Transcript Spasmodic Dysphonia - Med Speech Voice & Swallow Center

Spasmodic Dysphonia
Presented by Jennifer Peragine
Presented to Rebecca L. Gould, MSC,
CCC-SLP
Overview
 What is spasmodic dysphonia?
 Types, symptoms, and subtypes
 Diagnosis
 Tx for adductor SD
 Voice therapy
 RLN resection
 Botox
 Tx for abductor SD
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
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
Two main classifications of
Spasmodic dysphonia
 Adductor
 Abductor
*Classifications based on perceptual
qualities*
Adductor SD
 Most common form
 Involuntary muscle spasms cause the vocal
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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
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
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)
Diagnosis
 How symptoms developed
 Rule out other causes
 Diagnostic team: ENT, SLP, Neurologist
Treatment ADD/SD
(Izdebski, 2000, pp. 438-467)
 Voice therapy
 Surgical (RLN resection)
 Pharmacological (Botox)
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)
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
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
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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
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
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
Botox
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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
What does Botox do?
 Inhibition of acetylcholine releases
 Loss of ACH receptors
 Decline of action potentials
 grated paralysis
 Functional: denervation and atrophy of
TA
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
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
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
Conclusion
 Facts about SD
 Types and subtypes
 Diagnosis
 Voice therapy
 RLN resection
 Botox injections
 Abductor SD
References
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References
Dystonia Medical Research Foundation
http://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.asp
National Spasmodic Dysphonia Association (NSDA)
Retrieved on July 6, 2005, from 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.html