Arytenoid cartilage movements are hypokinetic in Parkinson’s disease: A quantitative dynamic computerised tomographic study

<div><p>Background</p><p>Voice change is one of the earliest features of Parkinson’s disease. However, quantitative studies of vocal fold dynamics which are needed to provide insight into disease biology, aid diagnosis, or track progression, are few.</p><p>Methods</p><p>We therefore quantified arytenoid cartilage movements and glottic area during repeated phonation in 15 patients with Parkinson’s disease (symptom duration < 6 years) and 19 controls, with 320-slice computerised tomography (CT). We related these measures to perceptual voice evaluations and spirometry. We hypothesised that Parkinson’s disease patients have a smaller inter-arytenoid distance, a preserved or larger glottic area because vocal cord bowing has previously been reported, less variability in loudness, more voice dysdiadochokinesis and breathiness and a shortened phonation time because of arytenoid hypokinesis relative to glottic area.</p><p>Results</p><p>Inter-arytenoid distance in Parkinson’s disease patients was moderately smaller (Mdn = 0.106, IQR = 0.091–0.116) than in controls (Mdn = 0.132, IQR = 0.116–0.166) (W = 212, P = 0.015, r = −0.42), normalised for anatomical and other inter-subject variance, analysed with two-tailed Wilcoxon’s rank sum test. This finding was confirmed in a linear mixed model analysis—Parkinson’s disease significantly predicted a reduction in the dependent variable, inter-arytenoid distance (b = −0.87, SEb = 0.39, 95% CI [−1.66, −0.08], t(31) = −2.24, P = 0.032). There was no difference in glottic area. On perceptual voice evaluation, patients had more breathiness and dysdiadochokinesis, a shorter maximum phonation time, and less variability in loudness than controls. There was no difference in spirometry after adjustment for smoking history.</p><p>Conclusions</p><p>As predicted, vocal fold adduction movements are reduced in Parkinson’s disease on repeated phonation but glottic area is maintained. Some perceptual characteristics of Parkinsonian speech reflect these changes. We are the first to use 320-slice CT to study laryngeal motion. Our findings indicate how Parkinson’s disease affects intrinsic laryngeal muscle position and excursion.</p></div

Inter-arytenoid distance.

<p>At each 100 ms interval, fiducial markers were placed on the vocal processes (VP) (A-C in the axial, sagittal and coronal planes), the anterior commissure (AC) (D-F in the axial, sagittal, and coronal planes) and finally on the superior cornua (SC) (G-I in the axial, sagittal, and coronal planes).</p

Glottic area during vocalisation.

<p>A. A representative subject. The shaded area, removed in pre-processing, corresponds to a variable time before the subject has begun vocalising. B. Relationship between glottic area (<i>ga</i>) and inter-arytenoid distance (<i>iad</i>) and C. Graphical representation. Arytenoid movement may be described as a circle centred at the anterior commissure: the relationship is quadratic. As the inter-arytenoid distance and the angle between the vocal folds increases glottic area also increases. Despite finding smaller inter-arytenoid distance during vocalisation in Parkinson’s disease, we did not find the expected reduction in the glottic area, suggesting the vocal folds are bowed during vocalisation in Parkinson’s disease.</p

Representative glottic areas measured by automated segmentation.

<p>Each row shows a measurement taken at a single time point in a different subject. Axial, sagittal and coronal images are shown left to right. Cords apart (A, B, C), Cords towards closure (D, E, F). Hourglass deformity (G, H, I). Annotations: A indicates the arytenoid cartilage, and C, the cricoid cartilage.</p

Subject and voice characteristics, lung function tests.

<p>Subject and voice characteristics, lung function tests.</p