Vocal Function Tests/ Laryngological EMG

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Vocal Function Tests/ Laryngological EMG

Laryngology, Voice and Swallowing
Author Credentials 

Yolanda D. Heman-Ackah, MD, MS
Director, Philadelphia Voice Center
25 Bala Avenue, Suite 200
Bala Cynwyd, PA 19004

Clinical Professor
Department of Otolaryngology-Head and Neck Surgery
Drexel University College of Medicine
Philadelphia, PA

Adjunct Associate Professor
Department of Otolaryngology-Head and Neck Surgery
Sidney Kimmel Medical College - Thomas Jefferson University
Philadelphia, PA

Module Summary

Vocal function tests are useful adjuncts to the evaluation and treatment of voice disorders. They allow for the objective measurement of the voice and of the functional impact of the voice disorder on the patient’s life. They also allow the ability to follow changes in the voice through time. No one test is sufficient to provide a global view of vocal function, and the use of vocal function testing is best used as a battery of cognitive, behavioral, physical, acoustic, aerodynamic, and electromyographic evaluation.

Module Learning Objectives 
  1. Evaluate the functional impact of voice disorders using subjective vocal measures.
  2. Objectively measure the severity of voice disorders.
  3. Apply laryngeal electromyography (EMG) to the assessment of movement disorders in the larynx.
  4. Interpret the results of laryngological EMG.

Anatomy

Learning Objectives 
  1. Describe the anatomical positions of the laryngeal muscles and their cartilaginous attachments in the larynx.
  2. Demonstrate the correct placement of EMG needle electrodes in the evaluation of electrical activity in each of the individual intrinsic laryngeal muscles.
References 
  1. Sataloff RT, Mandel S, Heman-Ackah Y, Abaza M. Laryngeal Electromyography. Third Edition. San Diego: Plural Publishing; 2017:7-32, 72-80.
  2. Sataloff RT. Clinical anatomy and physiology of the voice. In: Sataloff RT editor. Professional Voice: The Science and Art of Clinical Care. 3rd ed. San Diego: Plural Publishing; 2005.
  3. Clayman DA, Booth RP, Isaacs J Jr, Russo LS Jr. Percutaneous electromyography of the posterior cricoarytenoid muscles: electromyographic needle placement with computed tomographic guidance. Laryngoscope. 1994 Nov;104(11 Pt 1):1393-6. [EBM Level 4]
  4. Lipton RJ, McCaffrey TV, Cahill DR. Sectional anatomy of the larynx: implications for the transcutaneous approach to endolaryngeal structures. Ann Otol Rhinol Laryngol. 1989 Feb;98(2):141-4. [EBM Level 2]
  5. Thumfart WF. Electromyography of the larynx and related technics. Acta Otorhinolaryngol Belg. 1986;40(2):358-76. [EBM Level 5]
  6. Rossi G, Cortesina G. Morphological study of the laryngeal muscles in man: insertions and courses of the muscle fibers, motor end-plates and procprioceptors. Acta Otolaryngol. 1965;59:575-592. [EBM Level 4]

Basic Science

Learning Objectives 
  1. Describe the different components of the human voice
    1. Fundamental frequency
    2. Formant frequencies
    3. Periodicity and aperiodicity
    4. Harmonic structure of the voice
  2. Describe various ways to measure the voice
    1. Aerodynamic measures
      1. Spirometry
      2. Glottal airflow rate
      3. Subglottal air pressure
      4. Maximum phonation time
      5. s/z ratio
    2. Acoustic measures
      1. Fundamental frequency
      2. Sound pressure levels
      3. Spectrography
      4. Harmonic to noise ratio
      5. Glottography
        1. Light
        2. Ultrasound
        3. Electric
      6. Cepstral peak prominence
      7. Dysphonia Severity Index
  3. Describe the basic aspects of EMG interpretation
    1. Insertional activity
    2. Spontaneous activity
    3. Waveform morphology
    4. Recruitment
References 
  1. Awan SN, Novaleski CK, Yingling JR. Test-retest reliability for aerodynamic measures of voice. J Voice. 2013 Nov;27(6):674-84. [EBM Level 4]
  2. Awan SN, Krauss AR, Herbst CT. An Examination of the Relationship Between Electroglottographic Contact Quotient, Electroglottographic Decontacting Phase Profile, and Acoustical Spectral Moments. J Voice. 2015 Sep;29(5):519-29. [EBM level 4]
  3. Awan SN, Frenkel ML. Improvements in estimating the harmonics-to-noise ratio of the voice. J Voice. 1994 Sep;8(3):255-62.
  4. Watts CR, Awan SN. Use of spectral/cepstral analyses for differentiating normal from hypofunctional voices in sustained vowel and continuous speech contexts. J Speech Lang Hear Res. 2011 Dec;54(6):1525-37. [EBM Level 2]
  5. Awan SN, Miesemer SA, Nicolia TA. An examination of intrasubject variability on the Dysphonia Severity Index. J Voice. 2012 Nov;26(6):814.e21-5.  [EBM Level 4]
  6. Watts CR, Awan SN, Maryn Y. A Comparison of Cepstral Peak Prominence Measures From Two Acoustic Analysis Programs. J Voice. 2017 May;31(3):387. [EBM Level 4]
  7. Heman-Ackah YD, Sataloff RT, Laureyns G, Lurie D, Michael DD, Heuer R, Rubin A, Eller R, Chandran S, Abaza M, Lyons K, Divi V, Lott J, Johnson J, Hillenbrand J. Quantifying the cepstral peak prominence, a measure of dysphonia. J Voice. 2014 Nov;28(6):783-8.  [EBM Level 2]
  8. Smits I, Ceuppens P, De Bodt MS. A comparative study of acoustic voice measurements by means of Dr. Speech and Computerized Speech Lab. J Voice. 2005;19(2):187-96. [EBM Level 2]
  9. Heman-Ackah YD, Heuer RJ, Michael DD, et al. Cepstral peak prominence: a more reliable measure of dysphonia. Annals of Otology Rhinology and Laryngology. 2003;112(4):324-333. [EBM Level 2]
  10. Kaszuba SM and Garrett CG. Strobovideolaryngoscopy and Laboratory Voice Evaluation. In: Heman-Ackah YD and Sataloff RT. Otolaryngology Clinics of North America: The Professional Voice. Philadelphia : Saunders; 2007;40(5)991-1002.
  11. Munin MC, Heman-Ackah YD, Rosen CA, Sulica L, Maronian N, Mandel S, Carey BT, Craig E, Gronseth G. Consensus statement: Using laryngeal electromyography for the diagnosis and treatment of vocal cord paralysis. Muscle Nerve. 2016 Jun;53(6):850-5.  [EBM Level 1]
  12. Heman-Ackah YD, Mandel S, Manon-Espaillat R, Abaza MM, Sataloff RT. Laryngeal electromyography. Otolaryngol Clin North Am. 2007 Oct;40(5):1003-23, vi-vii.
  13. Sataloff RT, Mandel S, Heman-Ackah Y, Abaza M. Basic aspects of the electromyographic evaluation. In: Laryngeal Electromyography. Third Edition. San Diego: Plural Publishing; 2017:47-70.
  14. Koufman JA, Walker FO. Laryngeal electromyography in clinical practice: indications, techniques, and interpretation. Phonoscope. 1998;1:57-70. [EBM Level 4]

Patient Evaluation

Learning Objectives 

Evaluate the voice perceptually

  1. Characteristics of the voice
    1. Overall dysphonia
    2. Roughness
    3. Breathiness
    4. Asthenia
    5. Strain
    6. Tremor
    7. Range
  2. GRBAS scale
  3. CAPE-V
References 
  1. Nemr K, Simões-Zenari M, Cordeiro GF, Tsuji D, Ogawa AI, Ubrig MT, Menezes MH. GRBAS and Cape-V scales: high reliability and consensus when applied at different times. J Voice. 2012 Nov;26(6):812.e17-22. 
  2. Zraick RI, Kempster GB, Connor NP, Thibeault S, Klaben BK, Bursac Z, Thrush CR, Glaze LE. Establishing validity of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V).
  3. Am J Speech Lang Pathol. 2011 Feb;20(1):14-22. 
  4. Yamaguchi H, Shrivastav R, Andrews ML, Niimi S. A comparison of voice quality ratings made by Japanese and American listeners using the GRBAS scale. Folia Phoniatr Logop. 2003 May-Jun;55(3):147-57.

Measurement of Functional Status

Learning Objectives 

Describe measures of functional vocal disability

  1. Voice Handicap Index
  2. Voice Related Quality of Life
References 
  1. Jacobson BH, Johnson A, Grywalsky C, et al. The voice handicap index (VHI): development and validation. Am J Speech Lang Path. 1997;6:66-70. [EBM Level 2]
  2. Hogikyan ND, Sethuraman G. Validation of an instrument to measure voice-related quality of life (V-RQOL). J Voice. 1999;13(4):557-69. [EBM Level 2]
  3. Murry T, Medrado R, Hogikyan ND, et al. The relationship between ratings of voice quality and quality of life measures. J Voice. 2004;8(2)183-192. [EBM Level 2]
  4. Rosen CA, Lee AS, Osborne J, et al. Development and validation of the voice handicap index-10. Laryngoscope. 2004;114(9):1549-56. [EBM Level 2]

Review

Review Questions 
  1. What is the role of patient report indices in vocal function testing?
  2. What are the aerodynamic measures of vocal function?
  3. What is the best available method of quantifying vocal quality?
  4. What are the best available methods of describing clinician perceptions of the voice?
  5. What is the clinical significance of unstable subglottal air pressures during phonation?
  6. How is laryngeal electromyography performed?
  7. What information can be obtained from laryngeal electromyography?
References 
  1. Heman-Ackah YD, Sataloff RT. Care of the Professional Voice. In: Otolaryngology Clinics of North America. Elselvier Publishing, Philadelphia. 2007.
  2. Sataloff RT, Mandel S, Heman-Ackah Y, Abaza. Laryngeal Electromyography 3rd ed. San Diego: Plural Publishing, 2017.
Resources 

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  1. Annual Meeting Webcasts (AMW):