A,comparison of bilateral and unilateral botulinum toxin treatments for spasmodic dysphonia

Summary To assess the efficacy of bilateral or unilateral botulinum treatments for spasmodic dysphonia we injected botulinum toxin (type A) into the thyroarytenoid muscle of 24 patients with adductor type spasmodic dysphonia. Eleven patients underwent unilateral procedures and 13 bilateral procedures. Samples of sustained phonation were analyzed acoustically by a computer-assisted method and the air flow rates determined. All tests were conducted 1 week before injection and 1 week and 1 month after treatment. With unilateral injection, improvements in acoustic parameters occurred as early as 1 week after treatment. With bilateral injections, only the voice break factor was significantly reduced after 1 week, while standard deviations of fundamental frequency, jitter, shimmer and signal-to-noise-ratios were reduced 1 month after treatment. In comparison with unilateral injections, the mean air flow rate was twice as high 1 week after bilateral injections, with no significant differences found 1 month after treatment. Clinically, both injection modes resulted in the reduction of laryngeal spasms as early as within 48 h after injection.Portions of this work were presented at the 63th Annual Meeting of the German Society of Oto-Rhino -Laryngology-Head and Neck Surgery, Garmisch-Partenkirchen, 30 May–3 June 1992     

嗓音声学分析和电声门图的比较研究

目的比较嗓音声学分析和电声门图在嗓音障碍客观评估中的意义。方法声样采自153例嗓音障碍患者和80名嗓音正常者。客观检测采用Dr．Speech for Windows嗓音评估软件，在长元音／α：／上检测下列参数：基频(Fo)、基频微扰(jitter)、振幅微扰(shimlner)、基频标准差(FoSD)、基频震颤、振幅震颤、最大基频、最小基频、标准化噪声能量(NNE)、谐噪比(HNR)和信噪比(SNR)。主观听感知评估参数采用日本言语语音学会声音嘶哑评估GRBAS系统中的总嘶哑度，4级评估标准。结果除基频震颤和振幅震颤外，声学分析的基频微扰、振幅微扰、基频标准差、标准化噪声能量、谐噪比和信噪比的可靠性和敏感性高于电声门图。两种测试方法的基频、最大基频和最小基频基本一致。结论嗓音障碍的客观评估应选择声学分析参数。     

Effects of Botulinum Toxin Type A Injections on Aerodynamic Measures of Spasmodic Dysphonia

The effects of botulinum toxin type A (BOTOX^®) injections on aerodynamic measures of phonation were examined in 30 patients with adductor spasmodic dysphonia. Patients received bilateral injections of 2.5 U of botulinum toxin type A in each thyroarytenoid muscle. Measures of air pressure, average airflow, coefficient of variation (CV) of airflow, and laryngeal resistance were obtained before the injections and at 2 and 10 weeks after the injections. These measures were also obtained from 12 normal subjects. Compared with normal subjects, the spasmodic dysphonia patients had significantly higher preinjection values for air pressure, CV of airflow, and laryngeal resistance. At 2 and 10 weeks after the botulinum toxin type A injections, the spasmodic dysphonia patients showed a significant increase in the average airflow values and a significant decrease in the CV of airflow values and the laryngeal resistance values. At 10 weeks after the injections, the values for the three measures began to approach the preinjection values. It is concluded that these aerodynamic measures of phonation can provide useful measures of treatment outcome in adductor spasmodic dysphonia.     

Botulinum toxin management of spasmodic dysphonia (laryngeal dystonia): A 12-year experience in more than 900 patients

Objectives: This paper reviews a 12-year experience in more than 900 patients with spasmodic dysphonia who have been treated with botulinum toxin. Study Design: This is a retrospective analysis of patients with adductor spasmodic dysphonia (strainstrangled voice), abductor spasmodic dysphonia (whispering voice), and adductor breathing dystonia (paradoxical vocal fold motion), all of whom have been treated with botulinum toxin injections for relief of symptom. Methods: All of the patients were studied with a complete head and neck and neurologic examination; fiberoptic laryngostroboscopy; acoustic and aerodynamic measures; and a speech evaluation including the Universal spasmodic dysphonia rating scale. Some were given electromyography. All patients received botulinum toxin injections into the affected muscles under electromyographic guidance. Results: The adductor patients had an average benefit of 90% of normal function lasting an average of 15.1 weeks. The abductor patients had an average benefit of 66.7% of normal function lasting an average of 10.5 weeks. Adverse effects included mild breathiness and coughing on fluids in the adductor patients, and mild stridor in a few of the abductor patients. Conclusion: Botulinum toxin A injection of the laryngeal hyperfunctional muscles has been found over the past 12 years to be the treatment of choice to control the dystonic symptoms in most patients with spasmodic dysphonia. Laryngoscope, 108:1435–1441, 1998     

Effects of botulinum toxin therapy in patients with adductor spasmodic dysphonia: acoustic, aerodynamic, and videoendoscopic findings.

Botulinum toxin has been previously reported to be successful in the treatment of spasmodic dysphonia. To objectively document results, 11 patients with adductor spasmodic dysphonia who received unilateral treatment of the thyroarytenoid muscle were studied. Acoustic analyses and airflow rates during sustained phonation and flexible videoendoscopy were performed prior to, 1 week and 1 month after injection. 1. Acoustic parameters demonstrated significant voice improvement, although abnormal characteristics remained. 2. Mean airflow rates were increased 1 week after injection with almost normal values 1 month later. 3. Videolaryngoscopy showed an effective reduction of intrinsic laryngeal muscle hyperfunction with less effect on extrinsic muscle activity. Interrelations between videolaryngoscopic rating scores, acoustic results and aerodynamic results are discussed.     

Phonatory function of neurologically impaired patients.

Previous studies investigated the use of acoustic perturbation measures as a screening tool for neuropathologies with conflicting results. In the present study, five parameters of phonatory function (jitter, shimmer, signal-to-noise ratio, fundamental frequency, and standard deviation of fundamental frequency) were obtained from samples of sustained phonation in three neuropathological groups (Parkinson, Huntington, cerebellar ataxia) and a normal control group to assess the use of acoustic measures in differential diagnosis. In addition, perceptual judgements of the severity of dysphonia for each patient were obtained. The results indicated that perturbation measures of the neuropathological groups showed a higher degree of variability compared to normals. From the five parameters studied, only the standard deviation of fundamental frequency differentiated among neuropathological subgroups. The acoustic parameters studied did not clearly reflect the perceived dysphonia for all subgroups.     

Acoustic and aerodynamic measurement of speech production after supracricoid partial laryngectomy

BACKGROUND: Supracricoid partial laryngectomy (SCPL) results in laryngeal preservation in more than 95% of patients with T2 glottic carcinoma. After surgery, glottis function is characterized by an absence of vocal cords and poor glottis closure. Voice is an important postSCPL quality of life factor. OBJECTIVE: Enhance postSCPL vocal function. Obtain postsurgical acoustic and aerodynamic measurements and correlate multiple objective parameters with perceptual results. METHOD: Continuous speech voice samples from 61 patients who had undergone SCPL more than 1 year before were scored according to the global, roughness, breathiness, asthenia, and strain (GRBAS) scale by a jury of listeners. Acoustic and aerodynamic parameters were recorded: fundamental frequency (F0), intensity, jitter, shimmer, signal-to-noise ratio (SNR), signal-to-noise ratio greater than 1 kHz (SNR>1), oral airflow (OAF), maximum phonation time (MPT), and estimated subglottic pressure (ESGP). Nonparametric tests and logistic regression analysis were used to compare objective measurements and perceptual evaluations. RESULTS: All patients had various degrees of dysphonia: grade 1, 4.9%; grade 2, 55.7%; and grade 3, 39.4%. Correlations between perceptual grades and objective parameters were obtained for jitter, shimmer, SNR, SNR>1, ESGP, and OAF. No correlations were obtained between the different parameters and age, number of arytenoids, and time elapsed since surgery (TESS). Logistic regression analysis of jitter, SNR, ESGP, and OAF parameters revealed 92.6% agreement with the perceptual evaluation results.     

内收型痉挛性发音障碍的语音特征

目的 探讨内收型痉挛性发音障碍的语音特征.方法 采用嗓音和语音的声信号和三维语图分析及主观评价的方法对1O例内收型痉挛性发音障碍患者(女7例,男3例)的语音特征与10例健康志愿者(男5例,女5例)进行对比.结果 内收型痉挛性发音障碍主要表现为音质、音韵及语音的流畅性改变,在朗读文章时出现紧张性发音困难,语音颤抖,频率及响度瞬间起伏,嗓音挤卡、中断,语音延长,失去正常韵律.10例患者中表现为轻度障碍者(异常音节数<25%)1例,中度障碍(异常音节数占25%～49%)6例,重度(异常音节数占50%～74%)1例,极重度(异常音节数≥75%)2例.10例患者朗读时间中位数为49 S,声信号中间断出现无音区,无音比率中位数为42%;而健康对照组朗读时间中位数为30 S,无声音中断.在三维语图中不同的患者在各自症状音节中可以看到嗓音起始时间延长,元音共振峰不规则、断裂甚至消失,症状音节的辅音缺失,或塞擦音的擦音成分延长等.结论 内收型痉挛性发音障碍语音特征为音质、音韵及语音的流畅性改变,在症状音节的三维语图中可以看到相应的元音或辅音音素的特征性改变.     

Botulinum toxin A injection under electromyographic guidance for treatment of spasmodic dysphonia

Spasmodic dysphonia is a disabling voice condition caused by a chronic neurological disorder of central motor processing. Present therapy is directed at relief of symptoms rather than cure. Botulinum toxin type A injection into the thyroarytenoid muscle has become the pre-eminent approach for treatment of adductor spasmodic dysphonia. Botulinum toxin A injections can be performed in an out-patient setting under electromyographic guidance. We present our experience with 153 injections in 14 patients with adductor spasmodic dysphonia over a 10-year period. We demonstrate that the electromyography signal is a reliable prognostic indicator in terms of efficacy, and that patients' subjective opinion is a valid indicator of treatment success and future treatment strategy.     

痉挛性发音障碍诊断及治疗的研究

目的对痉挛性发音障碍患者临床特点,喉肌电图表现,疗效进行分析,探讨痉挛性发音障碍诊断及治疗特点。方法对22例痉挛性发音障碍患者治疗前后症状、嗓音声学特征,频闪喉镜下声带状态,喉肌电图特征进行分析;根据不同分型,应用肉毒素A行特定肌肉注射并观察疗效。结果22例痉挛性发音障碍患者中,内收肌型18例(81 8% ),外展肌型4例(18 2% )。内收肌型患者发音嘶哑,音质紧张、言语中断,发音时声带过度内收,杓间区明显,伴局部震颤; 2例患者发音时还同时伴有舌及软腭震颤;肌电图甲杓肌运动单位电位(motorunitpotential,MUP)振幅明显增加(P<0 01),干扰相呈密集束状放电,募集活动异常活跃,幅度明显增大(700~2500μV)。4例外展肌型患者发音低哑、震颤,气息声明显,发音时声门闭合不良;环杓后肌MUP振幅明显增加,在374~538μV间,募集活动异常活跃,幅度增大(3000~5000μV)。内收肌型患者应用肉毒素A进行甲杓肌注射,单侧剂量大于2 5U疗效明显。症状开始改善时间为注射后6h~2d,平均( x±s,下同)为( 1 4±0 8)d, 2周时最为明显,肌电图及喉肌诱发电位显示药物作用完全,注射肌肉失神经支配。疗效维持8~24周,平均维持(15 2±4 9)周,副作用包括不同程度的发音气息声,声门闭合不良,吞咽不适,饮水呛咳。外展肌型患者采用环杓后肌     

To study voice quality before and after thyroplasty type 1 in patients with symptomatic unilateral vocal cord paralysis

PURPOSE: The purpose of this study was to evaluate voice quality before and after thyroplasty type 1 in patients with symptomatic unilateral vocal cord paralysis. METHODS: Fifteen consecutive cases of unilateral symptomatic vocal cord paralysis of a known or idiopathic etiology with the duration of 6 months who have failed conventional speech therapy. The voice quality was assessed by perceptual evaluation, acoustic measures, and aerodynamic measures. The position of the cord was assessed by using fiberoptic laryngoscope. The procedure was done under local anesthesia. RESULTS: Among 15 patients, on the first postoperative day, 7 patients were changed to moderate dysphonia and 8 patients had a near-normal voice. On the 30th postoperative day, 3 patients had persistent moderate dysphonia, nine patients had near-normal voice, and 3 patients had normal voice. CONCLUSION: Thyroplasty type 1 successfully reduces glottic gap and improves voice quality in patients with unilateral vocal cord paralysis. Improved maximum phonation time, signal-to-noise ratio, shimmer, jitter, fundamental frequency, and intensity of voice appear to be directly related to medialization of the paralyzed vocal cord.     

Supraglottal Injection of Botulinum Toxin Type A in Adductor Type Spasmodic Dysphonia With Both Intrinsic and Extrinsic Hyperfunction

Patients with adductor type spasmodic dysphonia (SD) often exhibit both glottal and supraglottal hyperfunction. Based on the hypothesis that a “ventricular muscle” may contribute to the hyperfunction in these cases, eight patients with adductor type SD were treated with bilateral injection of botulinum toxin type A into the ventricular folds. Four weeks after injection, ventricular fold hyperfunction was absent in all cases. Number of voice breaks, standard deviation of fundamental frequency, and shimmer were significantly improved. Voice range profiles of the speaking voice were significantly extended in dynamic and frequency range. Side effects were a breathy phonation and mild swallowing difficulties without aspiration for about 1 week. Patients' self-rating concerning strangled and breathy voicing demonstrated an interval of acceptable voice quality between 1 week and 4 months after injection in all cases. Results suggest that supraglottal injection in patients with SD of both glottal and supraglottal hyperfunction, as a new approach, can normalize supraglottal activity and improve glottal voicing. Based on our experience with other patients with adductor type of SD, this injection technique is as efficient as injection into the thyroarytenoid muscle. Nevertheless, it remains to be proved that a pathologic ventricular muscle activity is addressed by this technique or if it is based on spreading to the thyroarytenoid muscle.     

Point-touch technique of botulinum toxin injection for the treatment of spasmodic dysphonia.

Intralaryngeal injections of botulinum toxin (Botox), under electromyographic guidance, have emerged as an effective treatment for adductor spasmodic dysphonia. To remain effective, these injections must be repeated every 3 to 9 months as the symptoms recur. One drawback to the current method is the need for electromyographic confirmation of needle placement into the thyroarytenoid muscle. This report describes an anatomic approach to Botox injection that requires only flexible nasopharyngeal endoscopy and careful evaluation of the anatomic landmarks. This technique has been used successfully on 13 patients, and objective pretreatment and posttreatment measures are reported.     

成人女性嗓音障碍的客观多参数分析

目的：探讨嗓音客观多参数分析与主观听感知评估的相关性，建立嗓音客观多参数评估模型，实现嗓音评估的客观化和数据化。方法：声音样本采自83例嗓音障碍患者和40例嗓音正常者，全部受试者均为女性。客观检测采用Dr．Speech Science for Windows嗓音评估软件，在长元音/α：/上测试下列参数：基频、基频微扰(jitter)、振幅微扰(shimmer)、基频标准差、基频震颤、振幅震颤、标准化噪声能量(NNE)、谐噪比(HNR)、信噪比和最大发声时间(MPT)。主观听感知评估参数采用日本言语音声学会声音嘶哑评估GRBAS系统中的总嘶哑度，4级评估标准。结果：应用逐步判别分析方法，建立了5个参数(MPT、jitter、NNE、HNR和shimmer)的嗓音客观评估模型。客观评估结果与主观评估结果的一致性达到79．8％。结论：嗓音的客观评估是多参数的；嗓音的客观多参数评估模型与主观听感知结果有较好的一致性。     

Spasmodic dysphonia in an adolescent patient with an autoimmune neurologic disorder

Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) has been primarily described in the neurology and psychiatry literature. The symptoms of this syndrome typically are a range of obsessive compulsive disorders and neuromuscular tics. The otolaryngologist occasionally becomes involved with these children when it is deemed that chronic tonsil infections are the source. We report here on a child diagnosed with PANDAS who presented with severe ventricular hyperfunction and adductor spasmodic dysphonia. She was treated with botulinum toxin, which resulted in a significant improvement in subjective voice as well as reduced jitter and shimmer on objective voice measurements.     

Findings of multiple muscle involvement in a study of 214 patients with laryngeal dystonia using fine-wire electromyography

Although perceptual and stroboscopic data help in diagnosing and classifying laryngeal dystonia, these measures do not aid the voice clinician in targeting which specific muscles to treat with botulinum toxin. Most patients achieve smoother, less effortful voicing with standard injection regimens. However, there is a notable failure rate. We performed fine-wire electromyography on 214 consecutive patients with laryngeal dystonia. We correlated voice ratings, stroboscopy data, and fine-wire electromyography data. Videostroboscopy was successful in visually demonstrating most of the audible findings in isolated vocal tremor, but it was much less successful in identifying breaks alone or a combination of breaks and tremor. Fine-wire electromyography revealed that the thyroarytenoid muscle was significantly more likely than the lateral cricoarytenoid muscle to be the predominant muscle associated with adductor spasmodic dysphonia, and that the thyroarytenoid and lateral cricoarytenoid muscles were equally likely to be predominantly involved in tremor spasmodic dysphonia. In addition, several patients in both the adductor spasmodic dysphonia and the tremor spasmodic dysphonia groups presented with interarytenoid muscle predominance. All of the intrinsic laryngeal muscles are capable of being the predominant muscle in laryngeal dystonia, and there are patterns of muscle abnormalities that differ between adductor spasmodic dysphonia and tremor spasmodic dysphonia. Some of the failures in treating adductor spasmodic dysphonia with botulinum toxin, and the greater difficulty with success in treating patients with tremor spasmodic dysphonia, are due to failure to deliver toxin to the appropriate muscles.     

Botulinum toxin for the treatment of spasmodic dysphonia

Spasmodic dysphonia is a focal laryngeal dystonia. Laryngeal dystonia presents as: adductor spasmodic dysphonia with the characteristic strain-strangle voice; abductor spasmodic dysphonia with hypophonia and breathy breaks in connected speech; and adductor respiratory dystonia with paradoxical vocal fold motion and intermittent stridor. Current treatment with periodic laryngeal intramuscular injections of botulinum toxin A has allowed patients to function more normally. In this article, the authors' treatment paradigm and experience in treating over 900 patients with laryngeal dystonia are discussed.     

Double-blind controlled study of botulinum toxin in adductor spasmodic dysphonia

The treatment of adductor spasmodic dysphonia using botulinum toxin A was conducted in 13 patients as a double-blind, placebo-controlled study. Patients were diagnosed independently by an interdisciplinary team consisting of speech pathologists, an otolaryngol-ogist, and a neurologist. The toxin or saline was injected into each thyroarytenoid muscle under electro-myographic and laryngoscopic guidance. Botulinum toxin A markedly reduced perturbation, decreased fundamental frequency range, and improved the spectrographic characteristics of the voice. Fundamental frequency and phonation time remained unchanged. Patients injected with botulinum toxin A noticed significant improvement in their voices in comparison with the placebo-treated group. Excessive breathiness of the voice occurred in two patients, and mild bleeding in one patient in the botulinum toxin A-treated group. Injection with saline resulted in edema of the vocal cord in one patient. Botulinum toxin A proved to be an effective and safe treatment of adductor spasmodic dysphonia.     

Effects of botulinum toxin on pathophysiology in spasmodic dysphonia

To determine the mechanism of symptom relief with treatment by botulinum toxin injection in persons with adductor spasmodic dysphonia (ADSD), we evaluated the effects of unilateral thyroarytenoid muscle injections on both injected and noninjected muscles in 10 subjects with ADSD, using electromyography on both sides of the larynx before and after treatment. The subjects' speech symptoms were reduced (p = .005) 2 weeks following injection, when the electromyographic study occurred. Muscle activation levels and the numbers of spasmodic muscle bursts decreased significantly (p < or = .03) postinjection in both the injected and noninjected muscles. The reductions in laryngeal muscle bursts correlated with symptom reduction (r > or = .7) in all muscles. Reductions in laryngeal muscle bursts did not relate to either absolute or normalized levels of muscle activity before or after botulinum toxin injection. The results suggest that changes in the central pathophysiology are responsible for changes in speech symptoms following treatment.     

Botox treatment in adductor spasmodic dysphonia: a meta-analysis.

Over the years many studies have been conducted to document the treatment effects of Botulinum toxin type A in adductor spasmodic dysphonia. The results of these studies have led to the view that overall Botulinum toxin treatment is moderately effective. This study reviews efficacy research qualitatively and quantitatively to determine the extent to which this conclusion is fully supported by the data. Although the data indicate moderate overall improvement as a result of Botulinum toxin treatment, they also suggest significant variation across patients, measurements, and treatment conditions. This result, together with methodological limitations and lack of standardization in BT efficacy research, justifies caution when making inferences regarding BT treatment benefit in adductor spasmodic dysphonia.