Analysis of spasmodic dysphonia by aerodynamic and laryngostroboscopic measurements

Sequential assessment of laryngeal function using laryngostroboscopy and phonatory air flow assessment was carried out in 18 patients with spasmodic dysphonia (SD). Comparison was made between findings in patients before treatment (n = 18), after unilateral recurrent nerve block by lidocaine (n = 6), after bilateral injections of botulinum toxin (Botox) (n = 13), and prior to Botox reinjection (n = 3). Unilateral nerve block resulted in higher mean phonatory airflows than after bilateral Botox injections. Both unilateral nerve block and Botox injections increased fluctuant or alternating flow source (AC); however, unilateral nerve block resulted in more unmodulated airflow leakage. Phonation time on a single breath was longer than with Botox injection. Bilateral Botox injections resulted in better glottal closure, fewer instances of vocal fold level differences, and, better vocal fold vibrations with phase symmetry, as determined by laryngostroboscopy. Partial bilateral denervation using Botox resulted in laryngeal function, which appeared to be intermediate between that of tightly squeezed pretreatment status and a breathy voice with incomplete adduction after unilateral nerve block. Of all treatments assessed, bilateral partial denervation by Botox appeared to be the most physiologic in restoring normal vocal fold vibratory function and airflow.     

A comparison of injection techniques using botulinum toxin injection for treatment of the spasmodic dysphonias

The benefit duration and side effects following effective treatment of spasmodic dysphonia or voice tremor using botulinum toxin injection were studied following 477 open trial unilateral or bilateral injections provided to 178 patients. A comparison of unilateral and bilateral injections in male and female patients with adductor spasmodic dysphonia demonstrated an increased benefit duration following unilateral injections in women, longer periods of breathiness in men than in women following bilateral or unilateral injections, and a trend for reduced benefit durations following repeated treatments using bilateral injections. Outcomes were similar in the adductor spasmodic dysphonia and vocal tremor groups following thyroarytenoid injection while benefit durations were reduced and side effects lasted longer in patients with abductor spasmodic dysphonia following cricothyroid injections. Long-term benefit > 1 year occurred in 12.3% of patients following injection.     

Combined-modality treatment of adductor spasmodic dysphonia with botulinum toxin and voice therapy

A combined-modality treatment program consisting of botulinum toxin injection (Botox) and voice therapy was used to treat 17 subjects diagnosed with adductor spasmodic dysphonia (ADD SD). Ten subjects with ADD SD served as the control and were given Botox only. Voice therapy after Botox injection was directed toward reducing the hyperfunctional vocal behaviors, primarily glottal overpressure at voice onset and anterior-posterior squeezing. The results indicated that subjects who underwent combined-modality treatment maintained significantly higher mean airflow rates for significantly longer periods. Moreover, there was a carryover effect in these patients when they received Botox only. Adductor spasmodic dysphonia is treated most effectively when intrinsic laryngeal muscle spasms are reduced or eliminated by Botox injection and extrinsic hyperfunctional vocal behaviors are treated with voice therapy     

Unilateral Versus Bilateral Injections of Botulinum Toxin in Patients with Adductor Spasmodic Dysphonia

Both unilateral and bilateral thyroarytenoid muscle injections of Botox provide effective management of voice symptoms in patients with adductor spasmodic dysphonia; however, the preferred injection technique has not been established. In this study, 16 patients were treated with unilateral injections (72 injections total) and 33 patients were managed with bilateral injections (133 injections total). Individual assignments to injection type were based on treatment previously received and dose was adjusted according to the patient's previous treatment response. An optimal treatment included a benefit lasting 3 months or more with side effects lasting 2 weeks or less. Compared to patients receiving bilateral injections, those receiving unilateral injections more frequently noted a benefit of 3 months or more (p = 0.03), side effects of 2 weeks or less duration (p = 0.03), as well as both a 3-month benefit and a 2-week or less side effect (p = 0.0004). Injection type had no effect on optimal Botox dosing with repeat injections. Successive unilateral injections at the same dose were more likely (p = 0.012) than successive bilateral injections to produce the same or longer duration of benefit. We conclude that a unilateral injection routine has a more optimal and consistent treatment effect/side effect profile.     

The Effect of Botulinum Toxin A on the Vocal Symptoms of Spastic Dysarthria: A Case Study

The vocal symptoms of spastic dysarthria and spasmodic dysphonia have many similar features. Botulinum toxin has been used effectively to treat spasmodic dysphonia. This study was designed to determine what vocal changes occur in an individual with spastic dysarthria following Botulinum toxin A injection into the thyroarytenoid muscles. Measures were obtained preinjection and three times postinjection. Acoustic and aerodynamic results were comparable to those reported for individuals with spasmodic dysphonia. The most marked change was increased DC airflow. Despite persistent breathiness, the participant reported great satisfaction with the result, particularly because of her more appropriate loudness. In addition, everyday listeners perceived significantly less listener burden and more relaxed and pleasant vocal quality postinjection.     

Bilateral vocal fold paralysis: an unsual treatment with botulinum toxin

We presented a patient with bilateral vocal fold paralysis treated with intralaryngeal Botox injection to improve the glottal airway. The use of Botox in this manner has not been previously reported and highlights the value and role of intralaryngeal Botox in changing the configuration of the glottis. The concept and various approaches for using Botox to alter pathologic vocal fold position is reviewed and discussed.     

Does botulinum toxin alter laryngeal secretionsand mucociliary transport?

Localized botulinum toxin injection disrupts cholinergic transmissionand has potential to cause focal dysautonomia. Mucociliary transport and laryngeal secretions are thought to be mediated in part by autonomic, cholinergic transmission. We questioned whether patients who receive Botox® injection for adductor spasmodic dysphonia (ADSD) report postinjection symptoms possibly related to altered mucociliary clearance or laryngeal secretions. Medical histories, audiotaped interviews, and symptom ratings were retrospectively examined for 29 patients with ADSD who were followed after one or more Botox injections. Patients had received bilateral, percutaneous Botox injections of 2.5 units using an EMG-guided approach. One or more weeks after injection, four patients reported either burning, tickling, or irritation of the larynx/throat, excessive thick secretions, or dryness. Symptoms recurred with subsequent injections in two patients and were not associated with swallowing difficulty. These symptoms are consistent with, but not diagnostic of, the known effects of botulinum toxin on cholinergic, autonomic transmission.     

Effect of a Single Injection of Basic Fibroblast Growth Factor into the Vocal Folds: A 36-Month Clinical Study

ObjectiveA single injection of basic fibroblast growth factor (bFGF) into the vocal folds of patients with glottal insufficiency has been shown to be effective for a few years. However, the long-term therapeutic effect of a single injection of bFGF into the vocal folds has yet to be demonstrated. In this study, the therapeutic effect of a single injection of bFGF into the vocal folds was investigated over several years by monitoring patients for 36 months following this treatment.MethodsNineteen patients with glottal insufficiency received injections of bFGF diluted to 20 μg/mL in the superficial layer of the lamina propria of the bilateral vocal folds. The following parameters were evaluated at preinjection baseline and 6, 12, 18, 24, and 36 months later, and statistical comparisons were performed. The parameters evaluated were: the Grade, Rough, Breathy, Asthenic, and Strained (GRBAS) scale score; maximum phonation time; acoustic analysis; and glottal wave analysis (GWA) and kymograph edge analysis (KEA) using high-speed digital imaging (HSDI). The amplitude perturbation quotient (APQ) and period perturbation quotient (PPQ) were measured by acoustic analysis. The mean minimum glottal area during vocalization and mean minimum distance between the vocal folds were measured by GWA. The amplitudes of the bilateral vocal folds were measured by KEA.ResultsPostinjection, the GRBAS scale score decreased from 6 months after injection, and maximum phonation time was prolonged. The mean minimum glottal area during vocalization and the mean minimum distance between the vocal folds calculated by GWA of HSDI decreased significantly after 6 months. These effects persisted until 36 months postinjection. APQ and PPQ derived from acoustic analysis tended to decrease, but not significantly. There was no clear change in the amplitudes of the bilateral vocal folds calculated by KEA of HSDI before and after injection.ConclusionsThese results suggest that the effects of a single injection of bFGF into the vocal folds persist for 36 months.     

Botox for hyperadduction of the false vocal folds: A case report

We present a patient with severe hyperadduction of the false vocal folds (FVF) treated with Botulinum Toxin injections to each FVF. This patient presented with severe dysphonia and was found to demonstrate severe hyperadduction of the FVF's with all phonatory tasks. The patient was treated with extensive speech therapy without improvement in voice quality nor FVF motion pattern. He was then injected with Botox A bilaterally using a peroral approach to the FVFs. Shortly after treatment the patient experienced dramatic improvement in voice quality. Videolaryngoscopy revealed no adduction of the FVFs with phonation and essentially normal true vocal fold motion. He remained with normal voice quality one year after treatment without any further treatment. Possible mechanism of action of this type of treatment are discussed.     

Electroglottographic tracking of phonatory response to botox™

Botox injection into the thyroarytenoid muscle is thought to alter the glottal competence and laryngeal adduction of patients with adductor spasmodic dysphonia (ADSD). Hypofunctional responses to treatment have been rated subjectively and inferred from postinjection breathy voice, aphonia, midline glottal gap, or subclinical aspiration. Clinical experience suggests that temporary hypofunction varies in duration and severity among patients. This study used electroglottographic measures to examine changes over time in glottal competence during the relatively stable phonation produced by 5 patients with ADSD. Hierarchical linear modeling was used to test 3 hypotheses: (a) that reduced laryngeal adduction would occur during the first 3 weeks postinjection, followed by a reversal; (b) that patients' hypofunctional response curves would differ one from another; and (c) that changes in adduction, if present, would be related to changes in severity ratings of ADSD symptoms. For 3 participants, significant hypoadduction occurred after injection and reversed toward preinjection level over an 8-week period. Two participants demonstrated a flat or increasing vocal fold contact response curve during the early postinjection period. Observations were consistent with the previously reported differences and possibly complex relation between the resolution of breathy hypofunction and ultimate return of ADSD symptoms.     

Electroglottographic tracking of phonatory response to Botox.

Botox injection into the thyroarytenoid muscle is thought to alter the glottal competence and laryngeal adduction of patients with adductor spasmodic dysphonia (ADSD). Hypofunctional responses to treatment have been rated subjectively and inferred from postinjection breathy voice, aphonia, midline glottal gap, or subclinical aspiration. Clinical experience suggests that temporary hypofunction varies in duration and severity among patients. This study used electroglottographic measures to examine changes over time in glottal competence during the relatively stable phonation produced by 5 patients with ADSD. Hierarchical linear modeling was used to test 3 hypotheses: (a) that reduced laryngeal adduction would occur during the first 3 weeks postinjection, followed by a reversal; (b) that patients' hypofunctional response curves would differ one from another; and (c) that changes in adduction, if present, would be related to changes in severity ratings of ADSD symptoms. For 3 participants, significant hypoadduction occurred after injection and reversed toward preinjection level over an 8-week period. Two participants demonstrated a flat or increasing vocal fold contact response curve during the early postinjection period. Observations were consistent with the previously reported differences and possibly complex relation between the resolution of breathy hypofunction and ultimate return of ADSD symptoms.     

The use of an auditory model in predicting perceptual ratings of breathy voice quality

Despite much research, the relationship between vocal acoustic signals and perceived voice quality is not well understood. The present study used an auditory model proposed by Moore et al¹⁰ to study how changes in the acoustic spectrum may relate to changes in perceptual ratings of breathiness. Perceptual ratings of breathiness were obtained using a multidimensional scaling (MDS) design. The stimulus distances on the dominant MDS dimension were correlated with several commonly used acoustic measures for voice quality. These distances were also compared with measures obtained from the output of the auditory model. Results show that the partial loudness of the harmonic energy obtained with the aspiration noise acting as a masker was the most important predictor of perceptual ratings of breathiness. Results also demonstrate that measures obtained from the auditory spectrum were better predictors of perceptual ratings of breathiness than were commonly used acoustic spectral measures.     

Analysis of factors affecting botulinum toxin results in spasmodic dysphonia

This study was designed to investigate how variations in patterns of injection could improve the efficacy of botulinum toxin injections in relieving the symptoms of adductor spasmodic dysphonia. A total of 64 adductor spasmodic dysphonia patients who were injected using indirect laryngoscopic localization (for a total of 426 injections) were analyzed retrospectively using their own subjective data on duration of voice improvement, optimal voice improvement, breathiness side effects, and intervals between treatments. Injection to both the thyroarytenoid (TA) and the lateral cricoarytenoid (LCA) simultaneously gave the best voice results; the overall improvement from baseline was the longest lasting, and the period during which the voice was the best was the longest lasting. TA + LCA also gave the shortest duration of undesirable breathiness side effect. On the basis of these data, it seems reasonable to recommend that initial botulinum toxin therapy for adductor spasmodic dysphonia patients should be a single unilateral injection placed strategically at the posterior portion of the TA and directed toward the LCA so that both muscle groups are affected.     

Spasmodic dysphonia symptoms as initial presentation of amyotrophic lateral sclerosis

A patient initially diagnosed with adductor-type spasmodic dysphonia was referred for botulinum toxin (Botox) injections, but found on subsequent evaluation to have amyotrophic lateral sclerosis, and therefore Botox was not administered. This unique case underscores the need to delay botulinum toxin treatments in any patient with recent onset symptoms, and to obtain thorough motor speech and voice, otolaryngologic, and neurologic evaluation in all patients prior to consideration for injection.     

Voice Handicap Index Results for Older Patients with Adductor Spasmodic Dysphonia

Adductor spasmodic dysphonia (ADSD) adversely affects a speaker's ability to effectively communicate. For many individuals suffering with ADSD, botulinum toxin (Botox) is the chosen treatment to remediate the symptoms. Although Botox's effects on symptom remediation have been examined before, patient perception of improvement post-Botox has been examined less frequently. Further, no studies have addressed the symptomatic changes in older adults that occur after Botox treatment. The Voice Handicap Index (VHI) was used as the instrument to assess older patient's (>65 years) perception of how ADSD impacts certain areas of their life pre- and post-Botox injection. The outcome of the VHI was related to a clinical judgment of voice severity. Participants also completed the Social Readjustment Rating Scale (SRRS) to examine overall stress level, and the outcome of the SRRS was correlated to postinjection VHI scores. Results indicated no significant correlation between VHI scores and voice severity or SRRS ratings. The current study suggests further study of voice outcomes with older adults with ADSD is needed.     

Complications of collagen injection of the vocal fold: report of several unusual cases and review of the literature

Injection laryngoplasty is one of the most frequently performed procedures in patients with voice complaints. Various biomaterials have been used to medialize vocal folds or to treat symptoms of vocal fold scar. The ideal biomaterial would be easily injected through a fine-gauge needle, well tolerated, and long lasting. Injectable collagen preparations fulfill at least two of these criteria, and collagen has been used widely for vocal fold injections. MATERIALS AND METHODS: We present a retrospective review of two unusual complications of collagen injection and a review of the relevant literature on the complications of medical use of collagen compounds. RESULTS: Two patients in whom collagen was injected formed firm submucosal deposits that interrupted the normal mucosal wave and produced significant dysphonia. Surgical removal of these deposits restored the mucosal wave and improved voice quality. Management of this unusual complication of human collagen injection in the vocal fold has not been reported previously. Other complications of collagen injection include hypersensitivity reactions to bovine collagen, local abscess formation at injection sites, and possibly induction of collagen vascular disease in some patients. CONCLUSIONS: Although collagen injections of the vocal fold rarely result in complications, physicians using collagen must be familiar with the types of complications that can occur. Proper diagnosis and prompt management of complications can result in good outcomes.     

Quantitative color analysis of laryngeal erythemain chronic posterior laryngitis

The purpose of this study was to quantitatively analyze the degree of erythema visible in the larynges of normal subjects and of patients with symptoms of chronic posterior laryngitis. Video-documented examinations of laryngoscopy were digitized and then analyzed using computer image analysis software that allowed quantification of average color values, hue, saturation, and brightness from digitized color images. Documented laryngoscopic images from 7 normal subjects and 64 patients complaining of chronic laryngitis symptoms were examined, and additional patient examinations which were obtained and documented during treatment for reflux laryngitis were analyzed. Analysis was made of five different areas of each laryngeal image: the right and left vocal folds, the right and left vocal processes, and the posterior arytenoid mucosa. Data analysis showed that average color value ratings of redness for the patients with chronic laryngitis were significantly (p <0 .0561) greater than the average values for normal subjects for the vocal folds. Color values for redness of the posterior laryngeal structures and vocal folds in the patients who were treated for reflux laryngitis were significantly (p < 0.05) reduced over time and correlated with the clinical response to treatment. The data suggest that computer color analysis of documented video-laryngoscopy examinations can provide quantitative data on degree of erythema and may be useful as a quantitative means of diagnosis and documentation of treatment outcome for reflux laryngitis.     

Statistical analyses of electromyographic activity in spasmodic dysphonic and normal control subjects

Heterogeneity in the quality and task sensitivity of vocal symptoms in the spasmodic dysphonia (SD) population contributes to controversy as to whether this is a single disorder or two disorders with different etiologies (neurogenic versus psychogenic). Perceptual and acoustic assessments of vocal symptoms are inadequate to resolve this controversy. However, myoelectric events are intimately proximal to the source of vocal disruption and may be informative. The present report employs statistical modeling of quantitative amplitude measures of electromyographic activity recorded from thyroarytenoid to examine neuromotor bases of vocal symptoms in SD. Consideration of perceptual ratings of the quality and task sensitivity of vocal symptoms in the context of statistical models provides support for the conclusion that the range of vocal symptoms identified as SD represents a single, neurogenic disorder.     

Arytenoid Cartilage Dislocation: A 20-year Experience

SUMMARY: Arytenoid cartilage dislocation is an infrequently diagnosed cause of vocal fold immobility. Seventy-four cases have been reported in the literature to date. Intubation is the most common origin, followed by external laryngeal trauma. Decreased volume and breathiness are the most common presenting symptoms. We report on 63 patients with arytenoid cartilage dislocation treated by the senior author (RTS) since 1983. Significantly more posterior than anterior dislocations were represented. Although reestablishing joint mobility is difficult, endoscopic reduction should be considered to align the heights of the vocal processes. This process may result in significant voice improvement even long after the dislocation. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography (CT) imaging are helpful in the evaluation of patients with vocal fold immobility to help distinguish arytenoid cartilage dislocation from vocal fold paralysis. Familiarity with signs and symptoms of arytenoid cartilage dislocation and current treatment techniques improves the chances for optimal therapeutic results.