Botulinum toxin treatment for laryngeal dystonia

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Botulinum toxin treatment for laryngeal dystonia

• Dr. Jens-Øyvind Loven
• ØNH avd. Lovisenberg sykehus

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Dystonia

• Dystonia is a condition characterized
• by involontary muscle contractions
• Dystonia can involve any volontary muscle

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Dystonia

• A)Focal
• blepharospasm
• laryngeal dystonia,torticollis
• 90 ideopatic,dysfunction in basal gangl?
• B)Segmental
• Meige Syndrom
• C) Generalized

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Classification-Laryngeal dystonia

• Adductor laryngeal dystonia
• Traube 1871
• -The vocal folds hyperadducts during phonation
  resulting in a hoarse, jerky,
• groanning voice with pitch breaks
• 80-90

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Classification-Laryngeal dystonia

• Abductor laryngeal dystonia
• Aronson 1968
• -Intermittent abduction of the vocal folds
  resulting in a whispering voice with aphonic
  segments of speech

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Classification-Laryngeal dystonia

• Compensatory adductor dystonia
• Compensatory abductor dystonia
• Blitzer/Brin
• Mixed dystonia
• Adductor breathing dystonia
• Supraglottic dystonia

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Dystonia-Classification

• a) Primary / ideopatic dyatonia
• b) Secondary / symtomatic dystonia
• ( Parkinson, Huntington, Tumor cerebri,
  Toxic, Postinfectious

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Epidemiology

• Rochester, Minnesota ( Nutt 1988)
• Total 400 pr. million
• Focal dystonia 300 pr. million
• Laryngeal dystonia 50 pr. million

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Spasmodic dysphonia-History

• Traube 1871 Òspastic dysphoniaÓ
• Schnitzler 1895 Òspastic aphoniaÓ
• Gowers 1899 Òphonic paralysisÓ
• Aronson 1968 Òadductor dystonia
• Òabductor dystonia

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Laryngeal dystonia/ Treatment

• Speech therapy
• Psychotherapy
• Acupuncture
• Hypnosis
• Pharmacotherapy

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Treatment/ laryngeal dystonia

• Surgery
• Unilateral recurrent laryngeal nerve section
• 60-70 of the patients had recurrency of
  spasmodic dysphonia within 3 years

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Botulinum toxin-History

• Elezelles, Belgum
• 3 died after eating raw, salted ham
• (neuroparalytic syndrom)
• Prof. E. van Ermegen
• Bacillus botulinus-Clostrideum botulinum
• 1979 Alan Scott ÒBotulinum toxin injectionof
  eye muscles to corret strabismusÓ

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Botulinum toxin/Pharmacology

• Botulinum toxin acts presynaptically at the
• nerve terminals by inhibiting release of
  acetyl-
• cholin
• Chemical denervation - paralysis after 24-72
  hours
• Scott 1979

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Botulinum toxin

• The bacteria Clostridium botulinum
• produces eight serologically distinct toxins
  A, B, C1, C2, D, E, F, G
• Potent neuroparalytic agent
• One Unit LD 50 Swiss Webster mice

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Botulinum toxin-Indications

• Strabismus TICS
• Hemifacial spasm Voice tremor
• Cervical dystonia Head tremor
• Laryngeal dystonia Spasticity
• Writers cramp Blepharospasm
• Stuttering Cosmetic
• Oromandibular dystonia

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Laryngeal dystonia 1991-2002

• 90 patients 55 women (61)
• 35 men
  (39)
• Age yr 25-86 mean 49 yr
• Age symtom onset 17-80 mean 45 yr

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Laryngeal dystonia 1991-2002

• Laryng. adductor dystonia 78 (86)
• Ò abductor Ò 6
• Adductor breathing Ò 4
• Supraglottic Ò
  2
• Total 90 patients

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Diagnosis

• Videostroboscopy of the larynx
• Voice analysis and recording of speech
• therapists at the National Center of
  logopedics, Oslo
• Neurological examination- CT scan

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Injection Technique-adductor laryngeal
dystonia/adductor breathing dystonia

• - Hollow, teflon-coated injection needle
• - Cricothyroid membran
• - Monopolar EMG
• - 1,25-2,5 U Botox bilaterally m. vocalis

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Injection Technique-Laryngeal abductor dystonia

• Blitzer/ Brin
• Botulinum toxin inj. of the posterior
• cricoarytenoid muscle

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Speech dysfunction-preceding events

• No history 39
• Stress 40
• Soare throat 8
• Surgery 2
• Head trauma 1
• Total 90 patients

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Results-Adductor laryngeal dystonia

• Excellent results 49 (61)
• (80-100 of normal voice)
• Improved voice 24 (33)
• No voice improvement 5 (6)
• Total 78 patients
• 0 total disability 100 normal voice

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Results-Abductor laryngeal dystonia

• Excellent result 1
• Voice improvement 2
• No voice improvement 3
• Total 6 patients

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Results-Adductor breathing dystonia

• Excellent results 3
• Improvement 1
• Total 4 patients
• 2,5 U Botox inj. m. vocalis bilat

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Adductor laryngeal dystonia-duration of voice
improvement

• -6 weeks - 132 months ( mean 3,5 months)
• Spontaneous remission of symptoms
• 6 patients

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Adverse effects

• Breathy voice 1-6 weeks after Botox injections (
  mean 12 days)
• Mild sensation of dysphagia first
• week after Botox treatment

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Neurologic Aspects-Excellent voice quality after
Botox treatment (n49)

• Laryngeal tremor 2
• Limb tremor 1
• Abnormal cerebral CT 1
• Blepharospasm 1
• Total 5 (9)
• Mean age of symptom onset (yr) 41
• (17-66)

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Neurologic Aspects-Improved voice after Botox
treatment (n22)

• Laryngeal tremor 17
• Oromandibular dystonia 2
• Blepharospasm 1
• Total 20 (90)
• Mean age of symptom onset (yr) 67
• 
  (37-80)

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Conclusions

• Focal laryngeal dystonia without
• neurological disturbances
• Excellent response to botulinum toxin
• treatment (80-100 of normal voice)
• Middle age

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Conclusion

• Laryngeal dystonia assosiated with other
• neurological disturbances
• Improved but not normal voice after botulinum
  toxin treatment
• gt 60 yr

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Conclusions

• Adductor breathing dystonia
• (paradoxical movements of vocal folds)
• Excellent results

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Conclusions

• Abductor laryngeal dystonia
• -difficult to diagnose
• -difficult treatment
• -mixed add-abductor dystonia ?

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Unilateral injection of botulinum toxin in
spasmodic dysphonia

• Ludlow C, Donovan D, Ford CN