Laryngeal Tremor 

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

Background

Laryngeal, or vocal, tremor is a common symptom of several neurologic disorders. Tremors are rhythmic, involuntary oscillating movements that, when the muscles of phonation are involved, have a disabling effect because of fluctuations in the amplitude and fundamental frequency of the voice. Vocal tremors involve not only tremor of the intrinsic muscles of the larynx but also, on occasion, the extrinsic laryngeal, pharyngeal, and palatal muscles, as well as the muscles of the diaphragm, chest wall, and abdomen (see the image below). (See Etiology and Presentation.)[1, 2, 3]

Laryngeal cartilages, posterior view. Laryngeal cartilages, posterior view.

Neurologic disorders characterized by vocal tremor include the following[4] (see Presentation, Workup, Treatment, and Medication):

Functional voice disorders may also result in vocal tremor. Vocal tremor in the absence of other neurologic disorders is called essential tremor of the voice (ETV).

Prevalence

Vocal tremor may be present in 25-30% of patients with essential tremor. Some reports describe vocal tremor in 66.7% of patients with adductor SD. Perez et al report vocal tremor in 55% of patients with Parkinson disease and in 64% of patients with Parkinson-plus syndromes.[5]

Prognosis

The degree of disability caused by laryngeal tremor may range from mild to incapacitating vocal symptoms. Progression of neurologic disease may lead to dysphagia and an increased risk of aspiration pneumonia. (See Presentation.)

Essential tremor of the voice (ETV) is a chronic condition with no cure. Without treatment, symptoms slowly worsen over months and years in patients with laryngeal tremor. (See Treatment and Medication.)

Patient education

The patient must know that no cure for ETV exists and that the treatment for this chronic condition addresses only the symptoms.

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Etiology

The larynx is under extensive neural control, and the physiology of phonation is complex. Several mechanisms have been implicated in the etiology of laryngeal tremor, including the interaction between a central oscillatory source and peripheral reflex loops.

As a rule, tremor results from a lesion that involves the extrapyramidal system or cerebellum. Electromyographic studies show that vocal tremor can arise from the involvement of muscles at any level of the speech production mechanism.

In contrast to spasmodic dysphonia (SD), which typically affects only the intrinsic laryngeal musculature, ETV that arises from the cerebello-olivary systems often affects a greater portion of muscles of the upper aerodigestive tract.

Approximately 50% of cases of essential tremor are inherited in an autosomal dominant fashion.

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Epidemiology

Measuring the true incidence of essential tremor is difficult because symptoms may be mild and go unnoticed in as many as 50% of affected people in the United States. Laryngeal dystonias are more prevalent in women, with a male-to-female ratio of 1:3-8.

Essential tremor is characterized by a bimodal age of onset, usually manifesting in the second and sixth decades of life. Parkinson disease is the most common movement disorder in patients older than 55 years, and dysphonia may be the initial symptom.

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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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Laryngeal cartilages, posterior view.
 
 
 
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