Laryngeal Tremor Treatment & Management

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

Approach Considerations

The treatment of vocal tremor depends on the etiology of the tremor. In Parkinson disease, for example, behavioral therapy can produce speech and voice improvements, while in adductor spasmodic dysphonia (SD), botulinum toxin A (BTA) is the mainstay of treatment. BTA can also be used to treat essential tremor of the voice (ETV), although the results of this treatment in ETV have been mixed. The efficacy of other pharmacologic interventions for ETV is unclear.[8]

Follow-up

The patient’s response to treatment needs to be periodically evaluated and, if needed, the medication dosage adjusted. Acoustic analysis or perceptual analysis may be used to monitor treatment response. The benefits of BTA injections for treatment of laryngeal tremor last approximately 3-4 months, so frequent follow-up is needed.

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Parkinson Disease

Standard levodopa (L-dopa) treatment has had limited and mixed results on laryngeal tremor. Some authors have found decreased jitter and increased fundamental frequency; other researchers have found no statistical improvement. Another therapy, the use of collagen vocal fold injections, has not been effective.

Patients with Parkinson disease gain a sustained benefit and improvement of speech and voice functions after behavioral therapy.

Deep-brain stimulation has been used to treat Parkinson vocal tremor, with mixed results. Side effects of this procedure include paresthesia, dysarthria, disequilibrium, and localized pain.

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Adductor Spasmodic Dysphonia

The mainstay of treatment for SD is BTA injection. It acts by blocking the release of acetylcholine at the neuromuscular junction. The toxin is thought to act as a zinc endopeptidase in the proteolysis of 1 or more neuronal proteins. Tremors in patients with adductor SD substantially improve with BTA injections. The benefits of this treatment generally last 3-4 months.

Side effects of BTA injections last for 2-3 weeks and include mild dysphagia and breathy hypophonia. Voice therapy was found to increase the benefits of BTA injections and is an important adjunct in the treatment of patients with adductor SD.

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Essential Tremor of the Voice

BTA injections and other pharmacologic treatments have been used to treat ETV. First-line treatment in patients who have other associated manifestations of essential tremor is pharmacologic. Propranolol and primidone have proven to be efficacious for essential tremor, with both of these medications decreasing the amplitude of tremor in about 50% of patients. The benefit of these agents in treating ETV is not known. Studies of a small number of patients have shown no improvement of vocal symptoms with either propranolol or primidone.

Methazolamide, a carbonic anhydrase inhibitor, showed promising results in the treatment of laryngeal tremor when studied in a small, open trial, but these results were not supported in a subsequent placebo-controlled, blinded investigation of 9 patients by Busenbark et al.[9]

BTA injections have shown mixed results in the literature. The recently described vocal tremor scoring system was able to predict favorable treatment outcomes with BTA injections.

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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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