Vocal Impact in Patients With Unilateral Diaphragmatic Paralysis

Published:January 09, 2023DOI:



      This study aimed to investigate the possible vocal impact confirmed by diagnostic tests, the degree of perception of possible vocal impairment by patients with Unilateral Diaphragmatic paralysis (UDP) and its correlation with ventilatory weakness.


      The researchers conducted an analytical, observational and case-control study with 70 individuals, including 35 UDP patients and 35 healthy patients in a control group, who underwent the following assessments: 1) Self-assessment of voice handicap (VHI-10); 2) Self-Assessment of Quality of Life (SF-36); 3) Self-Assessment of Dyspnea (MRC); 4) Objective vocal measures (Maximum Phonation Time (MPT) in /a/, /s/, /z/ and glottal-to-noise excitation ratio); 5) Functional respiratory pressures (Spirometry and maximum ventilatory pressures); 6) General degree of dysphonia – G on the GRBAS Scale. The sex, age and body mass index (BMI) of the individuals were the variables used to match the sample of this study.


      When compared with controls, patients with UDP had a restrictive functional pattern and inspiratory weakness, with symptoms of dyspnea and worsening quality of life. When associated with a possible vocal impact, these patients had voice handicap and decreased MPT values for all phonemes, especially /a/. There was also a correlation between vocal performance and inspiratory weakness. However, it should be noted that, despite having vocal impairment, many patients did not report the perception of this fact, somehow neglecting such impairment.


      In addition to the expected weakness of the ventilatory muscles, patients with UDP had clinically verified vocal impact, and those who had greater inspiratory weakness also had greater voice impairment. Finally, it is relevant that not all patients perceived such vocal impact, which showed a very reduced perception of this impairment in patients with UDP.

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        • McNamara JJ
        • Paulson DL
        • Urschel Jr., HC
        • et al.
        Eventration of the diaphragm.
        Surgery. 1968; 64: 1013-1021
        • Como JJ
        • Cohen-Kashi KJ
        • Alhindawi R.
        Posttraumatic diaphragmatic eventration.
        J Trauma. 2004; 56: 1149-1151
        • Riley EA.
        Idiopathic diaphragmatic paralysis. A report of eight cases.
        Am J Med. 1962; 32: 404-416
        • Chan CK
        • Loke J
        • Virgulto JA
        • et al.
        Bilateral diaphragmatic paralysis: clinical spectrum, prognosis and diagnostic approach.
        Arch Phys Med Rehabil. 1988; 69: 976-979
        • Lagueny A
        • Ellie E
        • Saintarailles J
        • et al.
        Unilateral diaphragmatic paralysis: an electrophysiological study.
        J Neurol Neurosurg Psychiatry. 1992; 55: 316-318
        • Pereira CAC
        J Pneumol. 2002; 28: S1-82
        • Costa D
        • Jamami M.
        Bases fundamentais da espirometria.
        Rev bras fisioter. 2001; 5: 95-102
        • Pereira CA
        • Sato T
        • Rodrigues SC.
        New reference values for forced spirometry in white adults in Brazil.
        J Bras Pneumol. 2007; 33: 397-406
        • Costa T
        • Oliveira G
        • Behlau M.
        Validation of the Voice Handicap Index -10 (VHI-10) to the Brazilian Portuguese.
        CoDas. 2013; 25: 482-485
        • Mahler DA
        • Wells CK.
        Evaluation of clinical methods for rating dyspnea.
        Chest. 1988; 93: 580-586
        • Mahler DA
        • Rosiello RA
        • Harver A
        • et al.
        Comparison of clinical dyspnea ratings and psychophysical measurements of respiratory sensation in obstructive airway disease.
        Am Rev Respir Dis. 1987; 135: 1229-1233
        • Ciconelli RMF
        • Bosi M
        • Santos W
        • et al.
        Brazilian-Portuguese version of the SF-36. A reliable and valid quality of life outcome measure.
        Rev bras reumatol. 1999; 39: 143-150
        • Behlau M
        • Madazio G
        • Feijó Pontes P
        Avaliação de voz.
        in: Behlau M. Voz- O livro do especialista, Volume I. Revinter, Rio de Janeiro2001 (Reimpressão 2008. p. 85 –245)
        • Miglioranzi SL
        • Cielo CA
        • Siqueira MA.
        Vital capacity and maximum phonation times of voiceless /e/and /s/ in adult women.
        Rev CEFAC. 2012; 14: 97-103
        • Leite AC
        • Christmann MK
        • Hoffmann CF
        • et al.
        Tempos máximo de fonação e capacidade vital de mulheres disfônicas.
        CEFAC. 2018; 20: 632-639
        • Englert MT
        • Mesquita LG
        • Azevedo R.
        Comparação entre formas de extração do tempo máximo fonatório em indivíduos sem queixas vocais.
        Rev CEFAC. 2014; 16: 1615-1620
        • Michaelis D
        • Gramss T
        • Strube HW.
        Glottal-to-noise excitation ratio – a new measure for describing pathological voices.
        Acta Acustica. 1997; 83: 700-706
        • Albuquerque ALP
        • Santana PV
        • Cardenas LZ
        • et al.
        Métodos diagnósticos para avaliação da força muscular inspiratória e expiratória.
        J Bras Pneumol. 2015; 41: 110-123
        • Neder JA
        • Andreoni S
        • Lerario MC
        • et al.
        Reference values for lung function tests. II. Maximal respiratory pressures and voluntary ventilation.
        Brazilian J Med Biol Res. 1999; 32: 719-727
        • Tisiologia SBdPe
        Guidelines for Pulmonary Function Tests.
        Brazilian Journal of Pneumology: official publication of the Brazilian Society of Pneumology and Tisilogy. 2002; 28: S155-S165
        • Pereira CA
        • Sato T
        • Rodrigues SC.
        New reference values for forced spirometry in White 2dults in Brazil.
        J Bras Pneumol. 2007; 33: 397-406
        • Bussab WO
        • Morettin PA.
        Estatística Básica.
        5th ed. Saraiva, São Paulo2006 (526p)
        • Siegel S.
        Estatística não-paramétrica para ciências do comportamento.
        2nd ed. Artmed, Porto Alegre2006 (448p)
        • Agresti A.
        Categorical data analysis.
        Wiley Interscience, New York1990 (558p)
        • Colton RH
        • Casper JK
        • Leonard R
        Compreendendo os problemas da voz. Uma Perspectiva Fisiológica no Diagnóstico e Tratamento das Disfonias.
        3rd ed. Revinter, Rio de Janeiro2010
        • Sheyona V
        • Devadas U.
        The prevalence and impact of voice problems in nonprofessional voice users: preliminary findings.
        J Voice. 2020; (Jul 10:S0892-1997(20)30230-7. Epub ahead of print. PMID: 32660848)
        • Behlau M.
        Voz: O livro do especialista – Volume 1. 1 Ed.
        Revinter, Rio de Janeiro2001
        • Gould WJ.
        Effect of respiratory and postural mechanisms upon action of the vocal cords.
        Folia Phoniatr. 1971; 23: 221-224
        • Gould WJ.
        The effect of voice training on lung volumes in singers and the possible relationship to the damping factor of Pressman.
        J Res Sing. 1977; 1
        • Hixon TJ
        • Goldman M
        • Mead J.
        Kinematics of the chest wall during speech production: volume displacements of the rib cage, abdomen and lung.
        J Speech Hear Res. 1973; 16: 78-115
        • Hixon TJ
        • Hoit JD.
        Physical examination of the diaphragm by the speech-language pathologist.
        Am J Speech-Language Pathol. 1988; 7: 37-45
        • Watson PJ
        • Hoit JD
        • Lansing RW
        • et al.
        Abdominal muscle activity during classical singing.
        J Voice. 1989; 3: 24-31
        • Thomasson M.
        Belly in or belly out? Effects of inhalatory behavior and lung volume on voice function in male opera singers.
        Speech, Music and Hearing, KTH, Stockholm, Sweden. TMH-QPSR. 2003; 45: 61-74
        • Sapienza C
        • Davemport PW
        • Martin AD.
        Expiratory muscles training increases pressure support in high school band students.
        J Voice. 2002; 16: 495-501
        • Anand S
        • El-Bashiti N
        • Sapienza C.
        Effect of training frequency on maximum expiratory pressure.
        Am J Speech-Languag Pathol. 2012; 12: 380-386
        • Titze I.
        Princípios da produção vocal. Trad. Claudia Liechavicius.
        National Center for Voice and Speech, Salt Lake City2013
        • Colton RH
        • Casper JK
        • Leonard R.
        Compreendendo os problemas da voz.
        Uma Perspectiva Fisiológica no Diagnóstico e Tratamento das Disfonias. 3rd ed. Revinter, Rio de Janeiro2010
        • Sundberg J
        Ciência da Voz, Fatos sobre a voz na fala e no canto.
        Trad. Gláucia Laís Salomão. Editora da Universidade de São Paulo, São Paulo2015
        • Sakata T
        • Kubota N
        • Yonekawa H
        • et al.
        GRBAS evaluation of running speech and sustained phonations.
        Ann Bull RILP. 1994; 28: 51-56
        • Omori K.
        Diagnosis of Voice Disorders.
        JMAJ. 2011; 54: 248-253
        • Michaelis D
        • Gramss T
        • Strube HW.
        Glottal-to-noise excitation ratio - a new measure for describing pathological voices.
        Acta Acustica. 1997; 83: 700-706
        • Jacobson BH
        • Johnson A
        • Gryvalski C
        • et al.
        The Voice Handicap Index (VHI): development and validation.
        Am J Speech-Languag Pathol. 1997; 6: 66-70
        • Holtbernd F
        • Zehnnhof-Dinnensen A
        • Dunning T
        • et al.
        An unusual case of Neuralgic Amyotrophy presentimg with bilateral phrenic Nerve and Vocal Cord Paresis.
        Case Rep Neurol. 2011; 3: 69-74
        • Badireddi S
        • Siddiqui M
        • Little Rock AR
        Respiratory failure with diaphragmatic palsy: a rare complication of relapsing polychondritis.
        Signs SympChest Dis Chest. 2012; 142: 992A
        • Freedman B.
        Unilateral paralysis of the Diaphragm and larynx associated with inflammatory lung disease.
        Thorax. 1950; 5: 169
        • Choi SW
        • Kim WJ.
        Vocal cord and diaphragmatic paralysis in a patient with bilateral mediastinal neurofibromatosis type 1.
        Ear Nose Throat J. 2020; 1–2