Spasmodic Dysphonia

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Spasmodic Dysphonia

• Presented by Jennifer Peragine
• Presented to Rebecca L. Gould, MSC, CCC-SLP

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Overview

• What is spasmodic dysphonia?
• Types, symptoms, and subtypes
• Diagnosis
• Tx for adductor SD
• Voice therapy
• RLN resection
• Botox
• Tx for abductor SD

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What is spasmodic dysphonia?

• Spasmodic dysphonia is one of the most frequently
  misdiagnosed conditions in speech-language
  pathology
• Psychogenic or organic?
• Cause is unknown
• Focal dystonia involving uncontrollable spasms in
  the muscles for voicing
• Basal ganglia malfunctioning

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Facts

• Onset is usually gradual
• Average age of onset is between 30 and 50
• More common in females than in males
• Some cases are hereditary (gene on chromosome 9)
• Often diagnosed following respiratory tract
  infections, laryngeal damage due to injury, and
  vocal overuse
• Symptoms worsen under stressful conditions and
  while talking on the phone

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Two main classifications of Spasmodic
dysphonia

• Adductor
• Abductor
• Classifications based on perceptual qualities

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Adductor SD

• Most common form
• Involuntary muscle spasms cause the vocal folds
  to slam together
• Stiffness of vocal folds
• Tight, strained, strangled or over pressurized
  voice (Stemple, 2000)
• Prolongation of vowel sounds
• Words are cut off or difficult to initiate due to
  spasms
• Stuttering like symptoms
• Most evident in vowels, liquids, glides

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Abductor SD

• Spasms in the PCA
• Abrupt, discontinuous escapes of air
• Inability of the TVF to close for voicing results
  in a whispered voice quality
• Voiceless consonants are prolonged
• /s/, /h/, /k/ before open vowel sound
• Difficulty coordinating speaking and breathing

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Subtypes

• Mixed
• Voice tremor (in addition to SD)
• Primary voice tremor (causes ADD/SD symptoms)
• Respiratory (abnormal adduction of vocal folds
  during breathing rather than speaking) (Thomas,
  2004)

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Diagnosis

• How symptoms developed
• Rule out other causes
• Diagnostic team ENT, SLP, Neurologist

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Treatment ADD/SD(Izdebski, 2000, pp. 438-467)

• Voice therapy
• Surgical (RLN resection)
• Pharmacological (Botox)

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Voice therapy

• Voice therapy for ADD/SD has been called
  undoubtedly the most challenging task in our
  field (Izdebski, 2000, p. 467)
• Intensive pre-TX therapy can greatly improve
  post-TX therapy outcomes
• Therapy goal reduction of main components
  responsible for ADD/SD symptoms
• TVF collision force, TVF contact area, and
  elevated subglottic air pressures (Ps)

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Successful voice therapy

• Must introduce acquisition of new voicing skills
  and patterns not characterized by overpressure
  and interruptions
• Eliminate negative effects of surgery
  (paralysis) and Botox
• Produce phonation with higher pitch, increased
  breathiness, decreased intensity

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RLN Resection

• Remove a 20 mm to 30 mm section of the RLN
• Ligature stump to prevent regrowth
• Results of surgery are a permanent unilateral
  paralysis of the VF
• Changes in voice quality are immediate
• Permanent paralysis of ipsilateral intrinsic
  muscles except cricothyroid
• Elevated pitch used in therapy
• Extrinsic muscles are intact allowing movement of
  larynx in swallowing/voicing
• Voice therapy should begin ASAP

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Post-paralytic TX

• Voice therapy should preserve an ideal, minimal
  glottal gap of or 1 to 1.5 mm
• Semiparamedian to median position of paralytic
  TVF
• Traditional pushing exercises can push paralyzed
  fold too far laterally breathiness or too far
  toward midline recurrence of ADD/SD symptoms
• Phonatory closure for voicing

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Steps of Therapy for RLN (Izdebski, 2000, pp.
447-449)

• Preoperative involvement with patient including
  voice evaluation, counseling, and introduce
  post-TX therapy principles
• Visit patient night before surgery in the
  hospital
• Visit patient in the recovery room in hospital
  (dysphagia, patient and family interaction,
  observe new voice quality)
• Actual voice therapy should start ASAP following
  patient discharge from hospital

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Botox

• Botulinum-A toxin
• Injections into the body of the vocal fold (TA)
• Unilateral or bilateral
• Needle through skin, cricothyroid membrane, into
  the midportion of TA
• Voice of patient monitored by EMG- acoustic
  monitoring system (accuracy of placement, target
  muscle)
• Second option is performed by ENT, syringe placed
  through oral cavity to the larynx
• TVF visualized using a laryngeal mirror

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What does Botox do?

• Inhibition of acetylcholine releases
• Loss of ACH receptors
• Decline of action potentials
• grated paralysis
• Functional denervation and atrophy of TA

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Post Botox

• Edema in TA can occur (3 days)
• Targeted muscle
• Adduction/abduction continues
• Post-injection acoustic variables of the voice
  depend on the degree of weakening caused by the
  Botox
• Decreased activation level for muscle
  contractions and bowing of the injected TVF
• Decrease in glottic compression reduces the force
  of adduction (no slamming)
• Incomplete glottic closure allows for the
  reduction of subglottic air pressure and
  increased air flow

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Recurrence of ADD/SD symptoms

• Not if but when
• Botox regeneration of ACH synaptic contacts and
  muscle gradually regenerates
• RLN resection positioning of paralyzed TVF too
  close to midline
• Expected because TX addresses symptoms and not
  the core disorder

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Abductor SD

• Research indicates that voice therapy is not
  effective in alleviating symptoms
• Voicing on inhalation may be an viable option
  includes relaxation of jaw, tongue posturing, and
  extrinsic neck musculature (Shulman, 2000)
• Some patients have benefited from Botox
  injections into the PCA (Blitzer Stewart, 2000)
• Danger of airway compromise

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Conclusion

• Facts about SD
• Types and subtypes
• Diagnosis
• Voice therapy
• RLN resection
• Botox injections
• Abductor SD

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References

• References
• Dystonia Medical Research Foundation
• http//www.dystonia-foundation.org/defined/sp
  asm.asp
• Blitzer, A. Stewart, C.F., (2000). Management
  of Abductor Spasmodic Dysphonia,
• Voice Therapy Clinical Studies (pp.
  467-478). Clifton, New York Thompson
• Learning.
• Izdebski, K., (2000). Surgical and Medical
  Treatment and Voice Therapy for Spasmodic
• Dysphonia, Voice Therapy Clinical Studies
  (pp.438-467). Clifton, New York
• Thompson Learning.
• National Institute on Deafness and Other
  Communication Disorders (NIDCD)
• Retrieved on July 6, 2005, from
• http//www.nidcd.nih.gov/health/voice/spasdys
  p.asp
• National Spasmodic Dysphonia Association (NSDA)
• Retrieved on July 6, 2005, from
  http//www.dysphonia.org/spasmodic/
• Shulman, S., (2000). Symptom Modification for
  Spasmodic Dysphonia Inhalation
• Phonation, Voice Therapy Clinical Studies
  (pp.479-486). Clifton, New York
• Thompson Learning.
• Stemple, J.C., (2000). Management Approaches for
  Spasmodic Dysphonia, Voice
• Therapy Clinical Studies (pp.431-437).
  Clifton, New York Thompson Learning.