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Transcript of Spasmodic Dysphonia
and Fatima Zavala Treatment
Techniques GOALS What is SD? The Patient 54 year old female
Voice problem since 1997
No history of allergies or voice disorders
13 sinus surgeries
Allergy and asthma medications
Tested negative for allergies
Doctor diagnosed...... out of breath
people can't hear me
I can't shout
I can't be heard in the drive through
People think I'm sick
"I used to sing in the church choir and teach and now I can't" Neurogenic Laryngeal Dystonia
Two Types: Adductor and Abductor
Is still not fully understood Long Term: The patient will demonstrate comprehensive knowledge of Spasmodic dysphonia and implement vocal hygiene techniques when appropriate
Short Term #1:Patient will demonstrate understanding of the vocal mechanism and intervention methods for spasmodic dysphonia by answering questions in 7/10 opportunities with no cues.
Short Term #2: Patient will demonstrate ability to use vocal hygiene techniques by performing and explaining vocal hygiene methods in 7/10 opportunities with not cues. 1. Voice Therapy
Focus: educating patients
teaching patient how to manage vocal function
2. Botulinum toxin injections
3. Selective deinnervation surgery
4. Transoral surgery
5. Bilateral thyroarytenoid myectomy Post-operative complications are minimal
Bleeding on right ventricular wound (TX: cauterized)
Granulomas on wound; disappeared within 3 – 4 months of operation
Moderate to marked improvement in speech for 12 of 13 patients in study.
Improved both perceptual assessment and subjective ratings of voice production. Discussion Partial resection of the false vocal folds.
Conducted with an operating microscope and CO2 laser.
True vocal folds become exposed.
Middle and posterior 1/3 of bilateral TA muscle and terminal fibers of RLN are vaporized. Laser Thyroarytenoid Myoneurectomy 1 -4 Weeks Post-Operation Laryngostroboscopic findings:
Aperiodic and rigid vibration patterns
Excessive arytenoid adduction
Ventricular fold hyperfunction
Tremors during phonation
Before Operation Findings Left false vocal fold and middle belly of TA muscle partially resected. Terminal fibers of RLN and muscle bundles are also resected. A) Prior to operation. B) Laser resection of left false vocal fold. C) Resection of mid-posterior belly of L. TA muscle. D) Completion of bilateral TA myotomy Laser Resection Abductor Dysphonia Adductor Dysphonia Differential Diagnosis Strain/struggle in voicing
Episodes of adduction of vocal folds during voicing
Treatment: Botox for adductor muscles Trouble with voice onset following voiceless phonemes
Episode of ABduction of vocal folds during voicing
Treatment: Botox injections for sole ABductor (two methods of injection) MD clearance
Process of elimination
Stroboscopy not helpful
Helpful phrases to diagnose What is NOT effective?
Voice Therapy with Medication (pharmaceutical) Rest vs. Exercise The Procedure What does Botox Do? Blocking Agent
Changes Neuromuscular Junction Physiology
Temporary Effects Nine Women (ages 42-76)
5 cycles of BOTOX
Exercise= reading aloud for 1 hour at loudness level that could be heard through a closed door
Data collection for all cycles
First samples showed no sign of significant differences but those in the latter portions of the injection cycle had the exercise group performing better Mendelshohn and Berke (2011) studied 77 patients who had surgery and 28 patients who had the Botox injections.
They used patient-oriented measures (VHI-10) and objectives single-blinded grading of digital voice recording as outcome measures.
Results demonstrated that the surgical patients had significantly improved voice outcomes compared to patients who had Botox injections.
The surgical group also demonstrated significantly improved voice-related functions on each VHI-10 component.
The Botox group reported that Botox successfully treats they spasmodic dysphonia; however, only 63% agreed that Botox improved their speech quality. Research Botox Injections
This surgery creates it “selective denervation” by opening a window in the thyroid cartilage so that the adductor branch of the recurrent laryngeal nerve (RLN) can be served, leaving the posterior branch intact., therefore the unaltered abductor muscle can continue normal functions.
However, in order to prevent RNL regrowth, the adductor branch is reinnervated via a direct anastomosis with a branch of the ansacervicalis. This occurs after 3-6 months and serves to maintain muscle tone and bulk while preventing RNL regrowth. Botox injections vs. Laryngeal adductor denervation-reinnervation (SLAD-R) surgery SLAD-R surgery vs. Boutlinum Toxic for adductor spasmodic dysphonia: Mendelshohn and Berke (2011) This study showed how patients who presented with ADSD were being performed bilateral thryroarytenoid myectomy under microlaryngoscopy.
There were 7 patients who underwent bilateral TA myectomy. These patients all had occupations involving vocal overuse.
Reasons why patients weren’t using BT injections was it was too expensive and the distant locations of the institution that was offering BT injection was too far. Bilateral TA myectomy under microlaryngoscopy Results indicated that spasmodic voice improved 1 month later after the operation. During the follow-up, patients had no recurrence of spasmodic dysphonia. Bilateral TA myectomy under microlaryngoscopy The bilateral TA muscles were resected and the defected site was filled with fibrin glue before the end of the operation. Bilateral TA myectomy under microlaryngoscopy However, microlaryngoscopy was performed under general anesthesia for a mucosal incision that was made on the lateral superficial surface of the vocal fold with a scalpel.
The TA muscle was exposed and separated with the vocal fold membrane using separation forceps. Bilateral TA myectomy under microlaryngoscopy Our Patient chose... Botox Injections.
Here are the before and after samples... Spasmodic dysphonia...? UTPA Comd Class 2013 Tessa MJ Kat Ellie Daniela Danilla Ana Fatima april dolly Tiffany carol christy eeman angela sarah s. sarah q. ylsse amy eva claudia Alyssa Reading Passage
Pre injections Reading Passage
Post-injections Immediately Post-Operation Laryngostroboscopic findings:
Edema in laryngeal mucosa
Slight aspiration Interview