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)

Diagnosis

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

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