Patient Care Voice and Airway

Multidisciplinary clinic offers a voice to patients with spasmodic dysphonia

Otolaryngologist, Matthew Rohlfing, MD (left), and Elliot H. Stein Family Professor of Neurology Joel Perlmutter, MD, discuss treatment plans for an upcoming patient.

A retired teacher of 30 years and now a volunteer tour guide at the St. Louis Zoo, Nancy Penrod has had to rely heavily on her voice, a voice that once wasn’t so reliable due to a condition called adductor laryngeal dystonia or spasmodic dysphonia.

A multidisciplinary clinic staffed by otolaryngologist Matthew Rohlfing, MD, and Elliot H. Stein Family Professor of Neurology Joel Perlmutter, MD, sees Penrod every few months to treat her condition, using injections of botulinum toxin (Botox) to weaken the laryngeal muscles that cause her voice to break.

Diagnosis requires a voice-trained specialist

Spasmodic dysphonia is a neurological condition which causes uncontrolled spasms of vocal cord muscles during voice use. The result is a voice that sounds strained or choppy, with intermittent brief stoppages in voice production.

Rohlfing explained that certain consonant sounds are more likely to cause the voice breaks, and proper diagnosis requires evaluation by a physician or speech-language pathologist with expertise in these voice patterns. Diagnosis also typically includes an exam called videostroboscopy, a high speed video evaluation of vocal fold function.

Penrod first noticed these symptoms in her mid-50s. There was no inciting event and no family history of the condition. Her voice simply starting “cracking” as she read to her students, an all-too-common task for a kindergarten-through-second grade teacher.

As her conditioned worsened, she sought medical treatment and was offered the Botox therapy. Unfortunately, that first treatment offered something less than a pleasant experience.

Correct dosage is key to success

“The first injection had terrible side effects,” she said. “I had difficult swallowing, and I didn’t want another!”

Her condition worsened however, and she reluctantly tried a second treatment a year later. With the dosage lowered, the improvement in her voice was dramatic, and without side effects.

According to Rohlfing, patients with laryngeal dystonia often respond very well to botulinum toxin injection to the vocal cord muscles involved in the spasms. Botulinum toxin is a medication that weakens, or partially paralyzes, muscles for several months at a time.

“We use very small doses of botulinum toxin to weaken the spasms, which allows the patient to have a voice that is less strained, with fewer voice breaks, and voice that is overall smoother and easier to use,” he said. “Many patients with laryngeal dystonia can have a near-normal voice when the injection is in good effect.”

The two physicians evaluate patients jointly, discuss their experience with past treatments, and collaborate on dosing. The injections are performed through the front of the neck, after numbing the overlying skin. Rohlfing performs the injection while Perlmutter monitors the EMG signals, to ensure proper placement of the injection. The injection itself often take as little as one minute to perform.

Penrod is now very comfortable with the procedure, stating it is never painful, but acknowledges the thought of a needle into the neck could be unnerving for some patients. She advises anyone with a similar condition to give it a try.

“You must have patience to get the dosage correct,” she explained. “I wouldn’t be able to give zoo tours without this treatment.”

Years of experience and new research drive patient satisfaction

For more than 35 years, the clinic has provided multidisciplinary management of neurologic voice disorders, including laryngeal dystonia, laryngeal tremor, and oromandibular dystonia (jaw spasms). In addition to diagnosis and treatment, the team also manages a number of clinical research projects investigating the causes of dystonia, which are not well understood. Patients are offered the option of participating in research studies for which they qualify.

Penrod highly recommends the procedure, and says her “experience with Drs. Rohlfing and Perlmutter has been life changing.”

To learn more about spasmodic dysphonia or to refer a patient for evaluation, please contact Matthew Rohlfing, MD.