1. Spasmodic Dysphonia Presented by Jennifer Peragine Presented to Rebecca L. Gould, MSC, CCC-SLP

2. Overview  What is spasmodic dysphonia?  Types, symptoms, and subtypes  Diagnosis  Tx for adductor SD  Voice therapy  RLN resection  Botox  Tx for abductor SD

3. 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

4. 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

5. Two main classifications of Spasmodic dysphonia  Adductor  Abductor *Classifications based on perceptual qualities*

6. 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

7. 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

8. 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)

9. Diagnosis  How symptoms developed  Rule out other causes  Diagnostic team: ENT, SLP, Neurologist

10. Treatment ADD/SD (Izdebski, 2000, pp. 438-467)  Voice therapy  Surgical (RLN resection)  Pharmacological (Botox)

11. 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)

12. 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

13. 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

14. 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

15. 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

16. 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

17. What does Botox do?  Inhibition of acetylcholine releases  Loss of ACH receptors  Decline of action potentials  grated paralysis  Functional: denervation and atrophy of TA

18. 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

19. 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

20. 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

21. Conclusion  Facts about SD  Types and subtypes  Diagnosis  Voice therapy  RLN resection  Botox injections  Abductor SD

22. References  References  Dystonia Medical Research Foundation  http://www.dystonia-foundation.org/defined/spasm.asphttp://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.asphttp://www.nidcd.nih.gov/health/voice/spasdysp.asp  National Spasmodic Dysphonia Association (NSDA)  Retrieved on July 6, 2005, from http://www.dysphonia.org/spasmodic/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.htmlhttp://www.voicedoctor.net/therapy/dystonia.html