Distributed Botox Injection for Spasmodic Dysphonia (Rather than Single Injection)

For many patients with spasmodic dysphonia, botox injections to the vocal cords are a regular right of passage every few months towards a clearer voice. Spasmodic dysphonia characterized by spastic or breathy voice breaks while talking causes much problems socially as well as misunderstandings.

For many physicians who perform botox injections for spasmodic dysphonia, a single injection is performed to either one or both vocal cords.

However a few and perhaps growing number of physicians are now using a more sophisticated method of injection where not only one, but multiple "mini"- injections are performed to the vocal cord during an injection.

Why would multiple injections be performed when one will do?

For that, I would like to take the reader to the world of cosmetic botox injections for facial wrinkles.

For the millions more sufferers of facial wrinkles, patients know that from the point of injection, there is a limited region of affect... typically no more than a dime to nickle area in size depending on the volume used. SO... in order to get rid of forehead wrinkles, 5 or more injections are required as shown here by the "x" marks.

The point is... in order for a great outcome in forehead wrinkles... multiple injections are performed. Not one single injection.

The same holds true for the vocal cord muscles. Rather than a single large injection to one spot in the vocal cord muscle, there is a growing belief that multiple "mini"-injections should be performed throughout the vocal cord muscle in order to produce a better outcome... a distributed injection. No specific research to prove this, but rather anecdotal.

Here is a video of botox being injected in a patient with spasmodic dysphonia.

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NYT: Can botox stop essential tremor (hand, face, etc)?

On April 22, 2010, the New York Times published a short story entitled "Can Botox Stop the Hands From Shaking?"

The story goes on to report that "Intramuscular injections of Botox, or botulinum toxin, may play a limited role in the treatment of wrist and voice tremors in patients with essential tremor."

Indeed, I do agree with the "limited" role botox has on essential tremor (emphasis on limited) whether the tremor involves the hand or head/neck region which is what I deal with more often.

Botox works GREAT when only 1 or 2 muscles are involved such as muscular dystonias where discrete muscles are afflicted such as torticollis (sternocleidomastoid muscle and/or trapezius muscles) and spasmodic dysphonia (thyroarytenoid muscle).

Unfortunately, in most cases of tremor (not dystonia), multiple different muscles are involved and it is very difficult to pinpoint and inject every single muscle that is suffering from tremor. A patient can end up with over a dozen injections to hit each affected muscle, and still not get a perfect outcome due to overall weakness from having so many injections.

Let's take vocal tremor... Vocal tremor often has both a laryngeal, oral, as well as neck component (patient's head often shakes while talking). As such, if one theoretically wanted to inject botox for vocal tremor, all these muscles may potentially need to be injected:

• thyroartenoid
• thyrohyoid
• sternothyroid
• infrahyoid
• omohyoid
• sternohyoid
• posterior cricoarytenoid
• lateral cricoarytenoid
• sternocleidomastoid
• superior pharyngeal constrictor
• middle pharyngeal constrictor
• inferior pharyngeal constrictor
• genioglossus
• hyoglossus
• styloglossus
• plalatoglossus
• levator veli palatini
• tensor veli palatini
• palatoglossus
• palatopharyngeus
• platysma
• etc.

That's a lot of muscles... which means a lot of injections... which means overall increased risk of overall weakness... AND the tremor may still be present.

However, botox injections may STILL be helpful to reduce symptoms of vocal tremor, but complete elimination of vocal tremor may be not be possible to achieve. Read more...

As many people already know, botox works great for wrinkles because discrete muscles are involved (just like for dystonia).

Our office provides botox injections for wrinkles, torticollis, spasmodic dysphonia, etc... but not for tremor UNLESS it is involving only a few muscles (very rare!).

Read the NYT article here.

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Possible Dystonia (Rare Neurological Condition) After Flu Shot

Desiree Jennings, a former Redskins cheerleader, received a seasonal flu shot on Aug 23, 2009 and has suffered from a possible dystonia reaction from the flu vaccination resulting in difficulties in eating, talking, and walking.

Here is a link to a video where Dr. Stephen Grill (neurologist) is interviewed by Fox News regarding Desiree's condition.

Here is a video/article of the initial story.

This story is a case of a VERY unfortunate EXTREMELY rare side effect (if true) of the flu vaccine. People should still get the flu vaccine, but be aware that it is not 100% benign in all cases.

However, it seems that Desiree's flu shot reaction may have been psychogenic (and not a true side effect of the vaccine at all). Read this blog article which goes into this in more detail.

Regardless, people have developed rare neurological conditions called laryngeal dystonia otherwise known more commonly as spasmodic dysphonia. The way Desiree talks (from what I can hear from the videos) is distinctly different from patients who suffer from classic spasmodic dysphonia. Click here to hear what laryngeal dystonia/spasmodic dysphonia sounds like.

(Of note, I received both the seasonal and the H1N1 vaccine and have encouraged all my friends, family, and patients who inquire to do so as well.)

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