Download - Spasmodic Dysphonia Presented by Jennifer Peragine Presented to Rebecca L. Gould, MSC, CCC-SLP
Overview
What is spasmodic dysphonia? Types, symptoms, and subtypes Diagnosis Tx for adductor SD Voice therapy RLN resection Botox Tx for abductor SD
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
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
Two main classifications of Spasmodic dysphonia
Adductor Abductor
*Classifications based on perceptual qualities*
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
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
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)
Treatment ADD/SD(Izdebski, 2000, pp. 438-467)
Voice therapy Surgical (RLN resection) Pharmacological (Botox)
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)
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
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
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
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
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
What does Botox do?
Inhibition of acetylcholine releases Loss of ACH receptors Decline of action potentials grated paralysis Functional: denervation and atrophy of
TA
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
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
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
Conclusion
Facts about SD Types and subtypes Diagnosis Voice therapy RLN resection Botox injections Abductor SD
References
References Dystonia Medical Research Foundation http://www.dystonia-foundation.org/defined/spasm.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/spasdysp.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. Thomas, J.P., (2005). Spasmodic Dysphonia, retrieved on July 6, 2005, from http://www.voicedoctor.net/therapy/dystonia.html