The Medical Consumer's Advocate

Spasmodic dysphonia

 

Q: I have had spasmodic dysphonia for eight years now. I have had all the conventional treatments, Botox, speech therapy and before that antibiotics and steroids. {The writer mentions which institutions she has travelled to for treatment.} Basically, I was told to learn to live with it. Have there been any new and promising developments in the past couple of yrs? I believe this is a neurologic condition. Is there reason to hold out hope for a cure in my lifetime?

 

A: An excellent description of spasmodic dysphonia (SD) was provided by Dr. Critchley in 1939: the patient’s voice sounds like she is "trying to talk whilst being choked." Speech in SD has a characteristic harsh, "strangled" quality, with frequent voice breaks and overall decreased intelligibility.

SD is certainly a neurologic condition: it is considered a "focal dystonia," and indeed, it is also known by the name "laryngeal dystonia." Dystonia refers to abnormal sustained contraction of a voluntary muscle. In the case of SD, there are frequent, inappropriate contractions of the muscles that move the vocal cords.

The vocal cords ligamentous/muscular bands that are joined together at one end, forming a V. When you breathe, the vocal cords form an open V, permitting air to pass into the trachea (windpipe.) When you speak, the vocal cords move together, forming parallel strips, || , that permit relatively little air to pass. Abductor muscles open the vocal cords, while adductor muscles close the vocal cords.

Dystonia of the laryngeal adductor muscles (adductor SD) results in the symptoms described above. In abductor SD, the vocal cords open inappropriately during speech; the result is breathy, whispery speech also characterized by frequent voice breaks. Approximately 90% of SD patients have adductor SD, and 10% have abductor SD.

The only accepted treatment for SD is injection of Botulinum toxin into the dystonic muscles. Botulinum toxin (trade name, Botox) is a chemical produced by the bacteria which causes the disease botulism. Although this may sound ominous, Botox is carefully prepared and is a safe, effective drug. Botox causes a lengthy paralysis of the muscle into which it is injected. This weakens the muscle so that it contracts with less force. Usually, patients have 3 to 4 months of relief after injection with Botox. The side effects of laryngeal Botox injection include a brief period (two weeks or less) of a breathy voice, and the patient may also have problems choking on thin liquids.

Botox is, by far, the newest and most promising development to occur in the treatment of SD. As you have personally discovered, other treatments fail miserably. I am not sure why you had an unfavorable response to Botox, and I find it worrisome that you have been treated at two excellent institutions, yet have not been helped. Here are a few possibilities why you might be having such difficulty finding appropriate treatment:

1. The success of Botox injection depends critically upon the accuracy of the injection. If the toxin is not injected into the correct muscle, it will have little or no effect (or even, conceivably, a detrimental effect) on the voice. Accuracy depends heavily upon the experience of the doctor doing the injection. If you were injected by anyone other than an experienced laryngologist (an ENT who has received fellowship training in the treatment of voice problems), you may have had an inaccurate injection.

2. Perhaps you have abductor SD; if so, then the issue of physician experience is even more critical, because the injection is technically more difficult than it is for adductor SD.

3. Efficacy of Botox injection also depends upon usage of the correct dose. The toxin is somewhat fragile, and if stored under adverse conditions its strength can diminish. Ideally, it is prepared fresh and used immediately. It is also very possible that your physician used a low initial dose with the intention of increasing the dose if you did not have a good response. If you did not allow your doctor to reinject you, then you have not given Botox an adequate chance.

I encourage you to give Botox therapy another chance. Find an experienced laryngologist in your area (a medical school librarian could probably assist you in this) and insist that he or she be the one to perform the injection. Do not give up after one failed injection.

For more information, you may want to visit The Voice Center from the Eastern Virginia Medical School. This web site contains specific information on spasmodic dysphonia and Botox therapy.

 

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