J Neurosurg 110:282–288, 2009

“The Mute Who Can Sing”: a cortical stimulation

study on singing

Clinical article
Franck-Emmanuel Roux, M.D., Ph.D.,1,2 Stefano Borsa, M.D., 2
and Jean-François Démonet, M.D., Ph.D.1,3
1
Institut National de la Santé Et de la Recherche Médicale, Unité 825; and Fédérations de
2
Neurochirurgie et 3Neurologie, Centres Hospitalo-Universitaires, Toulouse, France

Object. In an attempt to identify cortical areas involved in singing in addition to language areas, the authors used
a singing task during direct cortical mapping in 5 patients who were amateur singers and had undergone surgery for
brain tumors. The organization of the cortical areas involved in language and singing was analyzed in relation with
these surgical data.
Methods. One left-handed and 4 right-handed patients with brain tumors in left (2 cases) and right (3 cases)
hemi­spheres and no significant language or singing deficits underwent surgery with the “awake surgery” technique.
All patients had a special interest in singing and were involved in amateur singing activities. They were tested using
naming, reading, and singing tasks.
Results. Outside primary sensorimotor areas, singing interferences were rare and were exclusively localized in
small cortical areas (< 1 cm2). A clear distinction was found between speech and singing in the Broca region. In the
Broca region, no singing interference was found in areas in which interference in naming and reading tasks were
detected. Conversely, a specific singing interference was found in nondominant middle frontal gyri in one patient.
This interference consisted of abrupt singing arrest without apparent face, mouth, and tongue contraction. Finally,
nonspecific singing interferences were found in the right and left precentral gyri in all patients (probably by interfer-
ence in final articulatory mechanisms of singing).
Conclusions. Dissociations between speech and singing found outside primary sensorimotor areas showed that
these 2 functions use, in some cortical stages, different cerebral pathways. (DOI: 10.3171/2007.9.17565)

Key Words      •      cortical mapping      •      music      •      singing

I
n 1745, Olof Dalin, a Swedish literacy figure of his
time, reported the case of a farmer, Jan Person, who
suddenly suffered from a right hemiparesis. What at-
tracted Dalin’s attention was that Person, who completely
lost his ability to speak was still able to sing (certain re-
ligious hymns for instance), leading to the probably first
known striking observation of, as Dalin quoted, “a mute
who can sing.”26 Similar cases of aphasia and relatively
preserved singing were subsequently described by other
authors,2,8,11,14,16,19,29,34 leading to consideration that speech
and song could have distinct cerebral representations.12,13
Given that many of these reports concerned patients with
no special music training, this hypothesis would reflect
a general feature of brain organization. The introduc-
tion of noninvasive brain mapping tools has permitted
the study of the cerebral areas activated in response to
singing.3,23,24,27,30,33 It has been hypothesized that, among
Abbreviation used in this paper: fMR = functional MR.
other regions, the right frontal lobe plays a major role in
singing.23
We routinely use direct brain mapping in patients
with brain tumors to identify language cortical areas.
Some of the patients treated in our institution were ama-
teur musicians. Although infrequent, some of them were
involved in singing activities such as choral or folk sing-
ing. To identify cortical areas involved in singing in addi-
tion to language areas, we studied these patients by using
standard language tasks and a singing task during direct
cortical mapping. Because amateur musicians involved in
singing and who must undergo a neurosurgical procedure
and brain mapping are very rare, data from these succes-
sive brain mappings were prospectively collected by the
same team using the same protocol during a period of 10
years. To the best of our knowledge, singing has never
been systematically studied in a group of patients by di-
rect cortical stimulation. The organization of the cortical
areas, involved in language and singing respectively, was
analyzed in relation to the surgical data.

282 J. Neurosurg. / Vol 110 / February, 2009

Singing and cortical stimulation
Methods
Patient Population
Among the patients who underwent surgery for brain
tumor at our institution between 1996 and 2006, 5 non-
professional singers with no language deficit (4 men, age
range 37–68 years, mean 52 years) were prospectively
studied by cortical brain mapping using different lan-
guage tasks and a singing task. Lesions were in the left
hemisphere in 2 cases and in the right hemisphere in 3.
Tu­mors were low grade (in 3 patients) or World Health
Or­ganization Grade III malignant gliomas or metastasis
(in 1 patient each) originating from frontal areas (middle
and inferior frontal gyri) or rolandic region.
Testing of Language and Music Abilities
All of the patients in this study were amateur singers,
4 of them in choirs and 1 in a folk music group. Among
the French population, the ability to play an instrument is
common (total population of France > 63 million people; >
8 million people play an instrument as an amateur). Cho-
ral singing is a rather popular hobby in France, and ~ 2
million people perform regularly or occasionally. Because
these patients were involved actively in singing activities
but were amateurs, and some of them had no formal music
background, the formal testing of music function we used
was basic. The main inclusion criteria were the patient’s
involvement in singing activities and the will to preserve,
whenever possible, the ability to sing after surgery.
Four patients were right-handed and 1 was left-hand-
ed. Four patients were French natives and spoke only
French. One patient was bilingual (French and Rwan-
dan languages). All patients had language examinations
to control their ability to perform the required language
tasks. In this study, strict inclusion criteria were used;
dysphasic patients (with > 10% of errors in naming tests)
were excluded from this study.
Choice of the Mapping Tasks
Similar to that of other teams,31 our policy in brain tu-
mor surgery is to usually perform surgery using the “awake
surgery” technique22 if cortical mapping can be beneficial
to the surgical procedure and if the case is otherwise ap-
propriate for such a procedure. We decided to use singing
tasks on the following criteria: 1) the existing literature
showed that singing could be impaired after nondominant
and dominant frontal lobe damage;13,20 2) some articles in
which the authors undertook cerebral activation studies
described that the rolandic or frontal dominant and non-
dominant gyri could be involved in singing tasks;23,30,33 3)
in all patients in this study, singing was one of their main
extracurricular activities; and 4) the singing tasks chosen
were simple and easily performed during surgery (sing-
ing mappings were performed after language or motor
mappings in < 10 minutes to < 40 minutes for all tasks).
All patients and their families gave informed consent to
study their functional areas by direct brain mapping. The
patients in this study were asked to do 4 different tasks: a
naming task to search for a standard anomia (i.e. “This is
a….”) and an Arabic number–reading task, and an alpha-
J. Neurosurg. / Vol 110 / February, 2009
bet script-reading task, and finally patients were asked to
sing the words of a familiar song.
Cortical Mapping Procedures
Anatomic structures (gyri and sulci) were identified
according to neuronavigational data and by the shape of
gyri and sulci. Intraoperative cortical stimulation was
used to localize areas of functional cortex after determi-
nation of the afterdischarge threshold by using electro-
corticography. The cortex was directly stimulated using
the bipolar electrode of the Newmedic cortical stimu-
lator (1-mm electrodes separated by 5 mm; Radionics).
The current amplitude was progressively increased by 1
mA beginning at 2 mA. We used a standard procedure of
stimulation with biphasic square wave pulses of 1 msec at
60 Hz, with a maximum train duration of 4 seconds.
Our policy was to identify the language or singing ar-
eas found using this test during tumor removal by resect-
ing the tumoral tissue no more than 1 cm from eloquent
cortex (distance of the resection margin from the nearest
functional site).
Conditions of Validation of Functional Sites
To be accepted as language location, the functional
sites found were tested meticulously at least 3 times. Sites
showing no reproducible anomia or speech or singing
arrest were not included in this study. Cortical mapping
procedures were all video recorded in all patients, and
their answers were recorded using a microphone placed
near the patient’s mouth (to provide evidence of the pa-
tient’s cortical organization and to be further analyzed in
team meetings). Intraoperative photographs of the brain
were taken with the sites of positive or negative stimu-
lation. Small markers representing singing interference
sites were used in the intraoperative pictures.
Results
In 4 monolingual patients, 16 different brain map-
pings (4 tasks: object naming, word reading, Arabic num-
ber reading, and singing) were performed. One French/
Rwandan bilingual patient had all tasks performed in his
2 languages (8 different brain mappings). A total of 24
brain mapping studies were performed in all patients.
Speech arrests, anomia phenomena, paraphasias, or hesi-
tations during the object retrieval or reading tasks were
found in common or distinct sites (20 sites in all). At
least one of those sites was found in all patients. For all
the patients in this study, the highest current that did not
evoke afterdischarges ranged between 3.6 and 5.4 mA.
None of the patients had generalized seizures intraopera-
tively. Functional sites found could be extremely local-
ized. Some sites found were specific to naming, reading,
or singing tasks, but other sites could be common to 2 or
3 functions. For each patient, specific findings are pre-
sented in Fig. 1.
Stimulations on the Right and Left Pre- and Postcentral Gyri
All patients had their left (2 patients) and right (3 pa-
tients) pre- and/or postcentral gyri studied. Detected sing-
ing interferences in primary sensorimotor areas (10 sites)
283

Fig. 1.  Schematic representation of the localization of the singing interference and language (naming and reading tasks) found
in the left and right hemispheres in our 5 patients. The dotted line denotes the area of craniotomy. The numbers in the upper left
of each panel denote the case number. F1 = superior frontal gyrus; F2 = middle frontal gyrus; F3 = inferior frontal gyrus; T1 =
superior temporal gyrus.
were common with other language (naming or reading)
interferences. Within precentral gyrus, singing interfer-
ences were located preferentially close to the rolandic
sulcus. Almost all singing interferences detected in pre-
central gyri were abrupt singing arrests (probably due to
“articulatory” interference), sometimes with visible face
or mouth contraction. Although less visible, contraction
or impairment of the tongue or the vocal folds due to
stimulation could be suspected to explain these singing
interferences. We did not find specific effects stimulating
the left versus right precentral gyri except in the patient in
Case 5 in whom stimulation of one area within the right
precentral gyrus induced a singing impairment consisting
of a lack of melodic contours leading to monotonous sing-
ing. Stimulation of this area also affected speech prosody
during naming and reading tasks.
Stimulation of the Left Hemipshere (Outside Pre- and
Postcentral Gyri)
Interference sites related to naming and reading tasks
were found in 2 patients whose left hemisphere was stud-
ied (Cases 1 and 2). In the Broca region, we found 2 nam-
ing or reading interference sites in one patient and 3 in the
other. Four more language sites were found in the patient
in Case 1 in the supramarginal and superior temporal gy­
ri. These sites were extremely localized (1 cm2), either
af­fecting both reading as well as naming interference
or task-specific (reading or naming interference). Often,
when testing the opercular ramus, naming and reading in-
284
F. E. Roux, S. Borsa, and J. F. Démonet
terference found in this gyrus in our patients were abrupt
“speech arrest” (patient stopped naming or reading). In
these 2 right-handed patients, no singing interference was
found when stimulating either naming or reading interfer­
ence areas or other parts of the cortex. Singing was not
af­fected by stimulation of the Broca region (Fig. 2). Even
during stimulation of the opercular ramus where “speech
ar­rest” phenomena were frequent, patients kept singing
with­out any perturbation.
Stimulation of the Right Hemisphere (Outside Pre- and
Postcentral Gyri)
Three patients (Cases 3, 4, and 5) had their right
hemisphere studied. Two were right-handed and the other
was left-handed (Case 5). Naming and reading interfer-
ence were found once in the supramarginal gyrus in a
common area in left-handed patient. No other naming or
reading interferences were detected in frontal gyri in the
patients in Cases 3 and 4. Repetitive singing interference
was detected in the patient in Case 3 during stimulation
of 2 small areas in the middle frontal gyrus (Fig. 3). The
patient stopped singing abruptly after the electrode stim-
ulated the cortex. Within the middle frontal gyrus, this
interference was extremely localized. The patient became
silent, and no word or melody was heard. We are cautious
in analyzing the intrinsic mechanisms producing such
singing interference. We did not notice any face, mouth,
or tongue contraction. No seizure was detected and there
were no electrocorticographic spikes. In the other 2 pa-
J. Neurosurg. / Vol 110 / February, 2009
Singing and cortical stimulation

Fig. 2.  Case 1. Illustration of preserved singing during direct brain mapping in the Broca area and the supramarginal gyrus
where speech was impaired. The bilingual right-handed French/Rwandan 37-year-old patient had a low-grade astrocytoma in
the postcentral gyrus for which he had previously undergone surgery at another institution. Although the patient spoke rather
slowly, no preoperative language impairment was noted.  A and B: Intraoperative images showing naming mappings in French
and Rwandan. Naming interferences (L) in both languages were found in common (Broca region) or distinct areas (supramarginal
gyrus). To improve the understanding of the intraoperative pictures, cortical sites that did not produce a naming impairment were
not systematically labeled by a sterile ticket. The blue thread indicates the rolandic sulcus. Naming “motor” interferences were
found in primary sensorimotor areas.  C: Intraoperative photograph showing singing mapping in French and Rwandan. No
singing interference was found (N) in the regions (supramarginal and opercular ramus) where the patient had a typical “speech
arrest” during naming and reading tasks. Singing interference was only found in the primary sensorimotor area.  D: Diagram
showing the French and Rwandan naming and singing interference found in this patient. Outside the sensorimotor areas, no
singing interference was detected.

tients, no singing interference was detected in supramar-
ginal, nondominant middle or inferior frontal gyrus.
Discussion
Among the human music abilities, singing is one
of the oldest, individualized in the most ancient Meso-
potamian texts of antiquity.17 However, singing is not
specifically a human function because the same type of
pitch and rhythm modulations in vocal production, im-
plying that interindividual communication exists in other
species and especially in birds.28 The brain substrates of
singing in birds is bilaterally organized, each hemisphere
contributing in a specific way to produce coordinated out-
put.28 According to researchers such as Darwin6 and Jes-
persen,15 singing has been linked to the origins of speech;
the capacity to sing precedes the capacity to speak. The
ability to sing can be a basic music function but also a
very elaborate one, using all the musical capabilities as
professional opera singers who are able to read scores and
translate them into melodies.
The Striking Independence Between Speech and Singing in
Patients With Brain Lesions
Several reports have underlined the striking possi-
bility of a functional independence between speech and
singing in patients with brain lesions in their left hemi-
sphere.4,10,29,34 The classic interpretation of these dissocia-
tions between speech and song in aphasic patients is that
singing, a particular form of automatized speech (like
prayers, lists of the days of the week or months), would
depend on the right hemisphere. Contrary to “proposi-

J. Neurosurg. / Vol 110 / February, 2009 285

 F. E. Roux, S. Borsa, and J. F. Démonet

Fig. 3.  Case 3. Example of impaired singing in the right hemisphere in a right-handed 70-year-old patient with a metastasis
close the right precentral gyrus. Two specific singing interferences (S) were found in the nondominant middle frontal gyrus. No
naming or reading interference were found in this region.  A: Three-dimensional intraoperative reconstructions of the patient’s
brain with brain mapping findings.  B: Corresponding intraoperative picture. The black line indicates the rolandic sulcus.  C
and D: Photographs of the patient’s face during singing interference. Once stimulation was applied in nondominant middle frontal
gyrus, the patient stopped singing suddenly. Note that there is no contraction of the face, lips, or tongue. F = face motor areas
within the precentral gyrus; H = hand areas (contraction of the fingers during stimulation of these 2 areas); P = face or hand
paresthesia areas found in the postcentral gyrus.

tional” speech, over-learned songs (and other kinds of au-
tomatic speech) could also rely on subcortical networks
in the left hemisphere.
The occasional differential impairment between
speech and singing is a puzzling phenomenon. In 1898,
Mann20 reported the case of a nonaphasic patient who was
a good singer and lost his capacity to sing as well as to
whistle after excision of a right middle frontal gyrus cyst.
Jossman16 described a trained musician who could not
sing (or read a score) after right carotid artery ligation,
although he was not aphasic. Kleist18 reported the case
of a right-handed man with a wound in the lower end of
the right middle frontal gyrus whose singing ability was
partially impaired. Interestingly, when this right frontal
scar was frozen by ethyl chloride he was not able to sing
at all. Alexander et al.1 observed impaired singing follow-
ing damage to the internal capsule of the nondominant
hemisphere. Finally, among 24 patients with Broca apha-
sia and severely impaired speech output, Yamadori et al.34
reported that 21 could sing with words (6 excellently). All
these clinical observations seem to indicate that singing
critically depends on right-hemisphere structures.
Nonetheless, this right hemisphere predominance in
singing has been contested. Henschen13 believed that there
was a center for singing in the pars triangularis of the Broca
area, arguing that the cases that seemed to point to a local-
ization of singing in the right hemisphere did not provide
conclusive evidence. He conceded that in the cases in which
the so-called left-sided center for singing had been destroyed,
the right hemisphere could take over its function. More re-
cently, Calvin and Ojemann5 reported the case of a man,
whose hobby was singing folk songs, who had a hemorrhage
in the anterior part of left superior temporal gyrus. This man
whose speech was pretty good, could not sing at all (“neither
tune nor words came even for his old favorite”).
Studies on Singing Function
Although studies on singing functions are rather
scarce,3,23,30,33 recent research seems to indicate the pref-
erential involvement of the right hemisphere in singing.7
Using transmagnetic cranial stimulations in 5 right-hand-
ed individuals, Stewart et al.30 showed that although stim-
ulations over some sites of the left frontal lobe disturbed
speech, patients could sing with words without problem.
Studying singing with PET in 13 right-handed individu-
als, Perry et al.23 found 2 distinct peaks of activation in
the right insula and precentral gyrus during singing. They

286 J. Neurosurg. / Vol 110 / February, 2009

Singing and cortical stimulation
hypothesized that the cerebral network involved in sing-
ing could be similar to that previously reported in speech
but with opposite hemisphere asymmetries in motor and
auditory mechanisms. With fMR imaging, Wildgruber et
al.32 showed in 10 individuals that, compared with speech,
singing produced a predominant right-sided activation of
the rolandic area. They also established that the right ro-
landic cortex controls speech prosody.33
Neurosurgery has indirectly contributed to impor-
tant breakthroughs in the understanding of music func-
tion in the brain.21 Nevertheless, neurosurgical studies
focusing on singing organization are scarce. Gordon and
Bogen9 used the Wada test in 8 patients to test speech
and singing. They found that singing was more affected
(with monotone and absence of correct pitch renderings)
than speech after right carotid artery injection. After left
injection singing was possible with clearly recognizable
pitch and rhythm while speech was deeply impaired. In
our patients, cortical stimulation data showed that the
singing interferences were always found in the precen-
tral gyri, whether on the dominant or nondominant side.
It is not surprising that direct stimulation of the tongue,
vocal folds, or face areas impaired singing as it requires
bilateral articulatory control. On the other hand, no sing-
ing interference was found in the Broca region, whereas
speech interferences were detected in this region. In the
right inferior and middle frontal gyri, results were more
contrasted; interference in singing was found only once.
The scarcity of interference sites for singing in the
present study may have several origins. First our patient
sample was small. Moreover, direct cortical stimulation
has its own limitations and might fail in detecting func-
tional areas involved in a language or cognitive process.25
Finally higher-order functions are likely characterized by
a considerable individual variability, as demonstrated by
results of cortical mapping of language processes.22 On-
ly systematic studies in which multimodality approaches
are used (such as direct cortical stimulation, stereotactic
trans­cranial magnetic stimulation, and fMR imaging) will
be able to address whether some right hemispheric premo-
tor regions, especially portions of the right middle frontal
gyrus, play a specific role in singing that would mirror the
role of the left-sided premotor areas in speech.
Conclusions
Differential impairment between speech and sing-
ing has often been described since the 19th century when
brain functions and their localizations began to be stud-
ied. Linked to the origins of speech, singing could use
different neural pathways. Frequently, when direct elec-
trostimulation is used to map brain function, high vari-
ability among patients in the functions tested is found.
For this reason, we wanted to remain prudent and not
generalize our findings in this limited group of patients to
the overall population. Nevertheless, with the high accu-
racy provided by direct cortical stimulation, we showed
that speech and singing functions could use, at least in
some stages, different cortical areas. This could explain
the differential impairments between speech and singing
de­scribed in patients who suffer from aphasia.
J. Neurosurg. / Vol 110 / February, 2009
Disclaimer
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper.
Acknowledgments
The authors thank Denise Géblé for her help in supplying them
with the references for this article. The authors are also grateful to
Cath­erine Raux for editorial assistance.
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Manuscript submitted May 14, 2007.
Accepted September 4, 2007.
Please include this information when citing this paper: published
online September 26, 2008; DOI: 10.3171/2007.9.17565.
Address correspondence to: Franck-Emmanuel Roux, M.D.,
Ph.D., Institut National de la Santé Et de la Recherche Médicale 825
et Service de Neurochirurgie, Hôpital Purpan, F-31059 Toulouse,
France. email: franck.roux@club-internet.fr.
J. Neurosurg. / Vol 110 / February, 2009