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Spasmodic Dysphonia: Causes, Forms, and Treatment

Learn about the rare voice disorder Spasmodic Dysphonia (SD), its causes, manifestations, including adductor and abductor forms, and treatments such as BOTOX injections and Recurrent Laryngeal Nerve Section. Get insights into etiologic theories and FAQs about treatment.

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Spasmodic Dysphonia: Causes, Forms, and Treatment

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  1. Spasmodic Dysphonia A severe hyperadductive voice disorder

  2. The many faces of SD…. • Lalophobia • Psychophonasthenia • Mogiphonia • Apthongia • Stammer of the VF • Phonatory Glottal Spasm • Spastic Dysphonia

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

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

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

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

  7. Cause, cont.. • Trauma may trigger the onset • Medication: phenthiazines known to cause dystonias • Brin (1991) possibly a link in chromosome 9 • symptoms are thought to be the result of functioning in the basal ganglia; BG coordinates movements througout the body

  8. Forms of SD • Adductor • most common • Abductor • sudden aphonic episode • Mixed adductor/abductor • Essential Tremor??

  9. More….. • Many forms of dystonia: • belpharospasm (eyelids) • torticollis (neck) • SD is a focal (isolated) dystonia that involves one small group of muscles in one area of the body: the larynx • Most dystonias are “action induced” e.g., larynx is normal at rest, not during speaking

  10. Etiologic Theories • Psychogenic Origin • 1st described by Traube (1871) as a hysterical illness • tx included psychotherapy, acupuncture, hypnosis, biofeedback, drug treatment • Neurologic: physical cause 1st suggested by Schnitzler (1875), a Viennese laryngologist • Combination??

  11. Treatment of SD • Botulinum Toxin (BOTOX) injection • Recurrent Nerve Section • Traditional therapies

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

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

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

  15. BOTOX “side effects” • Temporary voice breathiness, • weak vocal intensive (decreased loudness) • transient difficulty with swallowing liquids (Brin, 1993)

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

  17. Bastian, cont.. • “Talking is golden” phase: 1-3 months after the weak-breathy phase ends; voice can be completely normal • “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

  18. FAQs • No 2 injections are alike even if dose and technique are the same. Maybe be due to small, unavoidable differences in needle placement • Individual differences: individual sensitivity to medication, absorption rate, etc. • Unsatisfactory response: consider alterations in the technique, dosage, timing, etc.

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