Coprevalence of anxiety and depression with spasmodic dysphonia: a case-control study

Analgesia in Transcutaneous Laryngeal Botulinum Toxin Injections: A Randomized Crossover Trial

OBJECTIVES

There is an absence of data in the literature regarding methods to improve the patient experience during the performance of awake in-office laryngeal injections. This study sought to evaluate whether the use of local anesthetic or a vibrating instrument decreased overall pain experienced by patients with laryngeal dystonia, frequently referred to as spasmodic dysphonia (SD), undergoing transcervical botulinum toxin injections.

METHODS

This was an unblinded, prospective randomized control trial with a crossover design where each patient received transcutaneous transcricothyroid injection of botulinum toxin with alternating use of no anesthesia, local anesthesia (2% lidocaine in 1:100,000 epinephrine), and vibrating instrument in three consecutive laryngeal injections to treat adductor SD. Patients were randomized to the order they received these treatments. Patients measured pain on a 0-10 visual analogue scale (VAS) and selected their preferred technique after receiving all three analgesic modalities.

RESULTS

Thirty-two patients completed the study. There was no statistically significant difference in pain between the three analgesic techniques (p = 0.38). The most preferred analgesic technique was the vibrating wand (44% (14/32)). Lidocaine was the second most preferred (37% (12/32)) and 19% (6/32) of patients preferred nothing. When combining the wand and nothing groups, 63% of patients preferred one of these two methods (95% exact CI: 44%-79%).

CONCLUSION

There was no statistically significant difference in median pain experienced by patients during laryngeal botulinum toxin injection between these different analgesic modalities. More than half of the patients selected a preference for a technique that did not include lidocaine. This data supports individualization of analgesia during transcutaneous laryngeal injections.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:2277-2281, 2024.

Spasmodic dysphonia: introductory phonetic analyses

Adductor spasmodic dysphonia (ADSD) is a neurological dystonia characterised by involuntary adductor spasms of the larynx during speech. Spasm frequency is often reported to increase during syllables that begin with voiced speech sounds, especially glottal stops. Because of its underlying physical and acoustic complexities, the voicing contrast in American English (AE) appears unlikely to interact consistently with a singular physical phenomenon like laryngeal spasm. This retrospective study investigated additional phonetic contrasts and their relationship to spasm frequency. Standardised, 144-word recordings of 36 participants with adductor spasmodic dysphonia were analysed. Productions were coded for rater-perceived syllable stress, voiced/voiceless onset, vowel/consonant onset, and word-onset place and manner of production. Phonetic contexts were compared using independent sample t-tests and Kruskal-Wallis statistics. Contexts in which spasm varied significantly included stressed/unstressed syllables, content/function words, and multisyllabic/monosyllabic words. Study results reaffirm the clinical usefulness of standardised ADSD/ABSD sentences during differential diagnosis but conflict with previous studies that report a connection between ADSD spasm and phoneme voicing.

Intersection of Mental Health and Dysphonia: A Scoping Review

OBJECTIVE

Previous research has indicated that voice disorders frequently co-occur with mental health disorders, which may influence voice treatment seeking behavior and effectiveness. Our goal is to characterize the existing literature on the relationship between voice disorders and mental health and to investigate nuances related to mental health and voice disorder diagnosis.

DATA SOURCES

Ovid MEDLINE, ProQuest PsycINFO, and Web of Science.

REVIEW METHODS

Using the PRISMA protocol, a scoping review was performed. Databases searched included: Ovid MEDLINE, ProQuest PsycINFO, and Web of Science. Our inclusion criteria were all adults seen in an outpatient setting for voice and mental health disorders, excluding those with a prior history of head and neck surgery, cancers, radiation, or developmental anomalies, and certain mental health disorders. Results were screened by two independent screeners for inclusion. Data were then extracted and analyzed to present key findings and characteristics.

RESULTS

A total of 156 articles, with publication dates ranging from 1938 to 2021, were included in the analysis, with females and teachers being the most described population groups. The most frequently studied laryngeal disorders were dysphonia (n = 107, 68.6%), globus (n = 33, 21.2%), and dysphonia with globus (n = 16, 10.2%). The two most common mental health disorders found in the included studies were anxiety disorders (n = 123, 78.8%) and mood disorders (n = 111, 71.2%). The Voice Handicap Index was the most used tool to gather data on voice disorders (n = 36, 23.1%), while the Hospital Anxiety and Depression Scale was the most used tool to gather data on mental health disorders (n = 20, 12.8%). The populations studied within the included articles were predominately female and worked in educational occupations. Race and ethnicity was only reported for 10.2% of included articles (n = 16) and the most commonly studied race was White/Caucasian (n = 13, 8.3%).

CONCLUSION

Our scoping review of the current literature on mental health and voice disorders reveals an intersection between the conditions. The current literature represents change over time in terms of terminology that recognizes the patient's individualized experience of mental health and laryngeal conditions. However, there is still a great deal of homogeneity in the studied patient populations in terms of race and gender, with patterns and gaps that require further investigation.

Non-motor symptoms in spasmodic dysphonia: A case control-study

OBJECTIVE

Non-motor symptoms (NMS) have been identified in some focal adult-onset dystonia. In the present study we aimed to evaluate the presence of NMS in patients with spasmodic dysphonia (SD), a focal action-induced dystonia that affects intrinsic laryngeal muscle control.

METHODS

Seventeen SD patients and 17 control subjects not significantly different in age and sex were evaluated for the presence of NMS. Additionally, voice handicap index (VHI-10), reflux symptom index, neuropsychiatric symptoms and QoL were assessed by validated scales and questionnaires.

RESULTS

Patients' group significantly differed from control group in mild depressive symptoms (4.35 ± 3.9 vs. 1.47 ± 2; p=0.01), insomnia (35.3% vs. 14.7%; p=0.016), smell and taste loss (11.8% vs. 0%; p=0.033), swallowing difficulties (17.6% vs. 0%; p=0.007) and throat pain (17.6% vs. 0%; p=0.007). In the group of SD, there was no correlation between voice perception evaluated by VHI-10, number of NMS or QoL.

CONCLUSION

Patients with SD have a greater burden of depressive, smell, taste, and sleep NMS than control subjects.

Demographics and coexisting tremor, cervical dystonia and vocal fold disorders in a group of patients with spasmodic dysphonia

The primary aim of this study is to describe the demographic and clinical characteristics of a group of patients with spasmodic dysphonia (SD). As a secondary aim, we examined associations of age at SD diagnosis and sex with co-existing cervical dystonia and nonvocal tremor; as well as association of vocal tremor with sex and nonvocal tremor. Seventy-four consecutive patients who were treated for SD at the Mayo Clinic in Jacksonville, Florida between October 1, 2015 and March 31, 2018 were included in this retrospective study. Information was collected regarding sex, age at SD diagnosis, BMI, SD diagnosis type, recent history of major stress/depression, recent history of upper respiratory tract infection (URTI), co-existing neurological diseases, and co-existing vocal disorders. The majority of patients were female (75.7%) and median age at SD diagnosis was 61 years (range: 17 – 80 years). The median BMI was 25.7 (range: 16.9 – 63.7). The most common diagnostic combinations were adductor dysphonia only (52.7%), adductor dysphonia and MTD (18.9%), and adductor dysphonia and tremor (17.6%). Co-existing tremor was present in 36.6% of patients and cervical dystonia was present in 15.5%. Co-existing vocal disorders were observed as follows: paresis/paralysis (3.1%), cyst (3.1%), mass (4.7%), polyp (1.6%), and anterior glottis web (1.6%). Sex was not notably associated with either cervical dystonia or nonvocal tremor (all P ≥ 0.30). Older age at SD diagnosis was significantly associated with cervical dystonia (P = 0.049), but not nonvocal tremor (P = .22). Other than co-existing tremor, most patients had no co-existing neurological diseases or vocal disorders. Additionally, patients who were older at SD diagnosis were significantly more likely to have co-existing cervical dystonia.

Group Voice Therapy Reduces Anxiety in Patients With Dysphonia

OBJECTIVE

To evaluate the impact of group therapy in patients with dysphonia, as well as to verify the correlation between vocal symptoms and levels of anxiety.

METHODS

The study was composed of 52 patients subdivided into two groups, named the Experimental Group (EG) with 28 volunteers and the Control Group (CG) with 24 volunteers. Anxiety and voice protocols were used for data collection. The State-Trait Anxiety Inventory (STAI) was used to measure trait levels of anxiety that after collection were categorized according to the variation in scores value: low anxiety (20-40 points); average anxiety (40-60 points); high anxiety (60-80 points). In addition, the Voice Symptom Scale (VoiSS) was used for voice assessment. Inferential statistical analysis from the Student's t test for paired and independent data, in order to compare the average scores of STAI trait levels and VoiSS domains of the pre- and postmoments, intra- and intergroups, EG and CG, respectively. For that purpose, the program Statistical Package for Social Sciences (SPSS) was used.

RESULTS

Half of the patients in the survey presented an average trait level of anxiety. Regarding the EG, there was a significant reduction of state anxiety when comparing the moments before and after group therapy. There was also a significant reduction in the values of the VoiSS-Total and VoiSS-Physical domains when compared to the pre- and postgroup therapy moments. It was verified the existence of a positive correlation between the levels of anxiety after group therapy and VoiSS-Total, VoiSS-Limitation, and VoiSS-Physical domains. As for the CG, there was an increase in anxiety levels as well as in all domains of the VoiSS scale when compared to the pre- and postmoments.

CONCLUSIONS

Group voice therapy was effective for a significant reduction of vocal symptoms and anxiety - common conditions in patients with dysphonia. It was possible to perceive the positive correlation between anxiety levels and vocal symptoms.

Anxiety and depression in spasmodic dysphonia patients

Objective/Hypothesis

Experts used to believe that spasmodic dysphonia (SD) was a psychogenic disorder. Although SD is now established as a neurological disorder, the rates of co-morbid anxiety and depression range from 7.1% to 62%. Our objective was to study the prevalence and risk factors associated with these mood disorders in SD patients.

Study design

Retrospective.

Methods

SD patients who presented for botulinum toxin injections were recruited. Demographic data, Hospital Anxiety and Depression Scale (HADS), Voice Handicap Index-10 (VHI-10), General Self-Efficacy scale (GSES), Disease Specific Self-Efficacy in Spasmodic Dysphonia scale (DSSE), and Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) were collected.

Results

One hundred and forty two patients (age (59.2 ± 13.6) years, 25.4% male) had VHI-10 of 26.3 ± 6.9 (mean ± standard deviation), GSES 33.2 ± 5.8, CAPE-V 43.9 ± 20.9, HADS anxiety 6.7 ± 3.7, and HADS depression 3.6 ± 2.8. About 19 (13.4%) and 4 (2.8%) had symptoms of anxiety and depression respectively. Final linear regression model for HADS anxiety (R² = 32.90%) showed that patients who were less likely to have anxiety symptoms were older age (p < 0.001), male (p = 0.002), have higher GSES (p < 0.001) and lower VHI-10 (p = 0.004). Final linear regression model for HADS depression score (R² = 34.42%) showed that patients who were less likely to have depressive symptoms had high DSSES (p < 0.001).

Conclusions

Prevalence of anxiety (13.4%) and depression (2.8%) in SD were lower than previously reported in the literature. Risk factors for anxiety were: younger age, female gender, lower general self-efficacy, and higher perceived vocal handicap. The main risk factor for depression was lower disease specific self-efficacy.

Factors Associated With Patient-perceived Hoarseness in Spasmodic Dysphonia Patients

OBJECTIVES/HYPOTHESIS

The American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice Guidelines on Hoarseness distinguishes between hoarseness, which is a symptom perceived by the patient, and dysphonia, which is a diagnosis made by the clinician. Our objective was to determine factors that are associated with patient-perceived hoarseness in spasmodic dysphonia (SD) patients.

STUDY DESIGN

Retrospective study.

METHODS

Adductor SD patients who presented for botulinum toxin injections from September 2011 to June 2012 were recruited. The main outcome variable, Voice Handicap Index-10 (VHI-10), was used to quantify patient-perceived hoarseness. Clinical data, Hospital Anxiety and Depression Scale (HADS), and VHI-10 were collected. Clinician-perceived dysphonia was measured by a speech-language pathologist with Consensus Auditory Perceptual Evaluation of Voice (CAPE-V). Statistical analysis included univariate analyses and multiple linear regression.

RESULTS

One hundred thirty-nine SD patients had VHI-10 score of 26.0 ± 7.2 (mean ± standard deviation), disease duration of 10.5 + 7.0 years, CAPE-V overall score of 43.2 ± 21.8, HADS anxiety score of 6.7 ± 3.8, and HADS depression score of 3.6 ± 2.8. In univariate analyses, there were positive correlations (P < 0.05) between VHI-10 and female gender, CAPE-V overall, older age, HADS anxiety, and depression. There was no correlation with professional voice use and disease duration. In multiple linear regression (R² = 0.178, P < 0.001), age, HADS anxiety, female gender, and CAPE-V were significant.

CONCLUSIONS

Older age, higher anxiety levels, female gender, and clinician-perceived dysphonia are associated with higher levels of patient-perceived hoarseness in SD patients. Hoarseness is a very personal symptom. Multiple factors determine its self-perception.

Behavioral Dysphonia and Depression in Elementary School Teachers

OBJECTIVE/HYPOTHESIS

To verify the relationship between behavioral dysphonia and current depressive episodes in municipal elementary school teachers. We hypothesize that teachers with behavioral dysphonia will be more susceptible to psychiatric disorders.

DESIGN

Cross-sectional study, quantitative, conducted across municipal schools in both rural and urban regions of Pelotas.

METHOD

Five-hundred seventy-five teachers from urban and rural areas of the same Brazilian state were included. The full version of the Voice Handicap Index validated into Brazilian Portuguese was used to determine the presence of behavioral dysphonia. A profile of vocal behaviors was also used to quantify the number of phonotraumatic events. In addition, the Mini-International Neuropsychiatric Interview was used to determine current episodes of depression. Data were analyzed via correlative studies using chi-square and Poisson regression analyses.

RESULTS

Across all teachers, the prevalence of dysphonia was 33.9% and 55% reported that they had already taken a leave because of their voice. Those teachers with a current depressive episode had a higher rate of dysphonia compared with those without depression (prevalence ratio [PR] 1.66; P < 0.000). Teachers who presented with a risk of serious vocal problems had a prevalence ratio of 2.58, indicating a greater proportion of dysphonia, whereas teachers classified as champions of abuse were five times more likely compared with those teachers with behaved or candidates for voice problems.

CONCLUSIONS

There is an association between behavioral dysphonia and current depressive episodes in elementary school teachers.

Spasmodic dysphonia: let's look at that again

G. Paul Moore influenced the study of spasmodic dysphonia (SD) with his 1960 publication that examined the neurological, medical, and vocal fold behavior in a group of patients with adductor spasmodic dysphonia (ADSD). This review of advances in the diagnosis and treatment of SD follows a time line of research that can be traced in part to the early work of Moore et al. This article reviews the research in ADSD over the past 50 plus years. The capstone events that brought SD to its present day level of management by laryngologists and speech-language pathologists are highlighted. A look to the future to understand more of the disorder is offered for this debilitating disorder.

Considerations for Initial Dosing of Botulinum Toxin in Treatment of Adductor Spasmodic Dysphonia

Objectives

To assess the effect on voice improvement and duration of breathiness based on initial dose of onabotulinum toxin A (BTX-A) in the management of adductor spasmodic dysphonia (SD) and to compare voice outcomes for initial bilaterally injected doses of 1.25 units (group A) vs 2.5 units (group B) of BTX-A.

Study Design

Case series with chart review of patients with adductor SD treated at a tertiary care facility from 1990 to 2011.

Setting

Academic subspecialty laryngology practice.

Methods

Demographic data (age and sex), voice rating, duration of voice improvement, and breathiness were evaluated and compared between groups A and B using the Student t test and χ2 analysis.

Results

Of 478 patients identified, 305 (223 in group A, 82 in group B) patients met inclusion criteria. The average age was 56.2 years in group A and 57.4 years in group B ( P = .5). The female to male ratio was 2.91 for group A vs 3.56 for group B ( P = .61). Good voice outcomes (grade 3 or 4) were reported by 91% of group A patients vs 94% of group B ( P = .75). The average duration of voice improvement was 99.7 days for group A and 108.3 days for group B ( P = .54). The average duration of breathiness was 10.88 days for group A vs 15.42 days for group B ( P = .02).

Conclusion

Patients injected with 1.25 units bilaterally had a statistically significant shorter duration of breathiness without a statistically significant difference in clinical effectiveness or voice outcome. It is therefore recommended that a relatively low initial BTX-A dose be used with subsequent titration to achieve improved voice outcomes.

Epidemiologic Advances in Spasmodic Dysphonia

Recently research offers new insights into the pathogenesis, pathophysiology, and socioemotional implications of spasmodic dysphonia (SD). Among these advances are epidemiologic studies clarifying (1) SD onset and course, (2) SD risk factors, and (3) the relationships among SD course, treatment, and psychosocial impact. In this paper, I will provide a summary of recent epidemiologic and socioemotional research advances involving the onset, course, risk factors, and psychosocial impact of SD.