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Heyes R, Adler CH, Yee C, Lott DG, Karle WE. Analgesia in Transcutaneous Laryngeal Botulinum Toxin Injections: A Randomized Crossover Trial. Laryngoscope 2024; 134:2277-2281. [PMID: 38157199 DOI: 10.1002/lary.31208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 10/25/2023] [Accepted: 11/16/2023] [Indexed: 01/03/2024]
Abstract
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.
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Affiliation(s)
- Richard Heyes
- Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - Charles H Adler
- Department of Neurology, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - Claire Yee
- Department of Biostatistics and Bioinformatics, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - David G Lott
- Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - William E Karle
- Department of Otolaryngology, Northwell, New Hyde Park, NY, U.S.A
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Larner P, Jonas R, Gutierrez CN, McGarey P, Lott J, Moosa S, Elias WJ, Daniero J. Voice Improvement After Essential Tremor Treatment via Focused Ultrasound and Deep Brain Stimulation. Laryngoscope 2024; 134:367-373. [PMID: 37458326 DOI: 10.1002/lary.30884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 05/05/2023] [Accepted: 06/09/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVES The primary objective of this study was to determine whether two neurosurgical procedures, deep brain stimulation (DBS) and focused ultrasound (FUS), to treat essential tremor (ET) of the upper limb also reduce vocal tremor (VT) in patients with comorbid dysphonia. METHODS Twelve patients with ET and concomitant VT scheduled for neurosurgical intervention (FUS or DBS) or returning for follow-up after DBS implantation were assessed. FUS patients were assessed pre- and post-intervention and DBS patients were assessed with the electrodes turned on and off post-implantation. Three voice recordings of a sustained /a/ were obtained for each participant condition. Percent fundamental frequency variability (FFV) was calculated for each recorded sustained vowel. Additionally, blinded expert perceptual VT rating (VTR) was performed to assess subjective changes in tremors. RESULTS Of the 12 patients, seven underwent unilateral FUS, and five underwent bilateral DBS. Mean FFV without neurosurgical intervention was 18.3%, SD = 7.8 and with neurosurgical intervention was 6.3%, SD = 3.0 (t (70) =8.7, p < 0.001). Mean FFV decreased in the FUS cohort from 22.0%, SD = 7.1 pre-ablation to 6.7%, SD = 2.4 post-ablation (t (40) = 7.7, p < 0.001). Mean FFV also decreased in the DBS cohort from 15.7%, SD = 7.0 to 6.0%, SD = 3.3 when stimulation was turned on (t (28)=5.7 p < 0.001). In the FUS group, mean VTR decreased from 4.0 to 1.4 post-ablation (Z = 7.8, p < 0.001). In the DBS group, mean VTR decreased from 3.3 to 2.1 with stimulation (Z = 4.1, p < 0.001). CONCLUSION Neurosurgical interventions for ET (bilateral DBS and unilateral FUS) demonstrate acoustic and perceptual benefits for VT. LEVEL OF EVIDENCE 4 Laryngoscope, 134:367-373, 2024.
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Affiliation(s)
- Peter Larner
- School of Medicine, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Rachel Jonas
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Claudia N Gutierrez
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Patrick McGarey
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Joanna Lott
- Department of Therapy Services, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Shayan Moosa
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - W Jeffrey Elias
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - James Daniero
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
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Pearce JJ, Thoma J, Vinson K, Sani S. Treatment of vocal tremor with bilateral magnetic resonance imaging-guided focused ultrasound of the ventral intermediate thalamic nucleus: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE2351. [PMID: 38015018 PMCID: PMC10550546 DOI: 10.3171/case2351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/03/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Essential vocal tremor is a difficult disease entity to treat with a poor response to existing medical management and limited options for surgical management of the disease. Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is an emerging treatment modality with encouraging results for limb tremor in patients with essential tremor, but data are limited for the treatment of vocal tremor. OBSERVATIONS This is the case of a 69-year-old male with a history of essential vocal tremor severely limiting his ability to perform his occupation as an opera singer. He underwent staged bilateral ventral intermediate nucleus of the thalamus thalamotomy with MRgFUS for the treatment of his bilateral upper extremity tremor with near complete resolution of his vocal tremor after a second procedure. LESSONS Bilateral MRgFUS may be a safe and efficacious option for the treatment of essential vocal tremor. Further research into optimal patient selection, precise target location, and treatment parameters is needed.
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Affiliation(s)
- John J. Pearce
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Jaclyn Thoma
- Rush University Medical College, Chicago, Illinois; and
| | - Kimberly Vinson
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sepehr Sani
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
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Gochman GE, Dwyer CD, Young VN, Rosen CA. Exploring Patient's Preference of Patient-Reported Outcome Measures in Laryngeal Movement Disorders. Laryngoscope 2023; 133:1448-1454. [PMID: 36314426 DOI: 10.1002/lary.30376] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/25/2022] [Accepted: 08/08/2022] [Indexed: 05/10/2023]
Abstract
BACKGROUND Despite many available patient-reported outcome measures (PROMs) for laryngeal movement disorders, there is a lack of patient input regarding which PROM most accurately and conveniently captures aspects related to their vocal disease. This study aimed to assess patients' preferences among a selection of voice-related PROMs (Voice Handicap Index-10 [VHI-10], OMNI-Vocal Effort Scale [OMNI-VES], Communicative Participation Item Bank-General Short Form [CPIB-10], and Visual Analog Scales [VAS]) within the laryngeal movement disorder population and investigate associations between selected instruments. METHODS Prior to botulinum toxin A injection, patients with laryngeal dystonia and/or essential tremor of the vocal tract were administered the VHI-10, OMNI-VES, CPIB-10, and three novel VAS questions in a randomized order. Patients rank ordered the four PROMs based on the PROMs' reflection of their voice problems. Pearson's correlation coefficients evaluated pairwise associations among PROM scores. Fisher's exact test compared the preferred PROM rankings. RESULTS Seventy patients (53 female, mean age = 60.7 years) participated. The VHI-10 and CPIB-10 were most preferred at 33.9% and 27.4% respectively. The OMNI-VES and VAS scales were less favored (19.4%, each). When analyzed by age ≥60 years, the CPIB-10 was most favored (33.3%), but for age <60 years, VHI-10 was most preferred (42.3%). There was a strong correlation between scores of all administered PROMs (strongest correlation between OMNI-VES and VAS, r = 0.8, p < 0.001; the weakest correlation between OMNI-VES and VHI-10, r = 0.6, p < 0.001). CONCLUSIONS With an increasing trend in PROMs usage and a strong correlation between all evaluated outcome instruments, insight regarding patients' PROM preferences is an area for further consideration. LEVEL OF EVIDENCE NA Laryngoscope, 133:1448-1454, 2023.
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Affiliation(s)
- Grant E Gochman
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Christopher D Dwyer
- Division of Otolaryngology, Department of Surgery, Harvard University, Brigham & Women's Hospital, Boston, Massachusetts, U.S.A
| | - VyVy N Young
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Clark A Rosen
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, U.S.A
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Torrecillas V, Dwenger K, Barkmeier‐Kraemer JM. Classification of vocal tremor using updated consensus-based tremor classification criteria. Laryngoscope Investig Otolaryngol 2021; 6:261-276. [PMID: 33869758 PMCID: PMC8035951 DOI: 10.1002/lio2.544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES This study characterized the clinical phenotypes of individuals with vocal tremor (VT) using tremor classification criteria published by the International Parkinson and Movement Disorder Society (IPMDS) including laryngeal features from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). METHODS VT phenotypic descriptors were extracted from participant medical records from 2017 to 2019. Clinical phenotype descriptors included the: (a) chief complaint and discipline for the first appointment, (b) demographics, (c) tremor body distribution, condition, frequency, and progression, (d) exacerbating/alleviating factors, (e) treatment approaches, and (g) neurologic comorbidities. Descriptive statistics were conducted. RESULTS Of 179 meeting inclusion criteria, 2/3 were female; tremor onset affected voice (43%) or extremity (32%) and 2/3 were documented with tremor duration of 3 years or more. Those with primary VT first saw otolaryngology or speech language pathology (59%), whereas those with primary extremity/head tremor first saw neurology (36%). Documentation commonly omitted tremor clinical features such as (a) observed conditions of tremor (64%), (b) laryngeal features (64%), and (c) tremor frequency (92%). Thus, VT classification was based on comorbidity in 49% of patients (ie, essential tremor (48%), dystonia (72%), and Parkinson's disease (100%)) and 32% had inadequate documentation to classify. CONCLUSION The majority of individuals with VT were unable to be classified based on documented clinical features highlighting the need for consistent multidisciplinary assessment of tremor affecting speech structures. The primary site of tremor determined the first discipline seen. Most commonly classified VT categories included essential tremor (47%), dystonia (28%), Parkinsonism (7%), and isolated VT (19%). LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Vanessa Torrecillas
- Division of Otolaryngology – Head and Neck SurgeryUniversity of UtahSalt Lake CityUtahUSA
| | - Kaitlyn Dwenger
- Division of Otolaryngology – Head and Neck SurgeryUniversity of UtahSalt Lake CityUtahUSA
- Department of Communication Sciences and DisordersUniversity of UtahSalt Lake CityUTUSA
| | - Julie M. Barkmeier‐Kraemer
- Division of Otolaryngology – Head and Neck SurgeryUniversity of UtahSalt Lake CityUtahUSA
- Department of Communication Sciences and DisordersUniversity of UtahSalt Lake CityUTUSA
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Hanna RM, Sun SF, Gaynor P. A Case of Ertapenem Neurotoxicity Resulting in Vocal Tremor and Altered Mentation in a Dialysis Dependent Liver Transplant Patient. Antibiotics (Basel) 2018; 8:antibiotics8010001. [PMID: 30583507 PMCID: PMC6466552 DOI: 10.3390/antibiotics8010001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 11/16/2022] Open
Abstract
Carbapenem agents are advanced derivatives of cephalosporins that are active against bacteria that produce extended spectrum beta lactamases (ESBL). These antibiotics are resistant to enzymatic cleavage, and have good central nervous system penetration. Given this fact, it is not surprising that these drugs have been reported to cause neurological side effects like seizures and encephalopathy. We report a case of a patient on hemodialytic support who had a notable change in mentation and vocal tremor. This was at first attributed to calcineurin toxicity, but after the finding of a normal tacrolimus level, ertapenem neurotoxicity was suspected. After discontinuation of the offending agent, the patient’s vocal tremor, cognition, and neurological function returned to baseline levels.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 700 Tiverton Ave., Los Angeles, CA 90095, USA.
| | - Shih-Fan Sun
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 700 Tiverton Ave., Los Angeles, CA 90095, USA.
| | - Pryce Gaynor
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 700 Tiverton Ave., Los Angeles, CA 90095, USA.
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Guglielmino G, de Moraes BT, Villanova LC, Padovani M, Biase NGD. Comparison of botulinum toxin and propranolol for essential and dystonic vocal tremors. Clinics (Sao Paulo) 2018; 73:e87. [PMID: 30020342 PMCID: PMC6015262 DOI: 10.6061/clinics/2018/e87] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 01/08/2018] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Vocal tremors, which cause social difficulties for patients, may be classified as resting or action tremors. Of the vocal action tremors, essential and dystonic tremors are the most common. Botulinum toxin and oral medications have been used to treat vocal tremors, but no comparative clinical trials have been performed. The aim of this study was to compare the effects of botulinum toxin injection and the oral administration of propranolol in the treatment of essential and dystonic vocal tremors. METHODS This clinical trial recruited 15 patients, divided into essential and dystonic vocal tremor groups. Patients in both groups received successive treatment with botulinum toxin and propranolol. The treatments were administered at different times; the order of treatment was randomly selected. Patients were assessed with flexible nasofibrolaryngoscopy and with perceptual and acoustic voice evaluations. A statistical significance level of 0.05 (5%) was used. RESULTS Botulinum toxin produced statistically significant improvements in perceptual measures of vocal instability in patients with dystonic vocal tremors compared with baseline values and treatment with propranolol. The acoustic measure of variability in the fundamental frequency was significantly lower in patients with dystonic vocal tremors after treatment with botulinum toxin. CONCLUSION Essential and dystonic vocal tremors responded differently to treatment. Dystonic vocal tremors responded significantly to treatment with botulinum toxin but not oral propranolol. Essential vocal tremors did not respond significantly to either treatment, perhaps due to the small number of patients, which is a limitation of this research.
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Affiliation(s)
- Grazzia Guglielmino
- Departamento de Otorrinolaringologia e Cirurgia de Cabeca e Pescoco, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | | | - Luiz Celso Villanova
- Departamento de Neurologia, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
| | - Marina Padovani
- Fonoaudiologia, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
| | - Noemi Grigoletto De Biase
- Departamento de Otorrinolaringologia e Cirurgia de Cabeca e Pescoco, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
- Pontifícia Universidade Catolica de Sao Paulo, Sao Paulo, SP, BR
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Kundu B, Schrock L, Davis T, House PA. Thalamic Deep Brain Stimulation for Essential Tremor Also Reduces Voice Tremor. Neuromodulation 2017; 21:748-754. [PMID: 29232019 DOI: 10.1111/ner.12739] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 09/14/2017] [Accepted: 10/22/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Voice tremor is a common feature of essential tremor (ET) that is difficult to treat medically and significantly affects quality of life. Deep brain stimulation (DBS) of the ventral intermediate nucleus (Vim) of the thalamus is effective in improving contralateral distal limb tremor and has been shown in limited studies to affect voice tremor. Our objective was to retrospectively evaluate whether Vim-DBS used to treat patients with essential motor tremor also effectively treated underlying concurrent voice tremor and assess whether particular lead locations were favorable for treating vocal tremor. MATERIALS AND METHODS In this retrospective cohort study, patients had unilateral or bilateral lead placement and were monitored for up to 12 months. We used the Fahn-Tolosa-Marin (FTM) subscore to assess vocal tremor. Changes in vocal tremor before and after stimulation and over several sessions were assessed. RESULTS Of the 77 patients who met the inclusion criteria and were treated for essential tremor, 20 (26%) patients had vocal tremor prior to stimulation. Active Vim-DBS decreased the amplitude of voice tremor by 80% (p < 0.001). The mean FTM score as 1.24 pre-operation, 1.08 post-implantation (consistent with a lesion effect), and 0.25 with stimulation. The effect magnitude was maintained at last follow-up with slight improvement over time (p < 0.05). Unilateral and bilateral stimulation resulted in similar degrees of tremor reduction. A model of the centroid of stimulation showed that Vim thalamic stimulation that is more anterior on average yielded better voice tremor control, significantly so on the left side (p < 0.05). Additionally, there was improvement in head, tongue, and face tremor scores (p < 0.05). CONCLUSIONS Unilateral and bilateral Vim-DBS targeted to treat the motor component of essential tremor also dramatically decreased the amplitude of voice tremor in this group of patients, suggesting a potential benefit of this treatment for affected patients.
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Affiliation(s)
- Bornali Kundu
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Lauren Schrock
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Tyler Davis
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Paul A House
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
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Abstract
Botulinum neurotoxin (BoNT) has existed for thousands of years; however, it was not medically utilized until investigations into its therapeutic use began in sincerity during the late 1970s and 1980s. This, coupled with the reclassification of spasmodic dysphonia as a focal dystonia, led to the use of chemodenervation for this disorder, which has since become a refined technique. Indeed, due to its safety and efficacy, BoNT has been investigated in multiple neurolaryngology disorders, including spasmodic dysphonia, vocal tremor, and muscle tension dysphonia. BoNT has been shown to be a useful and safe adjunct in the treatment for these disorders and may reduce or eliminate oral pharmacotherapy and/or prevent the need for a surgical intervention. We present the historical background, development, proposed mechanisms of action, uses, and techniques for administering BoNT for laryngeal disorders, with a particular focus on spasmodic dysphonia.
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