Celia Stewart

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

Abductor laryngeal dystonia: A series treated with botulinum toxin

Abductor laryngeal dystonia (LD) is characterized by a hoarse voice quality which is broken up by breathy or whispered portions. Botulinum toxin injection (Botox) has been a safe and effective treatment for adductor laryngeal dystonia and is currently accepted medical therapy. As an extension of the established treatment program, in 1989 treatment of abductor LD was initiated. Thirty‐two patients have been treated by sequential percutaneous electromyogram‐guided (EMG) injections of the posterior cricoarytenoid (PCA) muscles. Most patients required treatment of both PCA muscles and improved to an average of 70% of normal voice. Patients who had a preexisting tremor, evidence of dystonia in other muscle groups, vocal tremor, or respiratory dysrhythmia had less improvement. Ten patients also required injection of the cricothyroid muscles and/or type I laryngoplasty.

Laryngeal botulinum toxin injections for disabling stuttering in adults

Stuttering is an action-induced speech disorder with involuntary, audible, or silent repetitions or prolongations in the utterance of short speech elements (sounds, syllables) and words. Symptomatic treatment programs frequently have initial success; persistent benefit is variable and many patients remain disabled. Stuttering has many characteristics similar to spasmodic dysphonia (laryngeal dystonia), often including the presence of adductor laryngeal spasms that obstruct airflow (glottal block). We hypothesized that relief of the spasmodic dysphonic glottal blocks in stutterers would modify the stuttering phenomenon and increase fluency. We therefore studied the effects of bilateral vocal fold injections of botulinum toxin type A (BTX) on dysfluency and speech characteristics in stuttering. We treated 14 adult patients (12 men, 2 women) with persistent stuttering and glottal block who previously failed standard speech therapy with 1.25 U BTX into each thyroarytenoid (vocalis) muscle. Fluency evaluations included the Stuttering Severity Instrument, the Perceptions of Stuttering Inventory, and a global rating scale (percent of normal function). Patients were evaluated at baseline and at 2-, 6-, and 12-week follow-up visits. Improvement in fluency documented by each rating instrument occurred at 2 and 6 weeks, with functional relapse by 12 weeks in most patients. We conclude that therapeutic laryngeal injections of botulinum toxin are useful in the management of stuttering with glottal block and result in a moderate improvement in fluency. When an adult patient with developmental stuttering with glottal blocks has failed speech interventional therapy and presents for treatment, a trial of BTX can be considered early. The results of BTX treatment will be known within a relatively short period of time (weeks), whereas the impact of pharmacological trials can take several months or years. Although BTX therapy does not result in normal fluency, BTX treatment is a safe, reasonable intervention to use either in isolation or in conjunction with more classic therapies or pharmacotherapy. Further study is required to evaluate long-term efficacy.

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.

Botulinum Toxin Management of Adductor Spasmodic Dysphonia after Failed Recurrent Laryngeal Nerve Section

This study examined botulinum toxin type A (BTX-A) treatment of adductor spasmodic dysphonia patients who had previously undergone recurrent laryngeal nerve section that failed to control symptoms. Information was retrieved from records of patients treated by our group between 1984 and 1999. Complete records with standardized outcome measurements were available for 181 BTX-A injection sessions in 16 patients who had had nerve section. These were compared to previously published information regarding 4,621 sessions in 639 adductor spasmodic dysphonia patients also treated by our group. Treatment with BTX-A resulted in significant improvement in voice function in the studied patients (change, 38.2% ± 24.5%; p < .0001). The onset of effect took place approximately 2.3 days after treatment, and the peak effect about 10.0 days after treatment. The therapeutic effect lasted 14.1 weeks on the average. These features were not significantly different from those observed in adductor spasmodic dysphonia patients as a whole. The incidence of complications was also comparable. However, lower baseline and peak posttreatment perceptions of voice function in the nerve section group were statistically significant (baseline, 45.6% ± 23.0% versus 52.4% ± 22.0%; peak, 83.8% ± 16.4% versus 89.7% ± 13.0%; both p < .001). We conclude that BTX-A is effective in the treatment of adductor spasmodic dysphonia in patients who have had recurrent nerve section. However, nerve section may adversely affect perceived voice function and may make botulinum toxin therapy less satisfactory. Because of this finding, and because of the unusual pathological features of the focal dystonias, irreversible means of treating adductor spasmodic dysphonia should be approached with caution.

Disorders with Excessive Muscle Contraction: Candidates for Treatment with Intramuscular Botulinum Toxin (“Botox”)

The initial clinical use of local injections of type A botulinum toxin (botox) was for the treatment of strabismus.1 The intended goal was to block acetylcholinergic neuromuscular junctions and rebalance neural input to the extraocular rectus muscles; this enhanced convergence.2 Several drugs, including alpha-bungarotoxin, had been considered prior to botox, but each had limitations. These included lack of selectivity, undesired side effects, short duration of action, and substantial antigenicity. Botox has the advantage of being apotent neuromuscular blocking agent while not suffering as many limitations as other putative therapeutic agents.

Proposed guidelines for videotaping individuals with movement disorders.

Standardized rating scales for Parkinsons disease and dystonia have been validated and are now widely accepted as useful clinical assessment tools. However, the other movement disorders have been more difficult to quantify. The use of a standardized videotape protocol can provide a more precise audiovisual record of the movement disorder patient. With broader use by others and further revisions, these guidelines can be improved in order to provide an accurate assessment and teaching tool. The authors welcome comments.

Surgical Management of Airway Dysfunction in Parkinson's Disease Compared with Parkinson-Plus Syndromes:

Objectives: We sought to compare the laryngeal symptoms of Parkinsons disease (PD) with those of multiple system atrophy (MSA), a Parkinson-plus syndrome; to review the differences in surgical management of upper airway dysfunction between patients with PD and those with MSA; and to present a treatment algorithm for management of upper airway disorders in patients with PD and MSA. Methods: We analyzed the airway manifestations of each disease, including clinical and physiological test results and management outcomes, in a case series of 30 patients (24 with PD and 6 with MSA). Results: Vocal fold atrophy causing bowing with a midfold glottic gap was common in patients with PD. One third of patients with PD underwent vocal fold augmentation with noticeable improvement in vocal volume and phonation time. Tracheostomy was required for life-threatening sleep apnea in 50% of the patients with MSA. Systemic medications and speech therapy were integral components of the management regimen. Conclusions: Surgical management of laryngeal disorders in patients with PD should focus on restoring bulk to atrophic vocal folds to minimize glottic gaps, thus improving vocalization efficiency even in the presence of impaired respiratory effort. Conversely, the autonomic dysfunction that characterizes MSA results in upper airway obstruction, and thus surgical management focuses primarily on maintaining an adequate airway, which frequently necessitates tracheostomy.

Voice Training Methods in MFA Acting Programs: Preliminary Descriptive USA Data

Abstract Little is known regarding the incidence of voice problems in student actors and the methods used to train the speaking voice in Master of Fine Arts (MFA) acting programs. To gain insight, an electronic survey was emailed to faculty members at 41 universities that offer an MFA degree in acting. Twenty-eight student responses were analyzed for reports of voice problems, vocal load, and prevalence and impressions of each speaking voice methodology. Overall, students related concern about their voice quality, but few had a medical diagnosis. Fitzmaurice Voicework and Linklater Voice were the most frequently used training methods, and instructors varied in their delivery of the approaches.