Voice disorders Spasmodic Dysphonia - School of Medicine

Voice disorders –Spasmodic
Dysphonia

Jason Goodwin
Matt Page

Overview

• Laryngeal anatomy and function
• Assessing voice
• Voice disorders

– Adductor spasmodic dysphonia
– Abductor spasmodic dysphonia

• SD Treatments

Anatomy: Laryngeal Muscles

Netter

Anatomy: Laryngeal Muscles

Netter

Anatomy: Laryngeal Motion

• Abduction of vocal ligament

Netter

Anatomy: Laryngeal Motion

• Adduction of vocal ligament

Netter

Anatomy: Laryngeal Motion

• Tension of vocal ligament

Netter



Dysphonia

• Alteration in production of voice that impairs
social and professional communication

• Nearly 1/3 of population has impaired voice at
some point in their lives

• Most often benign but may be presenting
symptom of malignant condition

Dysphonia

• 30% of population affected at some point

– Higher in teachers, telemarketers, aerobics
instructors, ie those who use their voice professionally

– Women 60%, men 40%
– Children affected 4-23%
– Elderly 30-47%

• Estimated $2.5 billion in missed work costs
• 6% general population seek treatment

– 14% teachers

Voice evaluation

• Multi-dimensional. Use of SLP is helpful
• History is critical component
• Patient’s perception of problem is critical
• Perceptual evaluation

– GRBAS, CAPE-V

• Physical examination

History



Voice evaluation

• Physicians usually not experts in voice
classification, singing, etc.

• Most often relies on perception of physician

– Some objective scoring measures
– Poor inter-rater correlation

• Team approach

– Speech pathologist, vocal coaches, neurologist,
psychiatrist, etc.





GRBAS

• No standardized utterances
• Scale from 0(none) to 3(severe)

CAPE-V

• Six core parameters

– Severity
– Roughness
– Breathiness
– Strain
– Pitch
– Loudness

• Two sustained vowels
• 6 standard sentences
• 20 seconds of natural running speech

CAPE-V

• Two vowels

– \a\ and \i\

• Standard sentences

– The blue spot is on the key again
– How hard did he hit him?
– We were away a year ago
– We eat eggs every Easter
– My mama makes lemon jam
– Peter will keep at the peak.

• 20 secs of running speech

– “Tell me about your voice problem”



Physical examination

• Hearing acuity
• Allergic signs
• Neck- masses, thyroid, scars, strap muscle

tension and tenderness, laryngeal mobility
• Cranial nerves
• Laryngeal examination
• Be aware of systemic disorders that can affect

larynx

– Neurologic disorders, infectious, autoimmune

Video

Spasmodic Dysphonia

• Spasmodic dysphonia (SD)

– Focal, adult-onset dystonia of laryngeal muscles
– Intermittent phonatory breaks during speech

secondary to spasms
– Usually task specific - symptomatic when

attempting voluntary speech
– May be asymptomatic during reflexive phonation

(coughing, laughing, crying, yawning)
– Symptoms may be reduced/absent during singing

or whisper

Spasmodic Dysphonia

• Rare (1:100,000)

– Maybe underdiagnosed

• Often confused with MTD
• Female predominant

– Up to 80% reported

• Unknown mechanism
• Up to 20% may have another dystonia

Spasmodic Dysphonia

• Adductor SD

– Most common SD (85-90%)
– Spasm of adductor muscles causing vocal cords to

tightly shut during speech
– Typically occurs with efforts to voice words

beginning with vowels or in vowels in the middle
of a word
– “We eat eggs every day”

Adductor SD Video

Abductor SD

• Less common 10-15% of all SD cases
• Spasm of posterior cricoarytenoid muscle

during speech, causing breathy breaks during
speech.
• Typically occurs with “f”, “s”, “th”, “h”, “k”, “t”
sounds

Abductor SD Video

SD treatment options

• Voice therapy
• Medical therapy
• Surgical therapy



Voice Therapy

• No demonstrated effectiveness in treating SD
• May help:

– Rule out psychogenic/functional disorder
– Provide support for those who do not benefit from

Botox (mild symptoms)
– Some patients use it in adjunct to Botox to prolong

symptom free period

• Traditional voice therapy approaches for ADSD employ techniques for avoiding
overpressure. Breathy voice onsets, reduced speech force, using a head focus, and
laryngeal manipulation are aimed at reducing laryngeal tension. Can also use relaxation
and respiration training to help gain insight and control of laryngeal tension during

speech.

Medical therapy for SD

• No controlled studies demonstrate effective
symptom control

• Beta blockers – propranolol
• Anticholinergics – trihexyphenidylHCl (Artane)
• Benzodiazepines – diazepam, alprazolam
• Role has been to provide relief without any

demonstrable symptom reduction

Botox injection for SD

• Currently the gold standard for treatment of both AB- and AD- ductor SD
• For adductor type typical injection into bilateral thyroarytenoid muscles.

– Dosing is patient specific (0.625 to 2.5 unit or more). Initial dosing of 1.25 U/
side and titrate

– Most studies show 90%+ with voice improvement
– Average length of voice improvement: 3-4 months
– Initial period of breathiness and possible liquid aspiration from 7-15 days

(dose dependent)

• Abductor SD inject into PCA

– May stage this if concerns about knocking out bilateral PCA – lower dose to
second side

– Higher initial dosing (3.5 U recommended, then 1 unit to contralateral side)
– Lower response rate (70-80%, only 20-25% if done unilaterally)
– Adjunctive voice therapy or medication may help

Botox injections

Advantages Disadvantages
• Readily available
• Technically easy • Not permanent
• Minimally invasive • Risk of overdose
• Repeatable • Side effects
• Titratable
• Gold standard – Worsened voice
– Aspiration

• Rare chance of resistance

Injection technique for Adductor SD

Injection technique for Abductor SD

Surgical therapy

• Recurrent laryngeal nerve section first proposed
by Dedo in 1976

• Uncommonly done, but can be reserved for those
failing Botox

• General steps

– Expose larynx
– Open window in thyroid cartilage to expose RLN
– Selective sectioning of nerve along its distal branches
– Anastomosis of ansa cervicalis to stump

RLN section

Bottom Line

• Hoarseness and dysphonia is highly prevalent
and you will see this patients

• Goal is to rule out something more severe and
hopefully come up with distinct diagnosis for
treatment

• Stress interdisciplinary approach to treatment
• Certain dysphonias can be helped with

intervention

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