Abstract
IntroductionAlthough syndromes that cause voice tremor have singular characteristics, the differential diagnosis of these diseases is a challenge because of the overlap of the existing signs and symptoms. ObjectiveTo develop a task-specific protocol to assess voice tremor by means of nasofibrolaryngoscopy and to identify those tasks that can distinguish between essential and dystonic tremor syndromes. MethodsCross-sectional study. The transnasal fiberoptic laryngoscopy protocol, which consisted of the assessment of palate, pharynx and larynx tremor during the performance of several vocal and non-vocal tasks with distinct phenomenological characteristics, was applied to 19 patients with voice tremor. Patients were diagnosed with essential or dystonic tremor according to the phenomenological characterization of each group. Once they were classified, the tasks associated with the presence of tremor in each syndrome were identified. ResultsThe tasks that significantly contributed to the differential diagnosis between essential and dystonic tremor were /s/ production, continuous whistling and reduction of tremor in falsetto. These tasks were phenomenologically different with respect to the presence of tremor in the two syndromes. ConclusionThe protocol of specific tasks by means of transnasal fiberoptic laryngoscopy is a viable method to differentiate between essential and dystonic voice tremor syndromes through the following tasks: /s/ production, continuous whistling and reduction of tremor in falsetto.
Highlights
Syndromes that cause voice tremor have singular characteristics, the differential diagnosis of these diseases is a challenge because of the overlap of the existing signs and symptoms
The objective of this study is to develop a protocol of specific tasks for the evaluation of vocal tremor by nasofibrolaryngoscopy and to identify the tasks that phenomenologically differentiate the syndromes of essential and dystonic tremor
Through the information collected from the visual---perceptual assessment of the tremor by consensus among the three examiners, 12 patients were classified as having essential tremor and seven as dystonic tremor, according to the presence or absence of horizontal tremor of the larynx in the /s/ production task (Table 2)
Summary
Syndromes that cause voice tremor have singular characteristics, the differential diagnosis of these diseases is a challenge because of the overlap of the existing signs and symptoms. Voice tremor can be present in defined syndromes when it is associated with other neurological signs (especially for limbs and head), or it is frequently described as an isolated voice tremor when the voice tremor is the only manifestation.[1] Considering the phenomenology, the tremor can be present at rest or with action depending on the conditions present when the tremor occurs and the main clinical data that contribute to the syndromic diagnosis This description applies to the phonatory apparatus and can be evaluated by means of nasofibrolaryngoscopy, which allows a functional assessment during the performance of several tasks.[2]. Among the neurological syndromes with possible voice tremor manifestations, essential tremor is most prevalent followed by Parkinsonian tremor and dystonic tremor.[3,4] Despite being a relatively common entity, some case series show that Parkinson’s disease rarely exhibits a laryngeal tremor.[5,6] Considering that tremor at rest is physiologically and clinically different from the others, the greatest diagnostic difficulty lies in distinguishing between essential and dystonic tremor.[7]
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