our best knowl- A team approach with involve- SD: adductor spasmodic dyspho- edge, spasmodic dysphonia usually ment of Neurology, Speech Path- nia and abductor spasmodic dys- is not a disease of heredity. Much ology, and Otolaryngology is rec- phonia. Adductor SD is most research is being done regarding ommended. Medication (Levodopa) common (eighty percent) and is the genetic causes and links to the is commonly used for the motor characterized by a tight, strained, various dystonias. Recent research manifestations of Parkinson's, but strangled voice caused by spasms has found genetic causes, though, has little effect on the voice and of the muscles that move the vocal of other types of neurological move- speech. Rehabilitation of speech, folds to the center of the voice box ment disorders. It is hoped that this voice, and swallow function is typ- for producing voice. Abductor SD research will result in improved ically handled by a speech pathol- causes a breathy, weak voice dur- detection and treatment methods. ogist. The mainstay of the treat- ing speech due to spasms of the • How is SD diagnosed? ment of the communication muscles responsible for moving An otolaryngologist with spe- problems (slurred speech and soft, the vocal folds laterally (opening cialized interest and/or training weak voice) in patients with of the larynx for breathing).
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