Spasmodic Dysphonia

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Spasmodic Dysphonia

• A severe hyperadductive voice disorder

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The many faces of SD.

• Lalophobia
• Psychophonasthenia
• Mogiphonia
• Apthongia
• Stammer of the VF
• Phonatory Glottal Spasm
• Spastic Dysphonia

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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)

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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

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• 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

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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

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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

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Forms of SD

• Adductor
• most common
• Abductor
• sudden aphonic episode
• Mixed adductor/abductor
• Essential Tremor??

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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

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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??

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Treatment of SD

• Botulinum Toxin (BOTOX) injection
• Recurrent Nerve Section
• Traditional therapies

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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

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Botulinum Toxin

• BOTOX is a protein produced by the bacterium
  Clostridium Botulinum it is literally natures
  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

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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

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BOTOX side effects

• Temporary voice breathiness,
• weak vocal intensive (decreased loudness)
• transient difficulty with swallowing liquids
  (Brin, 1993)

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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

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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

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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.