Treatments: Spasmodic Dysphonia (Laryngeal Dystonia)

There is no cure for spasmodic dysphonia yet, but treatment helps most people speak more easily. This page explains botulinum toxin injections, voice therapy, medicines, surgery and newer treatments being studied.

What spasmodic dysphonia is, its types, and how it is diagnosed are covered on the spasmodic dysphonia conditions page.

The big picture

• There is no cure for SD yet, but treatment helps most people speak more easily. The goal is a voice that is smoother, takes less effort, and allows full participation in work and daily life.

• The best treatment depends on the type of SD. Treatments that work well for adductor SD (strained, strangled voice) often work less well for abductor SD (breathy breaks). Voice tremor also changes the plan.

• Botulinum toxin injections are the most common and best-studied treatment. Most people start here.

• Voice therapy is a helpful partner to other treatments, but it usually does not control SD well by itself.

• Surgery is an option for some people with adductor SD, especially those who want a longer-lasting result.

• Several new treatments are being studied and may become options in the future.

• Treatment is a partnership. Patients and their care teams choose together based on the type of SD, how much it affects daily life, goals, health, and preferences. Treatment plans are often adjusted over time.

Treatment options at a glance

Botulinum toxin injections

What is it?

Botulinum toxin is a medicine made from a protein that relaxes muscles. It has been used to treat SD since the late 1980s and is considered the standard first treatment for adductor SD. It is often known by the brand name Botox; other brands exist. (General information on how these medicines work is on the botulinum toxins page.)

A note about safety and dose: The amount used for SD is very small. For example, a single cosmetic treatment of forehead wrinkles commonly uses about 20 units. Doses for SD are often just a few units.

A note about "off-label" use: In the United States, botulinum toxin is not specifically FDA-approved for SD. This is called "off-label" use. That does not mean it is experimental. Botulinum toxin has been used for SD for more than 30 years in many thousands of patients, and national guidelines for ear, nose, and throat doctors recommend it as a treatment for SD. Insurance coverage varies by plan.

How does it work?

In SD, the brain sends too many "squeeze" signals to certain voice muscles. Botulinum toxin blocks the chemical signal between the nerve and the muscle, so the muscle becomes partly and temporarily weakened. The muscle can no longer spasm as strongly, so the voice becomes smoother.

It does not fix the problem in the brain that causes SD. Over a few months, the nerve grows new connections to the muscle, the effect wears off, and symptoms return. This is why injections are repeated.

Which muscles are injected?

• Adductor SD: the muscles that close the vocal folds (the thyroarytenoid muscle, and sometimes a nearby muscle called the lateral cricoarytenoid). These muscles may be injected on one side or both sides.

• Abductor SD: the muscle that opens the vocal folds (the posterior cricoarytenoid, at the back of the voice box). This is usually injected on one side at a time, because weakening both sides at once could make it harder to breathe.

• Voice tremor: similar muscles as in adductor SD, depending on where the tremor is.

How well does it work?

In large studies, people with adductor SD also reported better quality of life, more self-confidence, more social involvement, and less mental effort when speaking after injections. These benefits continue over years of repeated treatment. For most people, injections keep working just as well over time.

Before an injection

Several factors matter to the care team before an injection:

• Pregnancy, plans for pregnancy, or breastfeeding. Research is limited. So far, reports have not shown a higher rate of birth defects, but most doctors prefer to avoid or postpone injections during pregnancy unless the benefits clearly outweigh the risks. This is an individual discussion.

• A nerve or muscle disease such as myasthenia gravis, Lambert-Eaton syndrome, ALS, or a neuropathy. These can increase the risk of weakness from botulinum toxin.

• Existing trouble swallowing or breathing. People with swallowing problems before the injection are more likely to have swallowing trouble afterward.

• Medicines, especially certain antibiotics (aminoglycosides, such as gentamicin), muscle relaxants, or medicines with "anticholinergic" effects, which can make the toxin stronger. Blood thinners matter too.

• Botulinum toxin elsewhere in the body (for example, for migraine, neck dystonia, or cosmetic reasons) in the past few months.

• An important upcoming event (see "Planning around the injection cycle" below).

What happens during the injection?

Injections are usually done in the office while the patient is awake. The visit itself is often short, and the injection takes only a few minutes.

The most common method:

1. The patient sits or lies back with the head tilted slightly back.

2. The skin on the front of the neck may be numbed. Some doctors also numb the inside of the voice box, which may cause a brief cough.

3. The doctor passes a thin needle through the front of the neck, just below the Adam's apple, into the voice muscle.

4. The needle is often connected to an EMG machine, which plays the electrical activity of the muscle as a crackling sound. The patient may be asked to say "eee" so the doctor can hear when the needle is in the right muscle.

5. The medicine is injected, and the needle is removed.

Other methods some doctors use include injecting while watching through a thin camera passed through the nose (laryngoscopy), injecting through the mouth, or, rarely, giving the injection under general anesthesia in an operating room.

Most people feel pressure, a pinch, or a brief urge to cough or swallow, and return to normal activities the same day. If the throat was numbed, eating and drinking are usually held for a short time.

What to expect after the injection: the treatment cycle

Each injection follows a fairly predictable pattern. Knowing it ahead of time helps many people feel less worried.

Not all of the time between injections is "good voice" time. Many people have a breathy phase at the start and a wearing-off phase at the end. The aim is to make the good-voice period as long as possible.

Common side effects

• Breathy, weak, or soft voice. This is the most common side effect, reported after about half of injections in some studies. It usually lasts about 2 weeks. It means the muscle has relaxed, and many people consider it an expected part of the cycle.

• Trouble swallowing liquids. This may feel like water "goes down the wrong way," causing coughing. It happens after roughly 1 in 7 injections in some studies, and more often when patients are asked about it in detail. It usually lasts about 2 weeks and is usually mild.

• Mild soreness or bruising where the needle went in.

• For abductor SD injections: some people notice mild noisy breathing (stridor) or a feeling of tightness when breathing in, especially with exercise. This is one reason the injection is usually done on one side at a time.

Getting through the breathy, swallowing-change phase

Strategies people commonly use during this phase include:

• Small sips of liquids, taken slowly.

• Tucking the chin slightly toward the chest when swallowing liquids, which can help protect the airway.

• Thicker liquids (such as smoothies, nectars, or soups), which are often easier than water.

• Sitting upright when eating and drinking, and not talking while swallowing.

• Resting the voice rather than straining to push it louder, and using a voice amplifier, text, or email when needed.

• Lighter speaking days for the first week or two when possible.

• Other safe swallowing strategies from a speech-language pathologist.

Rare but serious side effects

Product labels for botulinum toxin warn that it can, rarely, cause serious swallowing or breathing problems, especially in people who already have swallowing or breathing difficulties or a nerve or muscle disease. The very small doses used for SD make this unlikely, but the warning signs are listed in "Symptoms that need prompt attention" at the end of this page.

Finding the best dose

• The first few injections are a "fine-tuning" period. Everyone responds differently. The dose, and whether one or both sides are injected, is adjusted based on how the last injection went.

• Injecting both sides tends to give a longer benefit (on average, about 3 weeks longer), but often with more breathiness and swallowing changes. Injecting one side tends to cause fewer side effects but may wear off sooner. Some people alternate sides.

• It can take several injection cycles (sometimes up to about 5) to find the dose that works best. After that, many people stay on a steady dose for years.

• A voice diary (see below) is one of the most useful tools for adjusting the dose.

What if the injection does not work well?

• Sometimes an injection does not work as well as expected. This happens after roughly 1 in 10 injections, and is more common with the very first injection or a new injecting doctor. Usually, a dose or technique adjustment fixes this.

• Losing response permanently is rare. Some people's bodies make antibodies against the toxin, but in SD this happens in fewer than 1 in 100 people, likely because the doses are so small.

• When injections are not giving enough benefit, or the repeated cycle becomes tiresome, other options include surgery or research studies.

A voice diary

A simple diary helps patients and their care teams understand the cycle. After each injection, people often record:

• The date of the injection

• When a change was first noticed

• When breathiness or swallowing trouble started and stopped

• When the voice was at its best, and how good it was (for example, on a scale of 0 to 10)

• When symptoms started coming back

• Anything else noticed

Planning around the injection cycle

Because the cycle is predictable, many people time their injections around important events, such as a wedding, presentation, job interview, trial, or holiday. In general, the aim is for the event to fall in the best-voice window (often about 2 to 6 weeks after the injection), and not in the first 1 to 2 weeks, when the voice may be breathy. Planning works best when started early with the care team.

Voice therapy

What is it?

Voice therapy is treatment with a speech-language pathologist (SLP) who specializes in voice. It usually involves a series of sessions plus practice at home. More about voice therapy in general is on the voice treatments page.

What is its role in SD?

• Voice therapy alone usually does not control SD well. SD is caused by faulty signals from the brain, and practice alone cannot fully override those signals. Research on voice therapy as the only treatment for SD is very limited.

• Voice therapy can still be very helpful as a partner to other treatments. Many people with SD develop extra muscle tension as they try to push through spasms. Therapy can help reduce this tension, which may make the voice easier to use.

• It can help after injections or surgery by teaching efficient use of the new voice, without slipping back into old, strained habits.

• It can help with diagnosis. If the voice improves a lot with therapy alone, a different condition such as muscle tension dysphonia may be more likely.

• It teaches practical communication strategies, such as using a voice amplifier, pacing, and managing difficult speaking situations like phone calls.

National guidelines for ear, nose, and throat doctors describe voice therapy as a useful add-on to botulinum toxin for SD. One small study did not find that adding voice therapy made injections last longer, so the benefit may vary from person to person.

What might therapy include?

• Gentle breathing and breath-support exercises

• Techniques for starting the voice more easily and with less force

• "Resonant voice" exercises, which focus on a buzzy, forward feeling in the face rather than squeezing in the throat

• "Semi-occluded vocal tract" exercises, such as humming or speaking through a straw, which can reduce strain

• Relaxation of the neck, jaw, and shoulders

• Strategies for the breathy phase after injections

• Help choosing and using a personal voice amplifier or other communication tools

Medicines taken by mouth

No pill is approved specifically for SD, and medicines by mouth usually provide only mild benefit, if any. Only a small number of people with SD use them regularly. They are sometimes tried, especially when there is also tremor or dystonia in other parts of the body.

Alcohol is not a treatment. Many people with SD notice their voice is briefly better after drinking alcohol. This is a known feature of the condition and is guiding research into new medicines (see "Treatments being studied" below), but alcohol is not a safe or effective treatment.

Surgery

Who considers surgery?

Surgery is an option mainly for adductor SD. It may be considered for people who:

• Do not get enough benefit from botulinum toxin injections

• Have side effects from injections that are hard to tolerate

• Want a longer-lasting result instead of repeated injections

• Have had a stable diagnosis for some time and understand the risks

Surgery for SD is specialized. It is done at a limited number of centers, and not every type of surgery is available everywhere.

Important things to know about all SD surgeries:

• Results vary. Most people improve, but not everyone, and the voice may not become completely normal.

• Some breathiness may remain long-term in some people.

• Symptoms can return in some people, sometimes requiring more treatment.

• Surgery does not cure the brain-based cause of SD. It changes the voice box so the spasms have less effect on the voice.

Selective laryngeal adductor denervation-reinnervation (SLAD-R)

• What it is: The surgeon cuts the small nerve branches that carry the faulty "squeeze" signals to the muscles that close the vocal folds. Then the surgeon connects a different nearby nerve to those muscles, so they stay healthy and have some tone but no longer receive the spasm signals.

• How it is done: Through an incision in the neck, under general anesthesia. Both sides are treated.

• Results: In long-term studies, about 8 out of 10 people had a clearly improved voice that lasted years. In one study comparing people who had SLAD-R with people who continued injections, most surgical patients said their voice was better after surgery than it had been with injections, and more than 8 in 10 said they would recommend the surgery.

• Recovery: The voice is usually weak and breathy for several months while the new nerve connections grow. This can last up to about 10 months, which matters especially for people whose work depends on their voice.

• Risks: Some people are left with some breathiness (about 3 in 10 in one study) or some remaining voice breaks. Temporary swallowing difficulty can occur. Very rarely, serious, long-lasting swallowing problems have been reported.

Type 2 thyroplasty (titanium bridge surgery)

• What it is: The surgeon makes a small vertical cut in the front of the thyroid cartilage (the "Adam's apple") and gently spreads the two halves apart, holding them open with small titanium bridges. This keeps the vocal folds from squeezing together too tightly during speech.

• How it is done: Through a small neck incision, usually with local anesthesia while the patient is awake, so the surgeon can listen to the voice and adjust the amount of spreading during the operation.

• Results: Studies show clear voice improvement that has lasted many years (up to about 8 years in reported studies). In one series, 7 out of 10 people rated their voice as excellent after surgery.

• Recovery: In published reports, people typically eat the next morning, go home after about 2 days, and rest the voice for about 1 week.

• Risks: Swelling inside the voice box usually goes away within about a month. A small number of people (roughly 2 to 7 out of 100) need a second surgery to adjust the result. The titanium bridges can sometimes crack over time, though this does not always cause symptoms to return.

• Availability: Most of the research on this surgery comes from Japan. It may not be available in all countries or centers.

Laser thyroarytenoid myoneurectomy

• What it is: Using a laser, the surgeon removes part of the main muscle that closes the vocal folds, along with its small nerve endings, to weaken the spasms permanently.

• How it is done: Through the mouth, using a scope, under general anesthesia. There is no neck incision.

• Results: In several studies, most people (about 8 to 9 out of 10) had moderate to marked improvement.

• Risks and limitations: The voice may become breathier. In one study, nearly half of patients needed a second procedure, on average about 1½ years later, because symptoms returned. Voice therapy after surgery may help.

Recurrent laryngeal nerve section (an older surgery)

This was the first surgery used for SD, starting in the 1970s. It involves cutting the main nerve to one vocal fold. Although many people improved at first, benefits often faded within a few years as the nerve grew back, and some people ended up worse. It is rarely done today and has largely been replaced by the surgeries above.

Surgery for abductor SD

Abductor SD is harder to treat with surgery. A few procedures have been described, such as procedures on the muscle that opens the vocal folds or procedures that move the vocal folds closer together. These have been studied in only a very small number of people, so results are less certain. People with abductor SD whose injections are not helping enough are sometimes evaluated at a specialized center.

Comparing surgeries for adductor SD

Treating voice tremor

When voice tremor is present, either with SD or on its own, treatment may be adjusted:

• Botulinum toxin is commonly used and can reduce shakiness, though tremor sometimes responds less completely than SD spasms.

• Propranolol or primidone may be tried. They tend to work better for hand tremor than voice tremor, but some people do benefit.

• Deep brain stimulation (see below) can reduce voice tremor in some people, usually as part of treating tremor elsewhere in the body.

• Treating both the SD and the tremor may require combining approaches.

Treatments being studied

Researchers are actively working on new ways to treat SD. The treatments below are not yet standard care for SD. Some may be available through clinical trials (research studies).

Sodium oxybate (a medicine by mouth)

• What it is: A medicine already approved in the United States for a sleep disorder called narcolepsy. It acts on some of the same brain chemical systems as alcohol.

• Why it is being studied: Because many people with SD notice their voice improves briefly after alcohol, researchers tested whether this medicine could do something similar, more safely.

• What research shows so far: In a carefully controlled study of 106 people with SD, a single dose worked better than a placebo (inactive pill) in people whose voice improves with alcohol. It did not clearly help people whose voice does not improve with alcohol. In an earlier study, the benefit started about 30 to 40 minutes after taking it and lasted a few hours.

• Status: Not approved for SD. It is a tightly controlled medicine with possible side effects such as drowsiness, dizziness, and nausea, and it can be dangerous if combined with alcohol or other sedatives. A larger study is planned. It is not safe to obtain or use outside a doctor's care.

Vibration therapy (vibrotactile stimulation)

• What it is: A small device placed on the front of the neck that vibrates gently over the voice box. It is painless and does not use needles or medicine.

• Why it is being studied: It may work like a "sensory trick," changing how the brain processes signals from the voice box.

• What research shows so far: In a study where people used the device at home, up to about half had a noticeable improvement in voice quality or effort. The effect lasted anywhere from less than 30 minutes to several days. It appeared to help people with adductor and abductor SD, and helped some people who were also receiving injections.

• Status: Experimental. Researchers are developing a wearable collar version.

Deep brain stimulation (DBS)

• What it is: A surgery in which thin wires are placed in specific areas of the brain and connected to a device similar to a pacemaker. It is already used for Parkinson disease, essential tremor, and some other types of dystonia.

• What research shows so far: Only a small number of people with SD (a few dozen worldwide in published studies) have been treated. Many reported a meaningful voice improvement.

• Status: Experimental for SD alone. Because it is brain surgery with real risks, it is generally considered only in research settings or for people who also have other conditions that DBS treats, such as essential tremor.

Brain stimulation from outside the head (rTMS and tDCS)

• What it is: Treatments that use magnetic pulses (rTMS) or a weak electrical current (tDCS) applied to the scalp to change brain activity.

• Status: Very early research. Small studies suggest these are safe, but it is not yet known whether they help SD.

Research studies

Clinical trials are how new treatments become available. Studies can be found by searching ClinicalTrials.gov for "spasmodic dysphonia" or "laryngeal dystonia," and patient organizations such as Dysphonia International and the Dystonia Medical Research Foundation often share news about research studies.

Choosing a treatment

There is no single "right" treatment for everyone. Things patients and care teams consider include:

• The type of SD (adductor, abductor, mixed) and whether tremor is present

• How much SD affects life, including work, relationships, and emotional well-being

• How well injections work and how the person feels about the repeated cycle

• Voice demands, such as speaking for a living or singing

• Other health conditions, including swallowing, breathing, nerve, or muscle problems

• Willingness to accept temporary side effects, surgery, or recovery time

• Practical factors, such as travel to a specialized center, time off work, and insurance coverage

Some people choose no treatment when symptoms are mild. That is a reasonable choice, and treatment can start later if needs change.

Emotional health during treatment

Treatment for SD is often a long-term process. It is normal to feel frustrated during the fine-tuning period, during the breathy phase after injections, or when the effect wears off. Counseling and support groups can help, and many people find that their mood improves as their voice improves.

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.

Symptoms that need prompt attention

These symptoms, at any time (including after an injection or surgery), call for emergency care (911 or the emergency room) right away:

• Trouble breathing, shortness of breath at rest, or a high-pitched or noisy sound when breathing in

• Choking, or being unable to swallow saliva

• Weakness spreading beyond the throat, such as trouble breathing, drooping eyelids, double vision, slurred speech, or generalized muscle weakness

These are worth bringing to the care team's attention soon:

• Coughing or choking with liquids or food that is severe, is getting worse, or lasts longer than about 4 weeks after an injection

• Fever, cough with mucus, or chest discomfort after swallowing problems, which could be signs of a lung infection from food or liquid going down the wrong way

• Weight loss or trouble getting enough to eat or drink

• Noisy breathing or breathlessness with activity after an abductor SD injection

• No change at all in the voice by about 2 weeks after an injection

• Redness, swelling, warmth, or increasing pain at an injection or surgery site

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

Questions people often discuss with their care team

About botulinum toxin injections: Which brand and dose, and why? One side or both sides? How long is the breathy phase likely to last? How can injections be timed around important events? What happens if an injection does not seem to work? Does insurance cover this treatment?

About other treatments: Would voice therapy help, and is a voice-specialized SLP available? Is a medicine worth trying for tremor? Is surgery an option, which type, and where is it done? What are the realistic results and risks of surgery? Are there research studies to join?

About the overall plan: How will it be clear whether treatment is working? How often is follow-up? What happens if symptoms change?

Glossary

• Abductor SD: a type of SD in which the vocal folds pull open during speech, causing breathy breaks.

• Adductor SD: the most common type of SD, in which the vocal folds squeeze together during speech, causing a strained voice.

• Anticholinergic: a type of medicine that blocks a nerve chemical called acetylcholine. Can cause dry mouth and can strengthen the effects of botulinum toxin.

• Botulinum toxin: a medicine that temporarily weakens muscles by blocking nerve signals. Botox is one brand.

• Clinical trial: a research study that tests whether a new treatment is safe and effective.

• Deep brain stimulation (DBS): a surgery that places thin wires in the brain to change abnormal brain signals.

• EMG (electromyography): a test that records the electrical activity of muscles. Often used to guide injections into voice muscles.

• Off-label: use of a medicine for a condition that is not listed on its official FDA label. This is common and legal when supported by experience and research.

• Placebo: an inactive pill or treatment used in research to compare against a real treatment.

• SLAD-R: selective laryngeal adductor denervation-reinnervation, a nerve surgery for adductor SD.

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

• Stridor: a high-pitched, noisy sound when breathing in, caused by a narrowed airway.

• Thyroplasty: a surgery that changes the shape of the voice box cartilage to change how the vocal folds meet.

• Vibrotactile stimulation: a research treatment that uses gentle vibration on the neck.

• Voice therapy: treatment with an SLP to improve how the voice is produced and used.