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BOTOX injection

(botulinum toxin)

Ways of injecting BOTOX

Surgical Approach

Laryngeal electromyography (most common)

Adductor

Abductor

Oral Laryngoscopy

Nasopharyngoscopy

  • Main treatment alongside voice therapy
  • Targets the prevention of the release of acetylcholine which stops muscle contraction.
  • BOTOX naturally weakens the muscle.
  • Three ways of injecting BOTOX
  • Three main phases:

Point-Touch technique

  • Denervating the recurrent laryngeal nerve.
  • Last Resort if therapy does not work.
  • Spasms causing vocal folds to open.
  • Cannot vibrate, allows air to escape in speech creating a breathy voice.
  • Less common than Adductor Spasmodic Dysphonia.

1. Breathy Phase (24 - 72 hours)

2. Normal Phase (2 weeks)

3. Recurrence Phase (3 - 6 months)

  • Typical doses 1-2 units
  • Spasms cause the vocal folds to slap together and stiffen.
  • Difficult for vocal folds to vibrate and produce sound.
  • Choppy speech, strangled and effortful for speaker.
  • Most common Spasmodic Dysphonia type.

The BOTOX injection diagram

Cut RLN as supply innervation to vocal folds

Mixed

  • Combination of Abductor and Adductor Spasmodic Dysphonia.
  • Opening and Closing muscles do not work.

Causes:

  • Exact cause is unknown

Voice Therapy

Treatments for Spasmodic Dysphonia

  • Aims to act as a adjunctive to BOTOX injection, enhancing effectiveness by reducing excessive compensatory vocal behaviours such as:

Possible Causes:

  • Psychological
  • Biological
  • Surgical Approach

Murry & Woodson (1995)

  • BOTOX Injection
  • Glottal overpressure at Voice Onset.
  • Excessive laryngeal tension.

  • Voice Therapy
  • Can be used before BOTOX to see if pathology resolves through behavioral intervention.
  • Always used after BOTOX to get vocal folds to move in the correct way.

BOTOX

Advantages

Disadvantages

  • Not permanent
  • Significantly improves voice quality in the optimum effect time
  • Non-invasive
  • If only needed once, cost effective treatment
  • Used alongside voice therapy
  • Quick application
  • Quick recovery period (24 - 72hrs)
  • Psychosocial advantages:
  • Reaction to injection dependant on individual
  • To avoid breathiness, more frequent bilateral mini-dose injections, dose only lasts 6-8 weeks.
  • Several days to take effect.
  • Overall dosage only lasts 3-6 months.
  • Remission of symptoms i.e. nerve regrowth
  • Expensive ( up to $4,000 )
  • Psychosocial disadvantages:
  • Renewed ability to participate in activities in social environments
  • Improved self-image (with SD, patient couldn't show authentic personality)
  • Effective treatment as BOTOX returns voice quality and provides relief from physical effort and fatigue.
  • Refuse treatment due to stigma
  • Lack of clinics which provide service
  • Accustoming to BOTOX effects

Spasmodic Dysphonia

VOICE THERAPY

  • Chronic Neurological Disorder
  • Irregular Vocal Fold vibration causing jerky, quivery, hoarse, tight or groaning voice.
  • Three types:
  • Adductor
  • Abductor
  • Mixed

Adductor Spasmodic Dysphonia Treatments

Advantages

References

Disadvantages

  • Methods of voice improvements cannot be easily carried over into everyday speech.
  • Speech can sound normal when laughing, crying or shouting.
  • Stress can emphasize symptoms.
  • Most commonly effects women from 30-50 years.

http://med.stanford.edu/content/dam/sm/ohns/documents/voicecenter/resources/Stanford_Medicine-SD_Handout.pdf

  • Can prevent the need for BOTOX injection
  • Can be carried out by therapeutic intervention and can be managed by the patient
  • Least expensive option

Task

Erickson, M. (2003). Effects of Voicing and Syntactic Complexity on Sign Expression in Adductor Spasmodic Dysphonia. American Journal of Speech-Language Pathology, 12, 416-424.

[Freeman, F., Cannito, M., & Finitzo-Hieber, T. (1985) cited in Murry, T., & Woodson, G. (1995)]

Kimmybuza (2014) Kimmy's Spasmodic Dysphonia Journey...Voice Sample January 10th 2014 [online] Retrived from: https://www.youtube.com/watch?v=nhr-MkZfdb [Accessed: March 2016]

Kimmybuza (2014) Kimmy's Spasmodic Dysphonia Journey...Singing the National Anthem January 10th 2014 [online] Retrived from: https://www.youtube.com/watch?v=s_fN1DZG0L [Accessed: March 2016]

  • Managed by patient, possible chance of lack of motivation/engagement
  • Temporary measure
  • Requires regular attention in order to be effective

Neuenschwander, M., Sataloff, R., & Pribitkin, E. (2005). Botulinum Toxin in Otolaryngology. In: Treatments of Voice Disorders, Sataloff R.T. Abingdon, Oxfordshire, United Kingdom: Plural Publishing Inc

National Spasmodic Dysphonia Association (2016) Spasmodic Dysphonia Available at: https://www.dysphonia.org/ [Accessed: March 2016]

Murry T. (2014). Spasmodic Dysphonia: Let's Look at That Again. Journal of Voice.28, 694-699.

Murry, T., & Woodson, G. (1995). Combined-Modality Treatment of Adductor Spasmodic Dysphonia with Botulinum Toxin and Voice Therapy. Journal of Voice, 9, 460-465. Philadelphia: Lippincott-Raven Publishers.

Peak ENT and Voice Center. (2011). Spasmodic Dysphonia (Adductor Type) [Online]. Retrieved from: https://www.youtube.com/watch?v=zFhLLIOKps [Accessed: March 2016]

Cedar-Sinai (2016) EMG-Guided Botox Injection [online] Available from: http://www.cedars-sinai.edu/Patients/Programs-and-Services/Neurology/EMG-Guided-Botox-Injections.aspx [Accessed: April 2016]

So...

Any Questions?

Damrose. E.J. (nd) BOTOX (Botulinum Toxin A): Spasmodic Dysphonia, Laryngospasm, Granulomas, Avaliable at:

[Accessed: March 2016]

Baylor, C.R, Yorkston, K.M, Eadie, T.L, & Maronian, N.C (2007) The Psychological Consequences of BOTOX Injections for

Spasmodic Dysphonia: A qualitative Study of Patients' Experiences, Avaliable at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649951/ [Accessed: March 2016]

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