Laryngeal Tremor Clinical Presentation

  • Author: Monika I Sidor, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Feb 1, 2012
 

History

Often, the voice disorder present is diagnosed based on history findings alone. Onset of voice tremor, aggravating and alleviating factors, associated neurologic symptoms, medications, and family history are important components of the patient history. A history of multiple neurologic findings may suggest that the laryngeal tremor is secondary to another disease. The patient should be asked about specific vocal symptoms, such as the following:

  • Tremor
  • Vocal fatigue
  • Pain with speaking
  • Increased effort
  • Hoarseness
  • Pitch breaks

Patients with laryngeal dystonia may have symptoms of adductor or abductor spasmodic dysphonia (SD). Adductor dysphonia is characterized by phonatory breaks, hoarseness, monotonal pitch, and a strained voice quality. A breathy voice quality and trouble with voiceless consonants (/p/, /t/, /l/, /h/, /f/, /s/) are associated with abductor dysphonia.

Essential tremor is characterized by postural or kinetic tremor of the upper extremities and head. Symptoms in patients with essential tremor of the voice (ETV) slowly worsen over months and years. Voice tremor increases with anxiety and, as with essential tremor in general, improves after alcohol ingestion.

Patients with Parkinson disease may experience the following symptoms:

  • Limb tremor
  • Bradykinesia
  • Rigidity
  • Poor articulation
  • Difficulty initiating speech
  • A soft, breathy voice
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Physical Examination

A thorough physical examination, including otolaryngologic and neurologic components, should be performed, with special attention paid to the neurologic examination of the mouth, pharynx, and larynx, as well as the evaluation of the voice. The assessment of vocal quality during conversational speech may enable the examiner to make a working diagnosis based only on the history and the sound of the patient’s voice.[6]

A neurolaryngeal examination, at rest and during phonation, is performed with a flexible laryngoscope. Spontaneous rhythmic muscular activity of the laryngeal, supraglottic, and pharyngeal muscles while at rest is characteristic of tremor. However, tremor may also occur during sustained phonation. Tremor should be differentiated from myoclonus, which is jerky and arrhythmic.

Full evaluation of the voice should include measures of fluidity, articulation, and voice quality (raspiness, breathlessness, strain). Phonatory tasks that isolate the abductor, adductor, and tensor muscle groups of the larynx allow the examiner to assess for paralysis, fatigability, and agility.

Bove et al developed a vocal tremor scoring system that standardized the evaluation and scaling of vocal tremor.[7] Furthermore, this system determined which patients were likely to benefit from botulinum toxin A (BTA) injection therapy.

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Contributor Information and Disclosures
Author

Monika I Sidor, MD  Resident Physician, Department of Surgery, University of Michigan at Ann Arbor Medical School

Monika I Sidor, MD is a member of the following medical societies: Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Soly Baredes, MD  Professor of Otolaryngology-Head and Neck Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Soly Baredes, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Society for Head and Neck Surgery, New York Head and Neck Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society

Disclosure: Nothing to disclose.

Brian E Benson, MD  Chief, Division of Laryngeal Surgery and Voice Disorders, Director, The Voice Center, Clinical Assistant Professor, Department of Otolaryngology, Hackensack University Medical Center; Attending Physician, Department of Otolaryngology, St Luke's-Roosevelt Hospital Center

Brian E Benson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, and Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

Additional Contributors

Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons

Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, American Society for Head and Neck Surgery, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Robert M Kellman, MD Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York, Upstate Medical University

Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Rhinologic Society, American Society for Head and Neck Surgery, Medical Society of the State of New York, and Triological Society

Disclosure: GE Healthcare Honoraria Review panel membership

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

References

  1. Fahn S. Involuntary Movements. In: Rowland LP. Meritt's Neurology. 11th. Philadelphia, PA: 2005:48.

  2. Merati AL, Heman-Ackah YD, Abaza M. Common movement disorders affecting the larynx: a report from the neurolaryngology committee of the AAO-HNS. Otolaryngol Head Neck Surg. Nov 2005;133(5):654-65. [Medline].

  3. Woodson GE, Blitzer A. Neurologic Evaluation of the Larynx and the Pharynx. In: Cummings CW, et al., eds. Otolaryngology Head and Neck Surgery. 4th ed. Philadelphia, PA: Mosby; 2005:2054-2064.

  4. Wolraich D, Vasile Marchis-Crisan C, Redding N, Khella SL, Mirza N. Laryngeal tremor: co-occurrence with other movement disorders. ORL J Otorhinolaryngol Relat Spec. 2010;72(5):291-4. [Medline].

  5. Perez KS, Ramig LO, Smith ME. The Parkinson larynx: tremor and videostroboscopic findings. J Voice. Dec 1996;10(4):354-61. [Medline].

  6. Korn GP, Moraes M, Vilanova LC, de Moraes BT, Madazio G, Padovani M, et al. Comparison of clinical characteristics of patients with adductor laryngeal dystonia in the focal and segmental types. Braz J Otorhinolaryngol. Jul-Aug 2011;77(4):413-7. [Medline].

  7. Bove M, Daamen N, Rosen C, et al. Development and validation of the vocal tremor scoring system. Laryngoscope. Sep 2006;116(9):1662-7. [Medline].

  8. Adler CH, Bansberg SF, Hentz JG. Botulinum toxin type A for treating voice tremor. Arch Neurol. Sep 2004;61(9):1416-20. [Medline].

  9. Busenbark K, Ramig L, Dromey C, Koller WC. Methazolamide for essential voice tremor. Neurology. Nov 1996;47(5):1331-2. [Medline].

 
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