Spasmodic Dysphonia A severe hyperadductive voice disorder

The many faces of SD…. zLalophobia zPsychophonasthenia zMogiphonia zApthongia zStammer of the VF zPhonatory Glottal Spasm zSpastic Dysphonia

What is Spasmodic Dysphonia? zA rare voice disorder affecting approx.. 50,000 people in the USA z“spasms” of the vocal folds that cause interruptions of voicing zrequires considerable effort to phonate zfrequently misdiagnosed (Aronson, 1968, Brin, 1991)

Dystonia? zSpecific cause of SD is unknown; considered to be a neruologic condition: dystonia. zDystonia is a syndrome dominated by sustained muscle contractions frequently causing twisting and repetitive movements, or abnormal postures that may be sustained or intermittent

zDuring speech, the laryngeal muscles over-contract so the voice is produced with excessive effort and force. zDystonic movements are rapid and repetitive; voice will be strained, strangled, tremulous or intermittently breathy

Suspected Cause of SD zAppears during adulthood but can start at anytime; symptoms most frequently occur in the 4th or 5th decade zCause is unknown but there is usually a sign or symptom of another Dsytonia in the body (genetic predisposition?) zRosenfeld (1990) reported a link between onset of SD and virus/bacteria

Cause, cont.. zTrauma may trigger the onset zMedication: phenthiazines known to cause dystonias zBrin (1991) possibly a link in chromosome 9 zsymptoms are thought to be the result of functioning in the basal ganglia; BG coordinates movements througout the body

Forms of SD zAdductor ymost common zAbductor ysudden aphonic episode zMixed adductor/abductor zEssential Tremor??

More….. zMany forms of dystonia: ybelpharospasm (eyelids) ytorticollis (neck) zSD is a focal (isolated) dystonia that involves one small group of muscles in one area of the body: the larynx zMost dystonias are “action induced” e.g., larynx is normal at rest, not during speaking

Etiologic Theories zPsychogenic Origin y1st described by Traube (1871) as a hysterical illness ytx included psychotherapy, acupuncture, hypnosis, biofeedback, drug treatment zNeurologic: physical cause 1st suggested by Schnitzler (1875), a Viennese laryngologist zCombination??

Treatment of SD zBotulinum Toxin (BOTOX) injection zRecurrent Nerve Section zTraditional therapies

Recurrent Laryngeal Nerve Section zDedo and Shipp: resected the RLN to resolve the hyperadductive spasm, e.g, unilateral cord paralysis would diminish the symptoms zover a 5 year period, 40-50% of patients had a relapse of symptoms

Botulinum Toxin z“BOTOX” is a protein produced by the bacterium Clostridium Botulinum; it is literally nature’s most powerful poison. zEffect is to to inhibit the synapse along the neuromuscular junction so that the overcontraction of laryngeal muscles is diminished zit blocks acetylcholine; leads to musc. weakness

BOTOX, cont.. zVery small amounts are injected into the thyroarytenoid; effect is to reduce the spasm zthe effect is temporary as the axons re- sprout to form new neuromuscular junctions zeffect produces reduced or eliminated voice symptoms (Ludlow, 1990 & Simon, 1990) zToxin lasts about 3-4 months

BOTOX “side effects” zTemporary voice breathiness, zweak vocal intensive (decreased loudness) ztransient difficulty with swallowing liquids (Brin, 1993)

BOTOX therapy (Bastian, 1994) zInitial Wait: no change in voice for initial 1-2 days post injection yspasms diminish on about the 3-4 days yvoice may vary during this time zWeak-breathy voice phase: voice is weak, breathing is inefficient for sph; some pts. Will cough on liquids

Bastian, cont.. z“Talking is golden” phase: 1-3 months after the weak-breathy phase ends; voice can be completely normal z“Spasms are back” phase: during the 2nd to 4th month, some symptoms re-appear; not immediate need but consult a calendar to consider the next injection

FAQs zNo 2 injections are alike even if dose and technique are the same. Maybe be due to small, unavoidable differences in needle placement zIndividual differences: individual sensitivity to medication, absorption rate, etc. zUnsatisfactory response: consider alterations in the technique, dosage, timing, etc.