Andrew Blitzer

Botulinum toxin management of spasmodic dysphonia (laryngeal dystonia) : A 12-year experience in more than 900 patients

Objectives: This paper reviews a 12-year experience in more than 900 patients with spasmodic dysphonia who have been treated with botulinum toxin. Study Design: This is a retrospective analysis of patients with adductor spasmodic dysphonia (strainstrangled voice), abductor spasmodic dysphonia (whispering voice), and adductor breathing dystonia (paradoxical vocal fold motion), all of whom have been treated with botulinum toxin injections for relief of symptom. Methods: All of the patients were studied with a complete head and neck and neurologic examination; fiberoptic laryngostroboscopy; acoustic and aerodynamic measures; and a speech evaluation including the Universal spasmodic dysphonia rating scale. Some were given electromyography. All patients received botulinum toxin injections into the affected muscles under electromyographic guidance. Results: The adductor patients had an average benefit of 90% of normal function lasting an average of 15.1 weeks. The abductor patients had an average benefit of 66.7% of normal function lasting an average of 10.5 weeks. Adverse effects included mild breathiness and coughing on fluids in the adductor patients, and mild stridor in a few of the abductor patients. Conclusion: Botulinum toxin A injection of the laryngeal hyperfunctional muscles has been found over the past 12 years to be the treatment of choice to control the dystonic symptoms in most patients with spasmodic dysphonia. Laryngoscope, 108:1435–1441, 1998

Botulinum toxin: basic science and clinical uses in otolaryngology.

The role of botulinum toxin as a therapeutic agent is expanding rapidly in otolaryngology. Botulinum toxin is a protease that blocks the release of acetylcholine from nerve terminals. Its effects are transient and nondestructive, and largely limited to the area in which it is administered. These effects are also graded according to dose, allowing for individualized treatment of patients and disorders. Botulinum toxin has been used primarily to treat disorders of excessive or inappropriate muscle contraction. In the field of otolaryngology, these include spasmodic dysphonia, oromandibular dystonia, and blepharospasm; vocal tics and stuttering; cricopharyngeal achalasia; various tremors and tics; hemifacial spasm; temporomandibular joint disorders; and a number of cosmetic applications. Botulinum toxin treatment has recently begun to show some benefit in the control of pain from migraine and tension headache. It may also prove useful in the control of autonomic dysfunction, as in Frey syndrome, sialorrhea, and rhinorrhea. In over 20 years of use in humans, botulinum toxin has accumulated a considerable safety record, and in many cases represents relief for thousands of patients unaided by other therapy.

Electromyographic Findings in Focal Laryngeal Dystonia (Spastic Dysphonia)

Spastic dysphonia is a clinical speech disorder characterized by spasms of the laryngeal muscles during phonation, producing a broken pattern of speech sometimes termed laryngeal stuttering. Fourteen patients with the diagnosis of spastic dysphonia based on voice quality were referred for evaluation; detailed clinical and electrophysiologic evaluations were performed. Laryngeal electromyographic (EMG) testing failed to demonstrate any spontaneous activity in the 14 patients tested. Seven patients (50 %) had normal number and amplitude of motor unit potentials. Four of these had disparate amplitudes when compared with the other side, and two had complex motor unit potentials. The other seven patients (50 %) had abnormal findings, including three patients with abnormally increased amplitude. Two patients had asynchronous activity characteristic of a tremor disorder. One patient had synchronous bursts of activity also affecting the diaphragm, later diagnosed as pyramidal and extrapyramidal disease. One patient had bursts of activity, and later presented with diffuse myoclonus. Laryngeal EMG therefore seemed to be a more precise way of evaluating patients presenting with a tremulous voice pattern termed spastic dysphonia. Clinical observation and EMG data demonstrated that spastic dysphonia is not a “spastic” disease. We identified patients with tremor (2), pyramidal and extrapyramidal disease (1), and myoclonic disorders (1). The remainder of the patients had clinical and EMG findings consistent with dystonia, a neurologic disorder characterized by abnormal, often action-induced, involuntary movements or uncontrolled spasms. We classify these patients as having “focal laryngeal dystonia” when the disorder occurs in isolation. It may also present as a component of a generalized dystonic syndrome.

Laryngopharyngeal Dysfunction From the Implant Vagal Nerve Stimulator

Objectives/Hypothesis The objective of the study was to examine the side‐effect profile of the vagal nerve stimulator. Vagal nerve stimulators have been used to treat intractable seizures in all age groups. They provide relief to the patient with a seizure disorder by decreasing the overall number and severity of seizure activities. Although significant complications are rare, many patients have some complaint, usually of their voice.

Botulinum toxin treatment for symptomatic Frey's syndrome:

Gustatory sweating, or Freys syndrome, usually occurs after surgery or trauma to the parotid gland as a result of inappropriate parasympathetic cholinergic innervation of cutaneous sympathetic receptors. Numerous medical and surgical treatments have been proposed to prevent or treat this condition. The results, overall, have been unsatisfactory. Botulinum toxin is a relatively new treatment modality for Freys syndrome. We review the literature and present our experience with 7 patients successfully treated with intradermal injections of botulinum toxin (Botox). Our technique and dosing are described. In all treated patients gustatory sweating ceased in the area injected with botulinum toxin. In 6 patients, symptoms reappeared, and additional injections were needed up to 4 times, at 6- to 8-month intervals. All patients now have been free of symptoms for a long period of time (mean 12.1 months). We strongly recommend intradermal injections of botulinum toxin as a safe, efficacious treatment for gustatory sweating.

Adductor spasmodic dysphonia: standard evaluation of symptoms and severity

Description and quantification of the symptoms of adductor spasmodic dysphonia often reflect the clinicians knowledge of the disorder, ideas about the cause of the disorder, and personal experience. No reliable instrument that identifies and quantifies the spectrum of perceptual symptoms has been available. Therefore, we developed a standardized measure called the Unified Spasmodic Dysphonia Rating Scale (USDRS) in cooperation with a team of 118 experienced voice judges. Consensual validations of content validity guided the incremental development of the scale. Using the USDRS allows more consistent and complete data collection, both clinically and in research clinical trials.

Approaches to the patient with aspiration and swallowing disabilities

Aspiration, or soiling of the tracheobronchial tree, can produce life-threatening pulmonary disease. Intermittent or persistent aspiration may cause symptoms including cough, intermittent fever, recurrent tracheobronchitis, atelectasis, pneumonia, and/or empyema. The pulmonary disease may be associated with weight loss, cachexia, and dehydration. In many cases the aspiration is caused by laryngeal dysfunction, allowing pulmonary contamination by swallowed material. In other cases the aspiration is caused by a dysfunction of the oral, pharyngeal, or esophageal phases of swallowing. In some cases the aspiration is caused by a combination of laryngeal and swallowing dysfunction. Geriatric patients are more likely to experience aspiration, since muscle weakness causing mechanical disability and neurologic impairment are more common in this age group. Therefore, with the ever-increasing aging of our population, these disabilities will be on the rise, with an associated increase in pulmonary disease and death. The approach to evaluation and management of these disorders must be based on an understanding of the underlying functional impairment.Aspiration, or soiling of the tracheobronchial tree, can produce life-threatening pulmonary disease. Intermittent or persistent aspiration may cause symptoms including cough, intermittent fever, recurrent tracheobronchitis, atelectasis, pneumonia, and/or empyema. The pulmonary disease may be associated with weight loss, cachexia, and dehydration. In many cases the aspiration is caused by laryngeal dysfunction, allowing pulmonary contamination by swallowed material. In other cases the aspiration is caused by a dysfunction of the oral, pharyngeal, or esophageal phases of swallowing. In some cases the aspiration is caused by a combination of laryngeal and swallowing dysfunction. Geriatric patients are more likely to experience aspiration, since muscle weakness causing mechanical disability and neurologic impairment are more common in this age group. Therefore, with the ever-increasing aging of our population, these disabilities will be on the rise, with an associated increase in pulmonary disease and death. The approach to evaluation and management of these disorders must be based on an understanding of the underlying functional impairment.

Treatment of spasmodic dysphonia (laryngeal dystonia) with local injections of Botulinum toxin

Summary In 1984 the authors performed the first laryngeal injection of Botulinum toxin for laryngeal dystonia via percutaneous, electromyographically guided technique. Since that time we have treated 450 patients with adductor spasmodic dysphonia, abductor spasmodic dysphonia, and adductor breathing dystonia. In general, the adductor patients received bilateral injections of 1.25 U to 3.75 U, obtaining greater than 90% of normal voice. The abductor patients received unilateral or staged bilateral injections of the posterior cricoarytenoid muscles with 0.6 to 3.75 U, obtaining 70% of normal function. We have found laryngeal injections of Botulinum toxin to be safe and effective therapy for the symptoms of laryngeal dystonia (spasmodic dysphonia).

The dystonic larynx

Summary “Spastic Dysphonia” or spasmodic dysphonia has been shown to be a focal laryngeal form of dystonia. Review of our 2556 cases of dystonia and 562 cases of laryngeal dystonia reveals similar male/female ratio, Jewish/non-Jewish ratio, family history, EMG data, and percent focal, segmental and general cases to be the same. Patients with the adductor form have a staccato, jerky, squeezed, labored, hoarse or groaning voice. In the abductor form, patients have a breathy, effortful voice with aphonic, whispered segments of speech. Compensatory forms may confuse the diagnosis. Fiberoptic videostroboscopy, EMG, and voice spectrograms are very useful for diagnosis.

Oromandibular dystonia: long-term management with botulinum toxin.

To review the long‐term management of patients with oromandibular dystonia (OMD) treated using botulinum toxin.