Rev. CEFAC, São Paulo MEDICAL TREATMENT AND SPEECH THERAPY FOR SPASMODIC DYSPHONIA: A LITERATURE REVIEW Tratamento médico e fonoaudiológico da disfonia espasmódica: uma revisão bibliográfica Eliana Maria Gradim Fabron (1), Viviane Cristina de Castro Marino (2), Talyssa de Carvalho Nóbile (3), Luciana Tavares Sebastião (4), Suely Mayumi Motonaga Onofri (5) (1) Speech Pathologist; PhD Professor at the Department of Speech Pathology, UNESP, Marilia, São Paulo, Brazil; PhD in Education from UNESP. (2) Speech Pathologist; PhD Professor at the Department of Speech Pathology, UNESP, Marilia, São Paulo, Brazil; PhD in Communication Sciences and Disorders from the Univer- sity of Florida (3) Speech Pathologist; B.A. in Speech Pathology from UNESP Marília, São Paulo, Brazil. (4) Speech Pathologist; PhD Professor at the Department of Speech Pathology, UNESP, Marilia, São Paulo, Brazil; PhD in Education from UNESP. (5) Medical Doctor; Assistant Professor at the Department of Speech Pathology, UNESP, Marilia, São Paulo, Brazil; Master’s Degree. Conflict of interest: non-existent � INTRODUCTION First described by Traube in 1871, spasmodic dysphonia (SD) was classified as a spastic form of nervous hoarseness. This disorder was discussed in literature as two types of spastic dysphonia: adductor spasmodic dysphonia (AdSD) and abductor spasmodic dysphonia (AbSD)1. Adductor spasmodic dysphonia is characterized by the strained-strangled voice, with interruption in word production or difficulty in starting2. Abductor spasmodic dysphonia was described as maintaining normal vocal quality followed by moments of breathy or whispery voice1. The term spastic dysphonia was ABSTRACT Spasmodic dysphonia (SD) is a voice disorder characterized by a strained-strangled voice, with sound breaks and has implications in one’s communication. The purpose of this study is to present a bibliographic review of the speech therapy and medical treatment suggested for SD from 2006 to 2010. The speech therapy and medical treatments described are: botulinum toxin injection, myectomy, neurectomy, denervation and reinnervation selective laryngeal adductor, thyroplasty, radiofrequency thyroarytenoid myothermy, injection of lidocaine, homeopathy and speech therapy. The use of botulinum toxin injection showed results that indicated the satisfaction of the patients who were treated, although some of the articles presented the frequent need of reapplication of the toxin as a disadvantage. The surgical procedures were considered long-lasting and indicated to patients who didn’t want to get botulinum toxin injections. The studies, however, presented a restricted contingency of patients, and the outcomes in many studies were based in the patient’s own judgment on his/her voice quality. The treatments using lidocaine and homeopathy had positive results in relation to the voice quality of the patients and were suggested as an option for those who wouldn’t like to undergo surgical treatment or have botulinum toxin injection. The few studies which discourse on voice therapy presented good results in association with botulinum toxin injection, showing the shortage of information in this field. A study on the literature review pointed out the need of developing researches to help us understand the neurological functioning in spasmodic dysphonia. Future study involving speech therapy in the treatment of ED is still necessary. KEYWORDS: Dysphonia; Spastic Dysphonia; Dystonia Fabron EMG, Marino VCC, Nóbile TC, Sebastião LT, Onofri SMM Rev. CEFAC, São Paulo recently published articles is essential in determining the best approach in the treatment and prognosis of this devastating communication disorder. Thus, this study aims to review literature on medical and speech pathology treatment for SD from the period between 2006 and 2010. � METHOD The study was conducted by searching national and international journal articles available in the databases Lilacs, Medline, and Scielo, which after careful analysis were incorporated into the study. The criteria used for inclusion were articles that presented data for SD treatment (medical and/ or speech therapy) reported within the last five years, i.e. between 2006 and 2010. Articles on SD that included investigation with animals were disregarded. In the search for articles, terms related to the theme “spasmodic dysphonia” were chosen and found in the Health Sciences Descriptors (HSD). These terms were used in isolation and cross reference as shown in Figure 1. The filters “year of publication” and “word” were used in each search. And with the database Medline it was possible to use the filter “subject description”, which allowed the search for the terms “voice”, “focal dystonia” and “spastic dysphonia”. subsequently discussed in literature and considered inadequate because it is not an alteration related to injury in the pyramidal or extrapyramidal tract3. Currently SD is classified as a focal laryngeal dystonia with a neurological etiology2. The standard treatment for SD, according to that presented in literature, is the injection of type A botulinum toxin (BT-A)4,5 which can be combined with speech therapy3. Speech therapy as the only proposed treatment is considered ineffective mainly due to the fact that emotional states influence the control of speech production in patients diagnosed with SD7. However, studies show that following BT injection, speech therapy may help in prolonging its effectiveness, providing longer intervals between applications8-10. Several other forms of treatment (medical and/ or surgical) for SD were presented in the literature, however, none showed lasting effectiveness. Despite the various proposals presented for surgical treatment, literature indicates that some patients with SD go to speech therapy in an attempt to minimize communication disorders when other treatments are not effective7,11. The search for treatment options for SD is caused by the need to find a better quality of life for the patients. Given the difficulty in obtaining conclusive information from literature about treat- ments available for SD, an updated search in Figure 1 – List of words and subject descriptors used in the search Search number Crossed words and descriptors 01 Voz 02 Voice 03 Voz and tratamento 04 Voice and treatment 05 Disfonia espasmódica 06 Spasmodic dysphonia 07 Disfonia espasmódica and tratamento 08 Spasmodic dysphonia and treatment 09 Distonia focal laríngea 10 Laryngeal focal dystonia 11 Distonia focal laríngea and tratamento 12 Laryngeal focal dystonia and treatment 13 Disfonia espástica 14 Spastic dysphonia 15 Disfonia espástica and tratamento 16 Spastic dysphonia and treatment Treatment of spasmodic dysphonia Rev. CEFAC, São Paulo Myectomy The treatment with myectomy has been described since the 1990s. The surgical procedure is performed with an incision on the lateral surface of the vocal fold which exposes the TA muscle, followed by resection. This surgical treatment is irreversible and, in consequence, has the advantage of maintaining the long-term positive effect. Studies have shown that the TA muscle does not regenerate after resection12. Myectomy of the TA and LCA muscle may be performed with local anesthesia and intravenous sedation so that the voice and function of the vocal folds may be evaluated during the procedure13. Neurectomy of the thyroarytenoid branch of the inferior laryngeal nerve associated with the partial myectomy of the TA muscle Upon completion of the partial myectomy of the TA muscle with CO2 laser, there is the sectioning by electrocoagulation of the thyroarytenoid branch of the recurrent laryngeal nerve (RLN), located between the internal perichondrium of the thyroid cartilage and the fascia of the TA and LCA muscles. The procedure described by the authors is performed in both vocal folds14. Selective laryngeal adductor denervation and reinnervation Selective adductor denervation interrupts the abnormal neural signals to the TA and LCA muscles. The adductor branch of the RLN is divided at its insertion in the TA and LCA muscles and the proximal stump is exteriorized from the larynx to prevent the regeneration of axons in this anatomical structure. The ansa cervicalis of the cervical nerve is then anastomosed to the distal stump of the TA to maintain muscle tone and volume and also prevent the regeneration of axons in the RLN endplates of the TA and LCA muscles15. Thyroplasty Type II thryoplasty, as described in the consulted literature, is carried out with local anesthesia followed by a midline incision of the thyroid cartilage holding the underlying tissue intact. During speech, the edges of the cartilage are separated from 2 to 6 mm, average 4 mm, to verify any voice change16,17. A variety of material has been described for securing the edges of cartilage, such as pieces of silicon or cartilage, and titanium plates and bridges above and below the anterior commissure16-18. � LITERATURE REVIEW A total of 3833 articles were found in the survey of the databases Scielo, Lilacs, and Medline. Each article was presented in one or more databases. From the analysis of the abstracts of these articles, we excluded those that had previously been selected in another database, those that did not meet the inclusion criteria, and also those from journals that did not provide the full article. Thus, we included 30 articles related to the study. These articles reported on treatment for SD by means of medical and speech pathological procedures with: (a) 11 (37%) articles on BT injection; (b) 10 (33%) on surgical procedures, such as myectomy (2, 7%), neurectomy (2, 7%), selective laryngeal adductor denervation and reinnervation (1, 3%), thyroplasty (4, 13%), and thyroarytenoid myothermy (1, 3%); (c) 2 (7%) on other medical treatments, such as homeopathy and lidocaine injection; and (d) 1 (3%) speech therapy. In addition to these, there were 6 (20%) literature review articles on the treatment of SD. The information on the proposed treatments for SD, as shown in the literature, is summarized below. Botulinum toxin is a protein produced by Clostridium botulinum bacteria with a potent neuro- toxic action that blocks the release of acetylcholine from nerve endings at the neuromuscular joint. BT has been a treatment option for SD since the 1980s. The injection of BT into the intrinsic muscles of the larynx results in a temporary paresis or paralysis of the injected muscle. The toxin may be injected into one or both vocal folds simultaneously. Several injection techniques may be used for BT, some of which are performed with the support of percutaneous electromyography or nasalaryn- goscopy. The injection of BT is usually carried out in the thyroarytenoid muscle (TA)4, however there are also reports of injection in other laryngeal muscles, such as the lateral cricoarytenoid muscle (LCA). One of the drawbacks of BT is the fact that the effect is temporary and it is necessary to reapply every three to six months. There is also the possibility of the body developing antibodies against BT which reduces its effectiveness. The following complica- tions have been reported regarding the use of BT: transient dysphonia, glottic incompetence with an extremely hoarse voice, dysphagia, and asthenia. Surgical treatments The five reported surgical procedures include: myectomy, neurectomy, laryngeal denervation and reinnervation, thyroplasty, and radiofrequency thyroarytenoid myothermy. Fabron EMG, Marino VCC, Nóbile TC, Sebastião LT, Onofri SMM Rev. CEFAC, São Paulo Speech Therapy Although the articles comment that speech therapy is a possible treatment for SD, there are no reports in these articles on the strategies used in speech therapy sessions. After a brief exposition of the information on the treatment proposed for SD, the following are the results of the literature reviewed, classified by type of treatment, presented in tables that include: the year of publication, the author(s) involved, the objective(s) of the study, and the results. Table 1 shows the articles found in the biblio- graphic survey with the proposed treatment of BT injection. Table 2 presents the articles that include surgical procedures for the treatment of SD. Table 3 presents the articles categorized as other medical treatments for SD. Table 4 presents articles that contemplate speech therapy in the treatment for SD. Table 5 presents the articles that contemplate studies of literary review in the treatment of SD. The literature review on the proposed topic showed that in the last five years the medical treat- ments and speech therapy described in the liter- ature were: BT injection, myectomy, neurectomy, selective laryngeal adductor denervation and reiner- vation, thyroplasty, radiofrequency thyroarytenoid myothermy, lidocaine injection, homeopathy and speech therapy. Radiofrequency thyroarytenoid myothermy This procedure involves the insertion of a bipolar radiofrequency probe at two points of the vocal folds, one in the membranous portion and the other in the anterior-lateral portion of the vocal process, 2 cm from the surface of the vocal fold mucosa. The authors have described an ablation from a depth of 20 to 11 mm to protect the vocal fold mucosa and that it was carried out five times during the procedure19. Other medical treatments In addition to the surgeries described, treatments with injection of lidocaine, homeopathy, and speech therapy were published. Injection of lidocaine The authors described the injection of lidocaine 1% into the RLN in doses that varied from 2.5 to 5 ml. For this a syringe and 27 gauge needle was used to penetrate the neck to the right along the tracheoesophageal groove, below the cricothyroid articulation in the region of the RLN entry point into the larynx20. After injection, laryngoscopy was performed on all subjects to confirm vocal fold paralysis on the right. Homeopathy The literature reported on the use of Argentum nitricum21 in the treatment of SD. Treatment of spasmodic dysphonia Rev. CEFAC, São Paulo Table 1 – Articles on the use of botulinum toxin (BT) injection for the treatment of spasmodic dysphonia Injection of BT (n = 11) Year Author(s) Objetive(s) Results Botulinum toxin: unilateral application (n = 1) 2006 Santos; Mattioli; Mattioli; Daniel; Cruz22. Report the case of a patient with adductor type laryngeal dystonia treated with BT and discuss the advantages and the reports presented in the literature. Efficiency, generated fluency and comfort during phonation. Breathy voice, initially, rising to stabilize the fundamental frequency, increased breathing capacity, increased maximum phonation time and coordination between breathing Botulinum toxin: bilateral application (n= 3) 2006 Thomas; Siupsinskiene23 Compare the efficacy and side effects of treatment with fresh or refrozen and reconstituted type A Botulinum toxin in the treatment of laryngeal dystonia. 43 patients between 30 and 70 years old were studied. The use of refrozen BT-A was effective in the treatment. There was no statistical difference in comparing the duration of medicine effect, the self-evaluation on the voice of the patients studied and no different side effects of vocal breathiness and dysphagia. The authors stressed the cost-benefit relationship. 2006 Cantarella; Berlusconi; Maraschi; Ghio; Barbieri24 Analyze the effects of BT applied bilaterally in the stability of AdSD airflow through oral phonatory flow measurements. The study was carried out in 24 patients (19 women and 5 men) and 23 controls. The injection of BT increased the phonatory airflow, but there was no significant difference between the measurements of patients with SD and the control group Paniello; Barlow; Serna25 Quantify the period of greatest benefit experienced by patients after treatment with BT, after 4 weeks of BT application among 3 cycles used. In this study the voice-related quality of life questionnaire(VRQOL) The highest score reported by patients in the best phase of the treatment cycles was lower than 80. The was used to analyze the effects of treatment. The study was performed with twenty-two patients. breathy voice in the period after BT application and the drop in the vocal quality at the end of a treatment cycle involves a reduction in the patient’s quality of life with an average score of 52.8. The authors propose long-term treatment to aid the periods in which the vocal quality is not good. Botulinum toxin: both unilateral and bilateral application (n= 4) 2006 Woodson; Hochstetler; Murry26 Present the clinical trial in treating AbSD with BT applied bilaterally in the PCA muscle with asymmetric staggered dosing. The authors considered the left side as having the stronger spasms, therefore initiated application with a dosage of 1.25 units to the non-dominant side and 5 units to the dominant, gradually increasing 5 units until achieving elimination of breaks with breathiness, abductor paralysis of the dominant side or compromise airflow. The study was conducted with seventeen patients. The result of treatment of AbSD with BT injection into the PCA muscle may reduce the spasms, with a persisting breathy voice due to inadequate glottic closure. Fourteen patients achieved good or reasonable voice quality with dosage between 10 and 25 units in the dominant side. 2008 Cannito; Kahane; Chorna27 Analyze the response to BT injection in patients of different ages with AdSD. The study was conducted with 42 patients aged between 20 and 79. The voices were analyzed by perceptual judgment of auditory recordings before and after BT application. There was no statistical difference between the younger and older voices in the judgement of recordings before the application of BT. Response to treatment was effective in most age groups, with the exception of those aged 70-79. 2009 Birkent; Maronian; Waugh; Merati; Perkel; Hillel 28 Investigate the dosage consistency of BT injections in patients with long-term treatment of laryngeal dystonia. A case study was conducted with 55 patients submitted to 20 injections into the TA muscle. The dosage of BT in treating laryngeal dystonia may be reduced during treatment without harming the interval between applications and duration of vocal quality effectiveness. 2009 Upile et al29 Compare the effects of uni- and bilateral BT injection in the TA muscle for the treatment of AdSD. The study was conducted with 31 patients (16 women and 15 men) who had received 5 or more consecutive uni- or bilateral applications of Dysport. Self-evaluation protocols were used for the analysis. There was no significant difference in the results with low doses of uni- or bilateral BT injection when considering the duration of the toxin action, the self-evaluation vocal score, and the complication rate. However, only in the unilateral treatment was there no report of loss of voice after BT application. The authors recommend the unilateral use of BT for treatment. Fabron EMG, Marino VCC, Nóbile TC, Sebastião LT, Onofri SMM Rev. CEFAC, São Paulo Injection of BT (n = 11) Year Author(s) Objetive(s) Results Botulinum toxin: undefined side of application (n=3) 2007 Chang; Chabot; Thomas; Warrenton; Warwick; Portland30 Objectively evaluate the type A Botulinum Toxin dosage by means of statistical relationship between the amount of injection, duration of side effects, and the normal voice in AdSD. There were 101 patients (70 women and 31 men) that participated in the study at a private clinic. The doses varied from 0.5 to 15 units of BT. There was a significant and foreseeable correlation between the duration of side effects and the duration of normal voice quality after BT injection. The smaller the side effects, the lower the durability of normal voice quality. The most severe tendency of side effects was found in higher dosages of BT injections. 2009 Paniello; Edgar; Perlmutter31 Test the effect of muscle activity immediately after intramuscular injection of BT for AdSD. The study included nine patients. The achievement of high intensity in vocalization by reading immediately after the application of BT improves the effectiveness of the injection. 2010 Braden; Johns; Klein; Delgaudio, Gilman; Hapner32 Examine the correlation between the clinical assessment and that of patients with AdSD on the effects of Botox in the voice quality and quality of life. The responses from self- assessment of voice impairment, EIS (Equal Interval Scale), and the CAPE-V (Consensus Auditory Perceptual Evaluation of Voice) and V-RQOL (Voice-Related Quality of Life) protocols were used. Charts from 199 patients (149 women and 50 men) with ages from 18 to 90 years with AdSD who received two consecutive injections of Botox were reviewed. A retrospective study from 2004 to 2007. There was a correlation in the relationship between the perception of vocal impairment reported by the patient and the voice quality and quality of life in the mild to moderate and moderate to severe dysphonia group, and also a weak correlation between patient assessment and the clinician’s perceptual judgement with the use of the CAPE-V only in the moderate to severe dysphonia group. Another issue that was studied was the correlation between the patient’s quality of life data and the clinical judgement on vocal quality. There was a weak correlation in the moderate to severe dysphonia group. There was no significant difference between genders in any of the measurements. Table 1 (continuation) Surgical treatment n = 10 Year Author (s) Objetive (s) Results Myectomy (n=2) 2006 Koufman; Rees; Halum; Blalock13 Discuss the surgical procedure for AdSD involving myectomy of the TA and LCA muscle. Five patients (2 men and 3 women) participated in the study. The authors suggested that monitoring must be done over time to determine if this is the treatment that should be offered to patients. 2008 Nakamura; Muta; Watanabe; Mochizuki; Yoshida; Suzuki12 Describe the efficacy of bilateral thyroarytenoid myectomy under microlaryngoscopy. The study was performed with seven patients (1 man and 6 women) who underwent bilateral thyroarytenoid myectomy. Bilateral thyroarytenoid myectomy under microlaryngoscopy was a technique used for AdSD with two key points: the cervical incision was not necessary and a long-term effectiveness was obtained. Myectomy e neurectomy (n=2) 2006 Tsuji; Chrispim; Imamura; Sennes; Hachiya14 Report the preliminary results of the impact on voice quality of neurectomy of the thyroarytenoid branch of the inferior laryngeal nerve, via endoscopy, combined with partial myectomy of the TA muscle using CO2 laser. The study was conducted with 7 patients (6 women and 1 man) between 22 and 75 years old. There was vocal improvement in all patients and the need for surgery in one. Post-surgery follow-up time was 23.7 months. 2007 Su; Chuang; Tsai; Chiu33 Investigate the effectiveness of transoral approach to laser thyroarytenoid mioneurectomy for treatment of AdSD. The study was conducted with 14 patients (12 women and 2 men) between 33 and 69 years old. Moderate and marked vocal improvement was observed in 92% of patients with a follow-up period of 17 months. Table 2 – Articles with surgical procedures for treatment of spasmodic dysphonia divided by year, author (s), objective (s) and results Treatment of spasmodic dysphonia Rev. CEFAC, São Paulo Table 2 (continuation) Surgical treatment n = 10 Year Author (s) Objetive (s) Results Selective laryngeal adductor denervation and reinnervation (n=1) 2006 Chhetri; Mendelsohn; Blumin; Berke15 Describe the long-term results of laryngeal adductor denervation and reinnervation surgery in patients with AdSD. Outcome was evaluated using perceptual voice assessment. Data were collected from 1996 to 2003 and included 83 patients (23 men and 60 women) who underwent surgery during this period and responded to participate in the research. Surgery provided lasting relief from the symptoms of dysphagia in most patients. And 91% of them agreed that their voices were more fluent after surgery and the VHI score also improved. Thyroplasty (n=4) 2007 Sanuki; Isshiki16 Analyze the effectiveness of type II Thyroplasty using a titanium plate in AdSD. The review was conducted with a questionnaire in which patients responded on the ease of phonation and vocal quality before and after surgery. Forty-one patients participated in the study. The answers to the questionnaire showed that 70% of the patients reported having achieved excellent results. 2009 Sanuki; Isshiki17 Identify the factor or factors that suggest a need to review type II thyroplasty for AdSD by means of an individually detailed analytical analysis of seven cases with unsatisfactory results. The main factors for failure in surgery were: a) inadequate indication for surgery. Individuals in need of a high intensity voice should not undergo this surgical procedure; b) patients with other dystonias or associated diseases, such as essential tremor; c) voices that did not present sufficient strangled voice quality; for the authors, the tension level in the vocal emission quality must be large enough to indicate this surgery and, d) inadequate technique in placing the bridge separating the anterior commissure from the thyroid cartilage; it appears that there is the need to use two titanium bridges in the surgical procedure. 2010 Sanuki; Yumoto; Minoda; Kodama34 Report analysis findings of aerodynamic and acoustic evaluations before and after type II thyroplasty in patients with AdSD. The study was conducted with ten women from 20 to 76 years old who underwent surgery and performed examinations before and six months after surgery. After surgery, patients did not present voice strangulation and expressed satisfaction. There was no significant difference among the aerodynamic measurements after surgery, however the acoustic measurements (jitter, shimmer, HNR, SDFO and DVB) improved significantly. The study demonstrated that type II thyroplasty is indicated for patients who were treated with BT and obtained either poor results or none. Surgery is also indicated for patients who desire permanent results. 2010 Isshiki; Sanuki18 After analyzing the dissatisfaction of patients undergoing type II thyroplasty, the researchers presented the possible causes of failure and, in this article, described the changes made in the surgical procedure for treating AdSD. The authors also reflect on the poor acceptance of surgery in AdSD patients. The authors stated that the review of the unsuccessful cases in the surgical procedure was important for the proposed changes. For them type II tyroplasty has advantages, such as: a) stable effect with no recurrence of dystonia; b) the possibility of making intraoperative adjustments; c) there is no change in the vocal fold itself; d) does not develop an iatrogenic disorder; and e) the procedure is reversible and readjustable. The disadvantge is the low acceptance of the procedure. Radiofrequency thyroarytenoid myothermy (n=1) 2008 Kim; Choi; Lim; Choi; Lim19 Study the treatment of AdSD by means of a modification in the Remacle surgical procedure. The study was conducted with twenty women with spasmodic dysphonia who had already received BT injection with success in the treatment. The result of treatment with radiofrequency thyroarytenoid myothermy was considered an alternative treatment, however the results were effective for two months after surgery. After six months a reduction in the results was noted in 50% of the patients. Fabron EMG, Marino VCC, Nóbile TC, Sebastião LT, Onofri SMM Rev. CEFAC, São Paulo Among the articles found, 37% reported medical treatment with BT injection and results indicated an improvement in the vocal quality analyzed by means of vocal and quality of life self-evaluation protocols. However, the observed results demonstrated the temporary effectiveness of the treatment and the need to reapply the toxin22-32 The articles that reported on surgical procedures (33%) were based on the premise that surgery would be a long-lasting treatment option for SD, without the need to return to control pathology symptoms. Among the surgical procedures, myectomy alone or combined with neurectomy was presented as an option in cases in which the patient desires a long-lasting outcome. The results presented were positive in most cases and the scholars stressed the irreversibility of the surgery12-14,33. Regarding selective laryngeal adductor dener- vation and reinnervation surgery, two articles from the same group of researchers were found. While one of these articles addressed a literature review36, the other reported on the satisfactory outcome of the surgical procedure from the vocal analysis done by the voice handicap index protocol15. In relation to thyroplasty, the results of this treatment were analyzed in more than one article showing the concern of a surgical team in improving the surgical procedures initially proposed. In general, the researchers discussed the indication and contra- indication of this surgery, presented modifications to the surgical technique, and pointed to the patient’s own satisfaction in his/her voice quality16-18. The use of the Remacle modified radiofrequency thyroarytenoid myothermy was reported on in one study. The result was described as a good alter- native to treat SD, though not considered effective in all cases since 50% of the patients had BT injection one year following myothermy19. There was only one single study that used lidocaine injection (lidocaine block of the RLN) Table 3 – Articles categorized as other treatments for spasmodic dysphonia divided by year, author (s), objective (s) and results Table 4 – Articles categorized as speech pathology (speech therapy) treatment for spasmodic dysphonia divided by year, author (s), objective (s), and results Other treatments (n=2) Year Author (s) Objetives Results Lidocaine (n=1) 2006 Smith; Roy; Wilson20 Investigate the effects on speech by using lidocaine to block the RLN in treating AdSD. The study was conducted with twenty-one patients with spasmodic dysphonia. The results showed that during the blockage of RLN, the patients reported a reduction in the severity of the symptoms and vocal effort. In the perceptual-auditory evaluation, judges verified that the voices were breathier and less tense. Homeopathy (n=1) 2009 Xue; Schepper; Hao21 Describe the perceptual and physiological changes in the vocal function of patients treated with classical homeopathy. The study was conducted with a 57 year-old male patiente diagnosed with AdSD. The medicine was offered after analysis of the initial medical interiew (Argentum Nitricum – 30C from Borion). Perceptual analysis was performed with the CAPE-V protocol and analysis of some acoustic parameters. The findings show that after three months of treatment there was a significant reduction in the severity of the strained-strangled voice quality. The number of breaks in the voice was reduced and the patients demonstrated increased control of the speech mechanism, as well as reporting an emotional well-being. This may be a possible treatment for those patients who desire to not use botox. Year (n=1) Author (s) Objetive (s) Results 2009 Haselden; Powell; Drinnan; Carding35 Examine the Health Locus of Control (HLoC), a protocol for evaluating the patient’s locus of control over their health in three groups of patients: 1 – spasmodic dysphonia, 2 – functional dysphonia, and 3 – a group without dysphonia and without laryngeal dystonia (control group). The study showed that in spasmodic dysphonia, the relationship between the frequency of injection and the health locus of control may be an interesting focus study. The study demonstrated the effect of vocal therapy on health control or the validity of health control as an indicator for prognosis of treatment. The authors argued that when the patient has a high value of internal control (Internal LoC), the voice therapy may have a positive outcome because the patient will be able to increase the sense of voice control. The LoC protocol was chosen as a good prognostic indicator for treatment in Speech therapy. However, they suggest that the use of BT before therapy may help the results. Treatment of spasmodic dysphonia Rev. CEFAC, São Paulo may be a possible treatment for those patients who do not wish to use botox21. Regarding speech pathology treatment, no articles that discussed the effects of vocal technique action in the treatment of SD during the period studied were found. Only one article commented on achieving positive results with speech therapy associated with BT injection in patients with good results in the Health Locus of Control “internal control” index (evaluation protocol of the patient’s locus of control in his/her health)35. Another literature review article pointed to two studies that discussed speech therapy as a treatment for SD. One of these studies reported that speech therapy improved speech intelligibility, voice functionality, confidence of the patient, when the therapy was combined with BT injection. In the other study, it was concluded in the AdSD in order to investigate the effects on phonation. The results showed that blockage is possible, however the study did not present length of effect. The authors pointed out that this procedure may be used as a differential diagnostic resource for SD20. Homeopathy treatment was found in only one article which aimed to describe the perceptual and physiological changes in the vocal function of patients treated with classic homeopathy. The results found in this study showed that after three months of treatment, a significant reduction in the strained-strangled severity and quality of the voice was observed. The number of voice breaks was reduced and the patients demonstrated greater control of the speech mechanism, as well as a reported emotional well-being. For the authors, this Table 5 – Articles categorized as literature review of spasmodic dysphonia treatments divided by year, author(s), objective(s), and results Year (n=6) Author (s) Objetive Results 2006 Chhetri; Berke36 Present, with literature support, the modifications in selective adductor laryngeal denervation and reinnervation since its proposal. Furthermore, the article presents step-by-step surgical procedure and research results of the impact on vocal quality and patient satisfaction. The research results of the impact on vocal quality and patient satisfaction showed that the surgery is an alternative therapy in treating SD, and patient satisfaction is high, and most patients managed voice fluency with minimum breathiness. The complications could be minimized by conservative LCA myotomy. Truong; Bhidayasiri37 Review in the literature about laryngeal muscle hyperactivity syndromes, techniques and types of toxin injections available, as well as doses used. In the literature, the use of BT is the most often described treatment for AdSD, especially applied in the TA muscle. It also described its application in the LCA and interarytenoid muscles depending on whether it is adductor or abductor SD. The studies presented results of uni or bilateral applied BT. In addition, the authors found the description of intramuscular toxin injection techniques as: percutaneous, transoral, transnasal, and point touch. Studies with type and toxin dosage control were also found. 2006 Watts; Nye; Whurr4 Determine the efficacy of BT in the treatment of SD through a randomized systematic analysis in the Cochrane database. The evidence of the results based on randomized and controlled studies is lacking in the literature surveyed 2008 Watts; Truong; Nye38 Review in the literature which high quality methodology researches were developed to show the effectiveness of BT treatment for AdSD in the period from 1973 to December 2006. Articles with studies classified as class I and II, which showed evidence on the effectiveness of BT, were published between 1991 and 2001, and pointed out the effectiveness of the application of BT in treating AdSD. According to the article, no high quality study has been published since 2001 2009 Ludlow39 Raise the advance of surgical approaches in recent years that aim to provide long-term control of SD symptoms The authors argue that the use of BT is considered the standard treatment for SD, but many surgical techniques have been proposed with both benefits and side effects, such as breathy voice and dysphagia. They concluded that it is necessary to develop studies aimed at understanding central neurological abnormality. 2009 Delnooz; Horstink; Tijssen; Warrenburg40 Systematic review of studies on paramedical strategies for the treatment of primary dystonia. Analyzed the studies based on evidence according to EBRO classification. Only articles published in English from 1970 to July 2008, from the databases Pubmed, The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINHAL and ISI-SCI and used clinical outcome measures were included. For laryngeal dystonia three articles were found: one of them, classification B, pointed out that vocal therapy combined with BT is beneficial to the patient and prolonging the interval of Botox injection improved respiratory measurements and the acoustic parameters. The other studies, with classification B, showed conflicting results, one of which suggested that speech therapy improved intelligibility, speech functionality, and patient confidence. The other concluded that speech therapy, psychotherapy, and biofeedback had not positive effect on SD. Fabron EMG, Marino VCC, Nóbile TC, Sebastião LT, Onofri SMM Rev. CEFAC, São Paulo and homeopathy. The use of BT injection showed results that indicated the satisfaction of the patients treated, although some of the articles point out the disadvantage of this treatment, i.e. the need to reapply BT after a few months. With regard to surgical procedures, they may be considered long- lasting and suitable for patients that do not wish to undergo BT injections. The studies, however, presented contingency of restricted patients and the results were based on the patient’s own judgement as to his/her vocal quality. The use of lidocaine and homeopathy showed positive results in relation to the vocal quality of the patient and was suggested as an option for those patients who would not like to submit to surgery or BT injection. The few studies that did contemplate speech therapy showed positive results from this treatment when combined with BT injection. However, it is clear the lack of evidence on the effects of speech therapy in treating SD, although associated with medical treatment. Thus, there is the need for further research involving speech therapy in SD in associated with clinical and/ or surgical treatment. that speech therapy, as well as pyschotherapy and biofeedback did not bring positive effect in controlling pathological symptoms40. In this survey, there were six literature review articles and half of them attempted to learn about treatment options published in a given period of time, whose scientific methodology could prove the effectiveness of treatments 4,38,40. The others also tried to obtain the knowledge of proposed treatment of SD by only considering the results of surgery or the use of BT36,37,39. A single literature review identified the need for further studies in the understanding of neurological functioning in SD, for then it would be possible to attempt a treatment without side effects39. � CONCLUSION This study presents a bibliographic review on the proposed medical treatment and speech pathology for SD in the period between the years 2006 and 2010. The reported medical treatments included BT injection, surgical procedures, lidocaine injection RESUMO A disfonia espasmódica (DE) é um distúrbio vocal caracterizado por voz tensa-estrangulada, com quebras de sonoridade e que compromete a comunicação do indivíduo. O objetivo deste estudo é apresentar uma revisão bibliográfica dos tratamentos médico e fonoaudiológico proposto para a DE no período entre 2006 e 2010. Os tratamentos descritos foram: injeção de toxina botulínica (TB), miectomia, neurectomia, denervação e reinervação laríngea seletiva adutora, tireoplastia, miotermia tiroaritenóidea com radiofrequência, injeção de lidocaína, homeopatia e tratamento fonoaudiológico (fonoterapia). O uso de injeção de TB mostrou resultados que indicaram a satisfação dos pacientes tratados, embora alguns dos artigos apontassem a necessidade de reaplicação da toxina frequente- mente, como desvantagem. Os procedimentos cirúrgicos foram considerados duradouros e indicados para os pacientes que não quiseram se submeter às aplicações de TB. Tais estudos, no entanto, apresentaram contingência de pacientes restrita e os resultados foram baseados, na maioria das investigações, no julgamento dos próprios pacientes sobre a sua qualidade vocal. Os tratamentos, com uso de lidocaína e homeopatia, mostraram resultados positivos em relação à qualidade vocal dos pacientes e foram sugeridos como uma opção, também, para aqueles que não gostariam de ser sub- metidos ao tratamento cirúrgico ou à aplicação de TB. Os poucos estudos que reportam fonoterapia assinalaram bons resultados quando a mesma foi associada à injeção de TB, mostrando a escassez de informações nesta área. Futuras pesquisas envolvendo a fonoterapia no tratamento da DE são necessárias. DESCRITORES: Disfonia; Disfonia Espástica; Distonia Treatment of spasmodic dysphonia Rev. CEFAC, São Paulo do músculo tireoaritenóideo em paciente com disfonia espasmódica de adução. Rev Bras Otorrinolaringol. [periódico na Internet]. 2006; [acesso em 21 de fevereiro de 2011]; 72(2): [número de páginas aproximado 5p.]. Disponível em: http://www.scielo.br/scielo.php?script=sci_ arttext&pid=S0034-72992006000200019&lang=pt& tlng=pt 15. Chhetri DK, Mendelsohn AB, Blumin JH, Berke GS. Long-term follow-up results of selective laryngeal adductor denervation-reinnervation surgery for adductor spasmodic dysphonia. Laryngoscope. 2006;116(4):635-42. 16. Sanuki T, Isshiki N. Overall evaluation of effectiveness of type II thyroplasty for adductor spasmodic dysphonia. Laryngoscope. 2007;117(12):2255-9. 17. Sanuki T, Isshiki N. Outcomes of type II thyroplasty for adductor spasmodic dysphonia: analysis of revision and unsatisfactory cases. Acta Otolaryngol. 2009; 129(11):1287-93. 18. Isshiki N, Sanuki T. Surgical tips for type II thyroplasty for adductor spasmodic dysphonia: modified technique after review unsatisfactory cases. Acta Otolaryngol. 2010;130(2):275-80. 19. Kim HS, Choi HS, Lim JY, Choi YL, Lim SE. Radiofrequency thyroarytenoid myothermy for treatment of adductor spasmodic dysphonia: how we do it. Clin Otolaryngol. 2008;33(6):621-5. 20. Smith ME, Roy N, Wilson C. Lidocaine block of the recurrent laryngeal nerve in adductor spasmodic dysphonia: a multidimensional assessment. Laryngoscope. 2006;116(4):591-5. 21. Xue S, Schepper L, Hao GJ. Treatment of spasmodic dysphonia with homeopathic medicine: a clinical case report. Homeopathy. 2009;98(1):56-9.. 22. Santos VJB, Mattioli JM, Mattioli WM, Daniel RJ, Cruz VPM. Distonia laríngea: relato de caso e tratamento com toxina botulínica. Rev Bras Otorrinolaringol. [periódico na Internet]. 2006 Mai/ Jun [acesso em 21 de fevereiro de 2011];72(3): [número de páginas aproximado 3p.]. Disponível em: http://www.scielo.br/scielo.php?script=sci_ arttext&pid=S0034-72992006000300022&lang=pt& tlng=pt 23. Thomas JP, Siupsinskiene N. Frozen versus fresh reconstituted botox for laryngeal dystonia. Otolaryngol Head Neck Surg. 2006;135(2):204-8. 24. Cantarella G, Berlusconi A, Maraschi B, Ghio A, Barbieri S. Botulinum toxin injection and airflow stability in spasmodic dysphonia. Otolaryngol Head Neck Surg. 2006;134(3):419-23. 25. Paniello RC, Barlow J, Serna JS. Longitudinal follow-up of adductor spasmodic dysphonia patients after botulinum toxin injection: quality of life results. Laryngoscope. 2008;118(3):564-8. � REFERENCES 1. Aronson AE. Adductor Spastic Dysphonia. Clinical voice disorders. New York: Thieme Medical Publishers, 1990, p. 161-83. 2. Siemons-Lurinhg DI, Merman M, Martens J-P, Deuster D, Muller F, Dejonckere, P. Spasmodic dysphonia, perceptual and acoustic analysis: presenting new diagnostic tools. Eur Arch Otorhinolaryngol. 2009; 266(12):1915-22. 3. Grillone GA, Chan T. Laryngeal Dystonia. Otolaryngol Clin North Am. 2006; 39(1):87-100. 4. Watts C, Nye C, Whurr R. Botulinum toxin for treating spasmodic dysphonia (laryngeal dystonia): a systematic Cochrane review. Clin Rehabil. 2006;20(2):112-22. 5- Ress CJ, Blalock PD, Kemp SE, Halum SL, Koufman JA, Differentiation of adductor-type spasmodic dysphonia from muscle tension dysphonia by spectral analysis. Otolaryngol Head Neck Surg. 2007;137(4):576-81. 6. Behlau M, Pontes P. A evolução do conceito da disfonia espástica. In: Ferreira LP, editor. Um pouco de nós sobre voz. 4ª ed., Carapicuíba: Pró-Fono; 1995. p.101-18. 7. Santos AO. As distintas manifestações fonoaudiológicas e psicológicas na disfonia espasmódica [trabalho de conclusão de curso]. Marília (SP): Universidade Estadual Paulista – UNESP. Curso de Fonoaudiologia. Departamento de Fonoaudiologia; 2010. 8. Zwiner P, Murry T, Swenson M, Woodson GE. Acoustic changes in spasmodic dysphonia after botulinum toxin injection. J Voice. 1991;5(1):78-84. 9. Fisher K, Scherer R, Guo C, Owen A. Longitudinal phonatory characteristics after botulinum toxin type A injection. J Speech Hear Res. 1996;39(5):968-80. 10. Zwiner P, Murry T, Woodson G. Perceptual acoustic relationships in spasmodic dysphonia. J Voice. 1993;7(2):165-71. 11. Viola IC. Atuação terapêutica e análise de um caso de disfonia espástica. In: Ferreira LP. Um pouco de nós sobre voz. 4ª ed., Carapicuíba: Pró-Fono; 1995. p. 95-9. 12. Nakamura K, Muta H, Watanabe Y, Mochizuki R, Yoshida T, Suzuki M. Surgical treatment for adductor spasmodic dysphonia: efficacy of bilateral thyroarytenoid myectomy under microlaryngoscopy. Acta Otolaryngol. 2008;128(12):1348-53. 13. Koufman JA, Rees CJ, Halum SL, Blalock D. Treatment of adductor-type spasmodic dysphonia by surgical myectomy: a preliminary report. Ann Otol Rhinol Laringol. 2006;115 (2):97-102. 14. Tsuji DH, Chrispim FS, Imamura R, Sennes LU, Hachiya A. Impacto na qualidade vocal da miectomia parcial e neurectomia endoscópica Fabron EMG, Marino VCC, Nóbile TC, Sebastião LT, Onofri SMM Rev. CEFAC, São Paulo 26. Woodson G, Hochstetler H, Murry T. Botulinum toxin therapy for abductor spasmodic dysphonia. J Voice. 2006;20(1):137-43. 27. Cannito MP, Kahane JC, Chorna L. Vocal aging and adductor spasmodic dysphonia: response to botulinum toxin injection. Clin Interv Aging. 2008;3(1):131-51. 28. Birkent H, Maronian N, Waugh P, Merati AL, Perkel D, Hillel AD. Dosage changes in patients with long-term botulinum toxin use for laryngeal dystonia. Otolaryngol Head Neck Surg. 2009;140(1):43-7. 29. Upile T, Elmiyeh B, Jerjers W, Prasad V, Kafas P, Abiola J, Youl B, Epstein R, HoppeR C, Sudhoff H, Rubin J. Unilateral versus bilateral thyroarytenoid botulinum toxin injections in adductor spasmodic dysphonia: a prospective study. Head Face Med [serial on the internet]. 2009 [cited 2011 Feb 21]; 5(20): [about 6p.]. Available form: http://www.ncbi.nlm.nih. gov/pmc/articles/PMC2770450/?tool=pubmed 30. Chang CY, Chabot P, Thomas JP, Warrenton VA, Warnick RI, Portland OR. Relationship of botulinum dosage to duration of side effects and normal voice in adductor spasmodic dysphonia. Otolaryngol Head Neck Surg. 2007;136(6):894-9. 31. Paniello RC, Edgar JD, Perlmutter JS. Vocal exercise versus voice rest following botulinum toxin injections: a randomized crossover trial. Ann Otol Rhinol Laryngol. 2009;118(11):759-63. 32. Braden MN, Johns MM, Klein AM, Delgaudio JM, Gilman M, Hapner ER. Assessing the effectiveness of botulinum toxin injections for adductor spasmodic dysphonia: clinician and patient perception. J Voice. 2010;24(2):242-9. Received on: September 29,2011 Accepted on: May 08, 2012 Mailing address: Eliana Maria Gradim Fabron Avenida Santa Helena, 909 – casa J214 – Jardim Alvorada Marília – SP CEP: 17513-322 E-mail: elianaf@marilia.unesp.br 33. Su CY, Chuang HC, Tsai SS, Chiu JF. Transoral approach to laser thyroarytenoid mioneurectomy for treatment of adductor spasmodic dysphonia: short term results, Ann Otol Rhinol Laryngol.2007;116(1):11-8. 34. Sanuki T, Yumoto E, Minoda R, Kodama N. Effects of type II tyyroplasty on adductor spasmodic dysphonia. Otolaryngol Head Neck Surg. 2010;142(4):540-6. 35. Haselden K, Powell T, Drinnan MIKE, Carding P. Comparing health locus of control in patients with spasmodic dysphonia, functional dysphonia and nonlaryngeal dystonia. J Voice. 2009;23(6):699-706. 36. Chhetri DK, Berke GS. Treatment of adductor spasmodic dysphonia with selective laryngeal adductor denervation and reinnervation surgery, Otolaryngol Clin North Am. 2006;39(1):101-9. 37. Truong DD, Bhidayasiri R. Botulinum toxin therapy of laryngeal muscle hyperactivity syndromes: comparing different botulinum toxin preparations. Eur J Neurol. 2006;13(1):36-41. 38. Watts CR, Truong DD, Nye C. Evidence for the effectiveness of botulinum toxin for spasmodic dysphonia from high-quality research designs. J Neural Transm. 2008; 115(4):625-30. 39. Ludlow CL. Treatment for spasmodic dysphonia: limitations of current approaches. Curr Opin Otolaryngol Head Neck Surg. 2009;17(3):160-5. 40. Delnooz CCS, Horstink MWIM, Tijssen MA, Bart PC. Paramedical treatment in primary dystonia: a systematic review. Mov Disord. 2009;24(15):2187-98.