I have had spasmodic dysphonia for eight years now. I have had all the conventional treatments, Botox, speech therapy and before that antibiotics and steroids. I have been all over Houston's medical center and went to the National Institutes of Health. Basically, I was told to learn to live with it. Have there been any new and promising developments in the past couple of years? As a former nurse, I believe this is a neurologic condition. Is there reason to hope for a cure in my lifetime?

J.L.

A physician of the 1930s provided an excellent description of spasmodic dysphonia (SD): the patient's voice sounds like she is "trying to talk whilst being choked." Speech in SD has a characteristic harsh, "strangled" quality, with frequent voice breaks and overall decreased intelligibility.

SD certainly is a neurologic condition: it is considered a "focal dystonia" and is also known by the name "laryngeal dystonia." Dystonia refers to abnormal sustained contraction of a voluntary muscle. SD involves frequent, inappropriate contractions of the muscles that move the vocal cords.

The vocal cords are bands of ligament and muscle joined together at one end, forming a V. When you breathe, the V opens, permitting air to pass into the windpipe. When you speak, the vocal cords move together. The muscles that open the cords are abductors, while those that close the cords are adductors. Dystonia of the adductor muscles results in the symptoms described above. In abductor SD, which is less common, the vocal cords open inappropriately during speech; the result is breathy, whispery speech characterized by frequent voice breaks.

The only accepted treatment for SD is injection of botulinum toxin into the dystonic muscles. Botulinum toxin (trade name Botox) is a chemical produced by the bacterium that causes botulism. Although this may sound ominous, Botox is carefully prepared and is a safe, effective drug. Botox causes a lengthy paralysis of the muscle into which it is injected. This weakens the muscle so that it contracts with less force. Usually, patients have three to four months of relief after Botox injection. The side effects include a brief period of a breathy voice and problems choking on thin liquids.

Botox is, by far, the newest and most promising development in the treatment of SD. As you have discovered, other treatments fail miserably. I am not sure why you had an unfavorable response to Botox, and I find it worrisome that you have been treated at two excellent institutions yet have not been helped. Here are a few possible explanations:

1. The success of Botox injection depends upon the accuracy of the injection. If the toxin is not injected into the correct muscle, it will have little or no effect (or even, conceivably, a detrimental effect) on the voice. Accuracy depends upon the experience of the doctor doing the injection. If you were injected by anyone other than an experienced laryngologist (an ear, nose and throat specialist with fellowship training in the treatment of voice problems), you may have had an inaccurate injection.
   
2. Perhaps you have abductor SD. If so, then physician experience is even more crucial, because the injection is technically more difficult than for adductor SD.
   
3. The effectiveness of the injection also depends upon receiving an adequate dose. The toxin is somewhat fragile, and if stored under adverse conditions its strength can diminish. Ideally, it is prepared fresh and used immediately. It is also possible that your physician used a low initial dose with the intention of increasing the dose if you did not have a good response. If you did not allow your doctor to reinject you, then you have not given Botox an adequate trial.
   

I encourage you to give Botox therapy another chance. Find an experienced laryngologist in your area (a medical school librarian could probably assist you) and insist that he or she be the one to perform the injection. Do not give up after one failed injection. For more information, visit The Voice Center webpage of the Eastern Virginia Medical School.