Spasmodic dysphonia

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Spasmodic dysphonia
Synonym Laryngeal dystonia
Specialty Neurology
Symptoms Breaks in the voice making a person difficult to understand[1]
Complications Depression, anxiety[2]
Usual onset 30s to 50s[1]
Duration Long term[1]
Types Adductor, abductor, mixed[1]
Causes Unknown[1]
Risk factors Family history[1]
Diagnostic method Examination by a team of healthcare providers[1]
Similar conditions Stuttering, muscle tension dysphonia[2]
Treatment Botulinum toxin into the affected muscles, voice therapy, counselling, amplification devices[1]
Frequency 2 per 100,000[1]

Spasmodic dysphonia, also known as laryngeal dystonia, is a disorder in which the muscles that generate a person's voice go into periods of spasm.[1][2] This results in breaks or interruptions in the voice, often every few sentences, which can make a person difficult to understand.[1] The person's voice may also sound strained or they may be nearly unable to speak.[2] Often onset is gradual and the condition is life long.[1]

The cause is unknown.[1] Risk factors may include family history.[1] Triggers may include an upper respiratory infection, injury to the larynx, overuse of the voice, and psychological stress.[1] The underlying mechanism is believed to typically involve the central nervous system, specifically the basal ganglia.[1] Diagnosis is typically made following examination by a team of healthcare providers.[1]

While there is no cure, treatment may improve symptoms.[1] Most commonly this involves injecting botulinum toxin into the affected muscles of the larynx.[1] This generally results in improvement for a few months.[1] Other measures include voice therapy, counselling, and amplification devices.[1] Rarely surgery may be considered.[1]

The disorder affects an estimated 2 per 100,000 people.[1] Women are more commonly affected.[1] Onset is typically between the ages of 30 and 50.[1] Severity is variable between people.[2] In some work and social life are affected.[2] Life expectancy is, however, normal.[3]


The three types of spasmodic dysphonia (SD) are adductor spasmodic dysphonia, abductor spasmodic dysphonia and mixed spasmodic dysphonia.

Adductor spasmodic dysphonia[edit]

In adductor spasmodic dysphonia (ADSD), sudden involuntary muscle movements or spasms cause the vocal folds (or vocal cords) to slam together and stiffen.[4] These spasms make it difficult for the vocal folds to vibrate and produce voice. Words are often cut off or are difficult to start because of the muscle spasms. Therefore, speech may be choppy but differs from stuttering. The voice of an individual with adductor spasmodic dysphonia is commonly described as strained or strangled and full of effort. Surprisingly, the spasms are usually absent while laughing, speaking at a high pitch, or speaking while singing, but singers can experience a loss of range or the inability to produce certain notes of a scale or with projection. Stress, however, often makes the muscle spasms more severe.[5]

Abductor spasmodic dysphonia[edit]

In abductor spasmodic dysphonia, sudden involuntary muscle movements or spasms cause the vocal folds to open.[4] The vocal folds cannot vibrate when they are open. The open position of the vocal folds also allows air to escape from the lungs during speech. As a result, the voices of these individuals often sound weak, quiet and breathy or whispery. As with adductor spasmodic dysphonia, the spasms are often absent during activities such as laughing or singing, but singers can experience a loss of range or the inability to produce certain notes of a scale or with projection.[5]

Mixed spasmodic dysphonia[edit]

Mixed spasmodic dysphonia involves both muscles that open the vocal folds and those that close them and therefore has features of both adductor and abductor spasmodic dysphonia.[4]

Whispering dysphonia[edit]

A fourth type has also been described. This appears to be caused by mutations in the TUBB4 gene on the short arm of chromosome 19 (19p13.2-p13.3).[6] This gene encodes a tubulin gene. The pathophysiology of this condition has yet to be determined.


The exact cause of spasmodic dysphonia (SD) is unknown.[4] Evidence is that most cases are in neurogenic or having to do with the nervous system.[5]

SD is a neurological disorder rather than a disorder of the larynx, and as in other forms of dystonia, interventions at the end organ (i.e., larynx) have not offered a definitive cure, only symptomatic relief. The pathophysiology underlying dystonia is becoming better understood as a result of discoveries about genetically based forms of the disorder, and this approach is the most promising avenue to a long-term solution.[7]

SD is classified as a neurological disorder.[8] However, because the voice can sound normal or near normal at times, some practitioners believe it to be psychogenic, that is, originating in the affected person's mind rather than from a physical cause. No medical organizations or groups take this position. A comparison of SD patients compared with vocal fold paralysis (VFP) patients found that 41.7% of the SD patients met the DSM-IV criteria for psychiatric comorbidity compared with 19.5% of the VFP group.[9] However, another study found the opposite, with SD patients having significantly less psychiatric comorbidity compared to VFP patients: "The prevalence of major psychiatric cases varied considerably among the groups, from a low of seven percent (1/14) for spasmodic dysphonia, to 29.4 percent (5/17) for functional dysphonia, to a high of 63.6 percent (7/11) for vocal cord paralysis."[10] A review in the journal Swiss Medicine Weekly states that "Psychogenic causes, a 'psychological disequilibrium', and an increased tension of the laryngeal muscles are presumed to be one end of the spectrum of possible factors leading to the development of the disorder".[11] Alternatively, many investigators into the condition feel that the psychiatric comorbidity associated with voice disorders is a result of the social isolation and anxiety that patients with these conditions feel as a consequence of their difficulty with speech, as opposed to the cause of their dysphonia.[12] The opinion that SD is psychogenic is not upheld by experts in the scientific community.[10][13]

SD is formally classified as a movement disorder, one of the focal dystonias, and is also known as laryngeal dystonia.[14]


Diagnosis of spasmodic dysphonia is often delayed due to lack of recognition of its symptoms by screening physicians. Most people who are correctly diagnosed are evaluated by a team that usually includes an otolaryngologist, a speech-language pathologist and a neurologist. The otolaryngologist examines the vocal folds using a ridged or flexible (transnasal) laryngoscopy to look for other possible causes for the voice disorder. Fiberoptic laryngoscopy, a method whereby a small lighted flexible tube is passed through the nose and into the throat, is a helpful tool that allows the evaluation of the vocal cords movement during speech. Additional diagnostic testing may include stroboscopy, which allows the viewing of the vibrations of the vocal cords in slow motion. The speech-language pathologist evaluates the patient's voice and voice quality. The neurologist evaluates the person for signs of other movement disorders.[5]


There are a number of potential treatments for spasmodic dysphonia, including botox, surgery and voice therapy.[15] A number of medications have also been tried including anticholinergics (such as benztropine) which have been found to be effective in 40-50% of people, but which are associated with a number of side effects.[16]

Voice therapy[edit]

Voice therapy appears to be ineffective in cases of true spasmodic dysphonia,[17] however as it is difficult to distinguish between spasmodic dysphonia and functional dysphonias and misdiagnosis is relatively common,[18] a trial of voice therapy is often recommended before more invasive procedures are tried.[15] Some also state that it is useful for mild symptoms and as an add-on to botox therapy[19] and others report success in more severe cases.[20]


A number of operations that cut one of the nerves of the vocal folds (the recurrent laryngeal nerve) has improved the voice of many for several months to several years but the improvement may be temporary.[5]

An operation called "selective laryngeal adductor denervation-rennervation (SLAD-R)" is effective specifically for adductor spasmodic dysphonia which has shown good outcomes in about 80% of people at 8 years.[17] Post-surgery voices can be imperfect and about 15% of people have significant difficulties.[17] If symptoms do recur this is typically in the first 12 months.[17] Another operation called "recurrent laryngeal nerve avulsion" has positive outcomes of 80% at three years.[19]

Botulinum toxin[edit]

Botulinum toxin (Botox) is often used to improve some symptoms of spasmodic dysphonia. Whilst the level of evidence for its use is limited,[21] it remains a popular choice for many patients due to the predictability and low chance of long term side effects. It results in periods of some improvement. The duration of benefit averages 10–12 weeks before the patient returns to baseline. Repeat injection is required to sustain good vocal production.[15]

Notable cases[edit]


  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x y "Spasmodic Dysphonia". NIDCD. 6 March 2017. Archived from the original on 4 July 2017. Retrieved 16 July 2017. 
  2. ^ a b c d e f "Laryngeal Dystonia". NORD (National Organization for Rare Disorders). 2017. Archived from the original on 16 November 2016. Retrieved 16 July 2017. 
  3. ^ Albert, Martin L.; Knoefel, Janice E. (1994). Clinical Neurology of Aging. Oxford University Press. p. 512. ISBN 9780195071672. Archived from the original on 2017-09-08. 
  4. ^ a b c d "Definition of Spasmodic dysphonia". MedTerms medical dictionary. Archived from the original on 2007-09-27. Retrieved 2007-05-11. 
  5. ^ a b c d e "Spasmodic Dysphonia". Publication No. 10-4214. National Institute on Deafness and Other Communication Disorders. Retrieved 2016-07-09. Includes text taken directly from the website. As a work of the National Institutes of Health, part of the United States Department of Health and Human Services, this text constitutes a work of the U.S. federal government, therefore it is in the public domain.
  6. ^ Lohmann K, Wilcox RA, Winkler S, Ramirez A, Rakovic A, Park JS, Arns B, Lohnau T, Groen J, Kasten M, Brüggemann N, Hagenah J, Schmidt A, Kaiser FJ, Kumar KR, Zschiedrich K, Alvarez-Fischer D, Altenmüller E, Ferbert A, Lang AE, Münchau A, Kostic V, Simonyan K, Agzarian M, Ozelius LJ, Langeveld AP, Sue CM, Tijssen MA, Klein C (2012). "Whispering dysphonia (DYT4 dystonia) is caused by a mutation in the TUBB4 gene". Ann Neurol. 73: 537–545. doi:10.1002/ana.23829. 
  7. ^ Sulica L (December 2004). "Contemporary management of spasmodic dysphonia". Current Opinion in Otolaryngology & Head and Neck Surgery. 12 (6): 543–8. PMID 15548915. doi:10.1097/01.moo.0000145959.50513.5e. 
  8. ^ Dystonias Fact Sheet: National Institute of Neurological Disorders and Stroke (NINDS)
  9. ^ Gündel H, Busch R, Ceballos-Baumann A, Seifert E (2007). "Psychiatric comorbidity in patients with spasmodic dysphonia - a controlled study.". J. Neurol. Neurosurg. Psychiatr. J Neurol Neurosurg Psychiatry. 78: 1398–400. PMC 2095627Freely accessible. PMID 17615166. doi:10.1136/jnnp.2007.121699. 
  10. ^ a b Newswise Medical News | Patients with Selected Voice Disorders Are Subject to Psychiatric Problems Archived 2008-08-02 at the Wayback Machine.
  11. ^ Seifert, E.; Kollbrunner, J. (2005-07-09). "Stress and distress in non-organic voice disorder.". Swiss Med Wkly. Swiss Med Weekly. 135: 387–97. PMID 16220409. 
  12. ^ Ann Otol Rhinol Laryngol. 2001 Oct;110(10):941–5.
  13. ^ Spasmodic Dysphonia is a Neurological Disorder Current Evidence and References Archived 2011-02-06 at the Wayback Machine., by Christy L. Ludlow, Ph.D.
  14. ^ Merati AL, Heman-Ackah YD, Abaza M, Altman KW, Sulica L, Belamowicz S (November 2005). "Common movement disorders affecting the larynx: a report from the neurolaryngology committee of the AAO-HNS". Otolaryngol Head Neck Surg. 133 (5): 654–65. PMID 16274788. doi:10.1016/j.otohns.2005.05.003. 
  15. ^ a b c Ludlow, CL (June 2009). "Treatment for spasmodic dysphonia: limitations of current approaches". Current Opinion in Otolaryngology & Head and Neck Surgery. 17 (3): 160–5. PMC 2763389Freely accessible. PMID 19337127. doi:10.1097/MOO.0b013e32832aef6f. 
  16. ^ Grillone, GA; Chan, T (February 2006). "Laryngeal dystonia" (PDF). Otolaryngologic Clinics of North America. 39 (1): 87–100. PMID 16469657. doi:10.1016/j.otc.2005.11.001. 
  17. ^ a b c d Chhetri, DK; Berke, GS (February 2006). "Treatment of adductor spasmodic dysphonia with selective laryngeal adductor denervation and reinnervation surgery" (PDF). Otolaryngologic Clinics of North America. 39 (1): 101–9. PMID 16469658. doi:10.1016/j.otc.2005.10.005. Archived (PDF) from the original on 2012-05-31. 
  18. ^ Bressman, edited by Thomas T. Warner, Susan B. (2007). Clinical diagnosis and management of dystonia. London: Informa Healthcare. p. 111. ISBN 978-1-84184-317-9. 
  19. ^ a b Wackym,, James B. Snow,... P. Ashley (2009). Ballenger's otorhinolaryngology : head and neck surgery. (17th ed.). Shelton, Conn.: People's Medical Pub. House/B C Decker. p. 918. ISBN 978-1-55009-337-7. 
  20. ^ Klaben, Joseph C. Stemple, Leslie Glaze, Bernice Gerdeman (2000). Clinical voice pathology : theory and management (3. ed.). San Diego, Calif.: Singular Publ. Group. p. 368. ISBN 978-0-7693-0005-4. 
  21. ^ Watts, C; Nye, C; Whurr, R (February 2006). "Botulinum toxin for treating spasmodic dysphonia (laryngeal dystonia): a systematic Cochrane review". Clinical rehabilitation. 20 (2): 112–22. PMID 16541931. doi:10.1191/0269215506cr931oa. 
  22. ^ "'Dilbert' creator recovers from rare disorder". Associated Press. 2006-10-27. Archived from the original on 2007-11-17. Retrieved 2007-07-30. 
  23. ^ Frank Allison Archived 2007-10-15 at the Wayback Machine.
  24. ^ Beal Jr., Jim (1998-04-29). "Golden country Johnny Bush hasn't run dry after almost 50 years of heartaches and honky-tonks". San Antonio Express-News. 
  25. ^ The Voice Gallery - Thomas Allen Publishers - Thomas Allen & Son Limited Archived 2007-10-19 at the Wayback Machine.
  26. ^ "Archived copy". Archived from the original on 2017-09-08. Retrieved 2017-07-16. 
  27. ^ McHale, Laurie; Degginger, Craig (May 14, 1999). "Chip Hanauer's restored voice gives him a new lease on life". University of Washington News and Information. Archived from the original on December 15, 2012. Retrieved September 22, 2012. 
  28. ^ Liebovich, Mark (2006-06-25). "Another Kennedy Living Dangerously". The New York Times. Archived from the original on 2008-04-07. Retrieved 2007-07-30. 
  29. ^ "Author Interview: Emily Lim". Asia in the Heart, World on the Mind. Tarie at Blogger. Archived from the original on 19 April 2012. Retrieved 7 April 2012. 
  30. ^ Sullivan, Jim (2004-02-19). "Hello, Mary Lou – Goodbye, Heartache". Boston Globe. 
  31. ^ Heffernan, Virginia (2006-02-25). "After the Hit Records, A Search for His Roots". The New York Times. 
  32. ^ [1] Archived 2007-12-03 at the Wayback Machine.
  33. ^ Clarke, Jenna. "The reason why '90s pop star Jenny Morris disappeared". Sydney Morning Herald. Archived from the original on 2015-10-11. 
  34. ^ Australian Story (Series 2015; Episode 37) - Raise Your Voice, Australian Broadcasting Corporation (ABC). First aired Monday 12 October 2015.
  35. ^ "About Diane Rehm". WAMU 88.5 American University Radio. Archived from the original on 2007-08-10. Retrieved 2007-07-30. 
  36. ^ "Jimmie Rodgers: A Singer Silenced". Archived from the original on 2015-09-21. 
  37. ^ "Mark Stuart informs his Facebook followers that he has Spasmodic Dyphonia". Archived from the original on 2017-09-08. 
  38. ^ "Thompson's Trials: UK Folk Rock Great Makes Triumphant Return to the Stage". Tim Perlich, NOW Toronto. 2002-10-17. Archived from the original on 2007-09-29. Retrieved 2007-08-23. 
  39. ^ "Shania Twain Not Only Lost Husband, But Also Voice". Jill Serjeant, 2011-05-04. Archived from the original on 2016-07-26. Retrieved 2016-07-20.