Conditions: Spasmodic Dysphonia (Laryngeal Dystonia)

Spasmodic dysphonia, now also called laryngeal dystonia, is a long-term neurological condition in which the muscles of the voice box tighten or pull open on their own during speech. This page explains the types, symptoms, causes, diagnosis and outlook.

What is spasmodic dysphonia?

Spasmodic dysphonia (SD) is a long-term neurological condition that affects the voice. It causes the muscles inside the voice box (larynx) to tighten or pull open on their own while a person is speaking. These sudden, involuntary movements are called spasms. They interrupt the voice and can make speech sound strained, choppy, broken, or breathy. SD is one of many causes of voice problems and hoarseness.

SD is a type of dystonia. Dystonia is a group of movement disorders in which the brain sends incorrect signals to muscles, causing unwanted squeezing or movement. Other types of dystonia affect the neck, eyelids, jaw, or hand.

A newer name: laryngeal dystonia. In 2021, a panel of experts recommended calling this condition laryngeal dystonia (LD) to match the names of other dystonias. Either name may appear in medical records, reading materials, or online. They mean the same thing.

What SD is not

• It is not "all in the head." For many years, SD was wrongly thought to be caused by emotional or psychological problems. It is now known to be a neurological condition caused by changes in how the brain controls the voice muscles. Stress can make symptoms worse, but stress does not cause SD.

• It is not caused by damage to the vocal folds. When the voice box is examined, the vocal folds (also called vocal cords) usually look healthy. The problem is in the signals coming from the brain, not in the voice box itself.

• It is not caused by anything the person did. SD does not come from using the voice "wrong," and it could not have been prevented.

• It is not contagious, and it is not considered life-threatening.

How the voice normally works

The voice box sits in the neck, at the top of the windpipe. Inside are two bands of muscle and tissue called vocal folds.

• During breathing, the vocal folds open so air can flow in and out.

• During speech, the vocal folds come together and vibrate as air passes between them. This vibration makes sound.

• Some speech sounds, like vowels (a, e, i, o, u) and sounds like "m" and "b," need the vocal folds closed and vibrating. Other sounds, like "p," "t," "k," "s," "f," and "h," need the vocal folds briefly open.

The brain controls all of this in fractions of a second. In SD, the brain's control signals for speech are disrupted, so the vocal folds squeeze shut too hard, or pull open at the wrong time, in the middle of talking.

Types of spasmodic dysphonia

There are several types of SD. The type matters because it affects which treatments are likely to help.

Adductor SD (the most common type)

About 8 or 9 out of every 10 people with SD have this type.

• What happens: The vocal folds squeeze together too tightly during speech.

• How it sounds: The voice sounds strained, strangled, tight, or effortful. Words may get "stuck" or cut off, with sudden stops or breaks in the voice.

• When it is worst: During words full of vowel sounds, such as "We eat eels every day."

• How it feels: Many people say talking feels like hard work, or like pushing words out.

Abductor SD (less common)

• What happens: The vocal folds pull open at the wrong times during speech.

• How it sounds: The voice has sudden breathy, whispery, or airy breaks, and may sound weak.

• When it is worst: During words with sounds like "p," "t," "k," "s," "f," or "h" followed by a vowel, such as "Peter will keep at the peak."

• How it feels: People may feel they run out of air while talking or that the voice "drops out."

Mixed SD

Some people have features of both adductor and abductor SD. The voice may sound strained at some times and breathy at others. Some specialists find that the mixed type is more common than was once thought, especially in people who also have dystonia in other parts of the body.

Voice tremor (often occurs with SD)

A tremor is a shaking or rhythmic movement. Many people with SD also have tremor in the voice box, which makes the voice sound shaky, wobbly, or quavery, especially when holding a long sound like "ahhh." There are two main kinds:

• Dystonic voice tremor: tremor that occurs along with SD and shows up mainly while speaking.

• Essential voice tremor: tremor that is not limited to speech. It is often linked to a condition called essential tremor, which may also cause shaking of the hands or head. It can occur with or without SD.

Having voice tremor in addition to SD can affect which treatments work best.

Rare types

• Singer's laryngeal dystonia: symptoms appear mainly or only while singing. This mostly affects professional or highly trained singers.

• Respiratory laryngeal dystonia: the vocal folds close while breathing in, which can cause noisy breathing or shortness of breath. This type is very rare and usually does not affect the speaking voice.

Common symptoms

Symptoms vary from person to person, and from day to day. Common symptoms include:

• A voice that sounds tight, strained, strangled, or "choked" (adductor SD)

• Breathy or whispery breaks in the voice (abductor SD)

• Words that cut off or get stuck partway through

• A voice that seems to stop and start

• A shaky or trembling voice (if tremor is present)

• Talking that feels effortful and tiring

• Feeling worn out after conversations

• Others asking the person to repeat themselves, or asking whether they have a cold or are upset

A key feature: SD usually affects talking, but not other voice sounds

One of the most important clues to SD is that it is task-specific. It mainly affects speaking, while other voice sounds often stay normal or close to normal. Many people with SD notice that they can:

• Whisper normally

• Laugh, cry, yawn, cough, and clear the throat normally

• Sing more easily than they can talk (true for many people, but not everyone; some find singing nearly as hard as speaking)

• Shout or speak at a higher pitch with fewer breaks (this varies)

This pattern can be confusing for family, friends, or coworkers, who may wonder why someone can laugh or sing but struggle to say a simple sentence. It is a normal part of SD and actually helps doctors make the diagnosis.

Things that often make symptoms worse

• Stress, anxiety, or feeling rushed

• Talking on the telephone

• Being tired, or long periods of talking

• Speaking in important situations (meetings, presentations, ordering at a counter)

Things some people notice help temporarily

• "Sensory tricks": Some people find their voice improves briefly when they touch the throat or face, hum before speaking, or change posture. These tricks are common in many types of dystonia and reflect how the brain processes touch and movement.

• Alcohol: More than half of people with SD notice their voice is better for a short time after a small amount of alcohol. This is a known feature of the condition. It is not a treatment and is not a way to manage symptoms.

• Rest and relaxation may help some people, though symptoms can still occur when calm.

Who gets spasmodic dysphonia?

SD is rare. Estimates suggest it affects roughly 3 to 5 people out of every 100,000, or around 50,000 people in the United States.

• Sex: Women are affected about 2 to 4 times more often than men.

• Age: Symptoms most often start in the 40s or 50s, but SD can begin at almost any age, including in young adults and, rarely, in children.

• Family history: Most people with SD have no family members with the condition. However, about 1 in 5 people with SD has a relative with some type of dystonia (not necessarily in the voice).

What causes spasmodic dysphonia?

The exact cause is not known. Here is what research has shown so far.

A brain network condition

Brain imaging studies show that SD involves differences in a network of brain areas that work together to plan and control speech. These include areas on the brain's surface that control movement and sensation, as well as deeper areas (the basal ganglia, thalamus, and cerebellum) that help start movements and keep them smooth. In SD, these areas do not communicate normally during speech, so the voice muscles receive mixed or excessive signals. Researchers have also found differences in brain chemicals, such as dopamine and GABA, which help the brain turn movements on and off.

Genes may play a role

• Most cases are "sporadic," meaning they occur without a clear genetic cause.

• A few genes linked to other types of dystonia (such as THAP1, GNAL, TOR1A, and TUBB4A) have been found in a small number of people or families with voice involvement.

• Scientists believe many genes may each add a small amount of risk.

• Genetic testing is not routinely needed for most people with SD. It may come up for people with a strong family history of dystonia, symptoms that started at a young age, or dystonia in several parts of the body.

Possible triggers

Some people notice their symptoms began after a particular event. Studies have found SD sometimes starts after:

• A cold, flu, or other upper respiratory infection (about 3 in 10 people report this)

• A period of major stress or a traumatic event

• Heavy voice use at work or in daily life

• Throat or neck injury, or ongoing acid reflux

• Rarely, certain medicines that block dopamine (such as some antipsychotic or anti-nausea medicines)

These are associations, not proven causes. Many people go through these same experiences and never develop SD. Researchers think these events may "unmask" the condition in people whose brains were already prone to it.

Conditions related to spasmodic dysphonia

Dystonia in other parts of the body

Some people with SD also have, or later develop, dystonia somewhere else. The most common areas are:

• Neck (cervical dystonia): the head may turn, tilt, or pull involuntarily

• Eyelids (blepharospasm): increased blinking or eyes squeezing shut

• Jaw, mouth, or tongue (oromandibular dystonia)

• Hand or arm (such as writer's cramp)

Sometimes dystonia elsewhere appears before the voice symptoms. A neurologist who specializes in movement disorders can evaluate these symptoms.

Tremor

As described above, voice tremor is common in people with SD. Some people also have tremor in the hands or head.

Mood and anxiety

Living with a voice that does not work reliably can be very hard. People with SD have higher rates of depression, anxiety, frustration, embarrassment, and social withdrawal than people without voice problems. Research suggests these feelings are mostly a result of living with the voice problem, not the cause of it, and that they often improve when the voice improves. See "The emotional side of SD" below.

Conditions that can look like SD

Several other voice problems can sound similar to SD. Telling them apart is important because they are treated differently.

It is also possible to have more than one of these conditions at the same time. For example, some people with SD develop extra muscle tension as they try to push through the spasms.

How is spasmodic dysphonia diagnosed?

There is no single blood test, scan, or X-ray that diagnoses SD. Instead, diagnosis is based on a careful evaluation by experienced specialists who listen to the voice, watch how the voice box moves, and rule out other causes.

The care team may include

• Laryngologist or otolaryngologist (ear, nose, and throat doctor, or ENT): a doctor who specializes in the voice box

• Speech-language pathologist (SLP): a voice specialist who evaluates how the voice is produced

• Neurologist: often a movement disorders specialist, especially if there are signs of dystonia or tremor elsewhere in the body

What the evaluation usually involves

1. Health history and questions. Common questions include when symptoms started and whether they began suddenly or gradually; whether the voice changes from day to day or in different situations; whether talking feels effortful or tiring; whether whispering, laughing, singing, shouting, coughing, and yawning are normal; whether anything makes the voice better or worse (stress, phone calls, alcohol, touching the throat); family history, medicines, and other health conditions; and how the voice affects work, relationships, and daily life. (The voice appointment preparation page lists this kind of information.)

2. Voice and speech tasks. The SLP or doctor typically asks the person to read special sentences (some loaded with vowel sounds to bring out adductor SD, others loaded with "p," "t," "k," "s," and "h" sounds to bring out abductor SD); count out loud (for example, from 60 to 70, and from 80 to 90); hold long vowel sounds like "eee" or "ahhh"; whisper, sing, shout, and laugh; and have a normal conversation. The voice is usually recorded so it can be reviewed in detail and compared with future recordings.

3. Looking at the voice box (laryngoscopy). This is an essential part of the evaluation. A thin, flexible camera is passed gently through the nose to view the vocal folds during talking, singing, coughing, and breathing. The nose is usually numbed with a spray first. The exam takes a few minutes, and breathing continues normally throughout. It may feel odd or cause mild pressure but is usually not painful. Some clinics use a special light (stroboscopy) or a high-speed camera to see the vocal folds vibrate in slow motion.

In SD, the vocal folds typically look healthy and move normally during breathing, coughing, and other non-speech tasks, but spasm during speech. This exam also rules out growths, paralysis, and other structural problems.

4. Questionnaires. Forms such as the Voice Handicap Index measure how much the voice affects daily life and help track changes over time.

5. Other tests (sometimes).

• A trial of voice therapy. If the voice improves a lot with therapy alone, a condition like muscle tension dysphonia may be more likely. If it does not improve much, SD becomes more likely.

• A neurological exam to check for dystonia or tremor in other parts of the body.

• Laryngeal EMG, a test that measures electrical activity in the voice muscles using a small needle, is occasionally used but is not needed for most people.

• MRI scans are not routinely needed for diagnosis. Brain imaging is an active area of research and may one day help confirm the diagnosis.

Why diagnosis can take time

Many people with SD see several doctors over several years before getting the correct diagnosis. On average, it takes about 4 to 5 years and visits with about 4 different clinicians. This happens because:

• SD is rare, and many health care providers have seen few cases

• It can sound like other, more common voice problems

• There is no single test that confirms it

• Even experts sometimes disagree, especially in mild or mixed cases

Evaluation at a specialized voice center with an experienced team can help. It is also normal for a diagnosis to be "probable" at first and become clearer over follow-up visits.

What to expect over time

Every person's experience with SD is different, but some general patterns are known.

• Onset: In most people, symptoms come on gradually over weeks to months. In others, symptoms seem to start more suddenly, often after an illness or stressful time.

• Early course: Symptoms often worsen during the first months to years, then tend to level off. In about one-third of people, symptoms may continue to slowly progress.

• Day-to-day changes: The voice may be better on some days than others. Symptoms often worsen with stress, fatigue, and phone calls.

• Long-term: SD is a chronic (lifelong) condition. It does not usually go away on its own, although a small number of people report periods of improvement.

• Spread to other areas: About 15 to 18 out of 100 people who start with SD in the voice later develop dystonia in a nearby area such as the jaw, face, tongue, or neck. When spread happens, it most often occurs within the first few years. People who still have voice-only symptoms after about 5 years are less likely to develop spread.

• What SD does not usually do: Common types of SD do not usually affect breathing, swallowing, or eating. SD does not turn into Parkinson disease.

Effective treatments are available that help most people speak more easily, and many people with SD continue to work, socialize, and live full lives.

The emotional side of SD

The voice is a big part of who a person is. It is how people work, connect with others, express emotion, and get their needs met. Losing reliable control of it can be deeply upsetting. People with SD commonly describe:

• Frustration and embarrassment when speaking

• Avoiding phone calls, meetings, restaurants, or social events

• Feeling misunderstood, or being told they sound nervous, sick, or upset

• Difficulty at work, especially in jobs that require a lot of talking

• Feeling a loss of control over their own body

• Sadness, worry, or feeling isolated

These feelings are real and common. Research shows that about 4 in 10 people with SD experience significant anxiety or depression at some point. Counseling, support groups, and treatment for depression or anxiety can make a meaningful difference, alongside treatment for the voice.

Anyone having thoughts of self-harm can get help right away: in the United States, call or text 988 (Suicide and Crisis Lifeline), or call 911 in an emergency.

Daily life with SD

Many people with SD find practical strategies that make communication easier. They do not treat SD itself.

Communication

• Explaining SD to people seen often. A simple statement such as "I have a neurological voice condition. I'm not sick or upset, it's just how my voice works" can ease many conversations.

• Using text messages, email, and online chat when phone calls are difficult.

• Using a personal voice amplifier (a small microphone and speaker) in noisy places or meetings. An SLP can help with choosing one.

• Planning ahead for important conversations and writing down key points.

• Choosing quieter places for conversations to avoid straining.

• Using speech-to-text or text-to-speech apps on a phone or computer.

• Workplace accommodations, which a care team can document when needed.

Self-care

• Managing stress. Stress does not cause SD, but it can make symptoms worse. Relaxation techniques, exercise, and good sleep may help.

• Pacing talking during the day and taking breaks.

• Staying hydrated.

• Keeping a symptom diary of good and bad voice days, possible triggers, and mood, to bring to appointments.

• Not relying on alcohol to improve the voice, even when it seems to help.

Connecting with others

Many people find it helpful to connect with others who have SD. Support organizations offer education, support groups (in person and online), and research updates, including Dysphonia International (formerly the National Spasmodic Dysphonia Association) and the Dystonia Medical Research Foundation (DMRF).

A brief note about treatment

There is currently no cure for SD, but there are effective ways to manage symptoms. Options include botulinum toxin injections (the most commonly used treatment), voice therapy as a support, surgery for carefully selected people, and research studies of newer approaches. The best treatment depends on the type of SD and whether tremor is also present. More on these options is on the botulinum toxins page and the voice treatments page. These options are explained on the spasmodic dysphonia treatments page.

Symptoms that are not typical of SD

Some symptoms are not part of SD and are urgent:

• Trouble breathing, or a high-pitched or noisy sound when breathing in

• Choking, or being unable to swallow saliva

These call for emergency care (911 or the emergency room) right away.

Other changes are worth bringing to a doctor's attention soon:

• New problems with swallowing, or coughing or choking while eating or drinking

• New involuntary movements elsewhere, such as neck pulling or turning, excessive blinking, jaw or tongue movements, or hand cramping with writing

• A sudden or major change in the voice

• Hoarseness along with throat pain, ear pain, a lump in the neck, coughing up blood, or unexplained weight loss. These are not typical of SD and are checked promptly.

• Feelings of sadness, hopelessness, or anxiety that affect daily life

Questions people often discuss with their care team

• What type of SD is it? Is voice tremor also present?

• How certain is the diagnosis? Could anything else be causing the symptoms?

• Are there signs of dystonia anywhere else in the body?

• Would a movement disorders neurologist be helpful?

• Is genetic testing worthwhile for the person or family?

• What changes are worth watching for over time?

• Is a speech-language pathologist available?

• What resources are available for support or counseling?

• Which treatment options fit this type of SD?

• Are there research studies to join?

Glossary

• Abductor: a muscle movement that opens the vocal folds.

• Adductor: a muscle movement that closes the vocal folds.

• Dystonia: a neurological condition that causes involuntary muscle contractions, leading to abnormal movements or postures.

• Dysphonia: any problem with producing voice.

• Focal: affecting one area of the body.

• Larynx (voice box): the organ in the neck that holds the vocal folds and produces voice.

• Laryngeal dystonia (LD): the newer name for spasmodic dysphonia.

• Laryngoscopy: an exam using a small camera to look at the voice box.

• Laryngologist: an ear, nose, and throat doctor with extra training in voice disorders.

• Muscle tension dysphonia: a voice problem caused by excess tension in the muscles around the voice box.

• Sensory trick: a touch or action that temporarily reduces dystonia symptoms.

• Speech-language pathologist (SLP): a specialist who evaluates and treats speech, voice, and swallowing problems.

• Task-specific: symptoms that appear during certain activities (like speaking) but not others (like laughing).

• Tremor: a rhythmic shaking movement.

• Vocal folds (vocal cords): two bands of tissue in the voice box that vibrate to make sound.

For more on how the voice box works, see the voice learning center page.