Laryngeal Tremor Treatment & Management
- Author: Thomas L Carroll, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
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, 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. Although systemic tremor symptoms can improve, the efficacy of other pharmacologic interventions for ETV is typically poor.
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.
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, specifically Lee Silverman voice 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.
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. These agents are not usually successful in treating ETV. Studies of a small number of patients have shown no improvement of vocal symptoms with either propranolol or primidone. On the other hand, a study by Nida et al found improvement in essential vocal tremor in 14 of 26 patients treated with primidone, with the investigators suggesting that this agent can be used as an alternative to botulinum toxin.
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.
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.
Newer voice therapy techniques have shown promise with the behavioral management of ETV.
Fahn S. Involuntary Movements. Rowland LP. Meritt's Neurology. 11th. Philadelphia, PA: 2005. 48.
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. 2005 Nov. 133(5):654-65. [Medline].
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.
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].
Patel AB, Bansberg SF, Adler CH, Lott DG, Crujido L. The Mayo Clinic Arizona Spasmodic Dysphonia Experience: A Demographic Analysis of 718 Patients. Ann Otol Rhinol Laryngol. 2015 Nov. 124 (11):859-63. [Medline].
Perez KS, Ramig LO, Smith ME. The Parkinson larynx: tremor and videostroboscopic findings. J Voice. 1996 Dec. 10(4):354-61. [Medline].
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. 2011 Jul-Aug. 77(4):413-7. [Medline].
Bove M, Daamen N, Rosen C, et al. Development and validation of the vocal tremor scoring system. Laryngoscope. 2006 Sep. 116(9):1662-7. [Medline].
Adler CH, Bansberg SF, Hentz JG. Botulinum toxin type A for treating voice tremor. Arch Neurol. 2004 Sep. 61(9):1416-20. [Medline].
Nida A, Alston J, Schweinfurth J. Primidone Therapy for Essential Vocal Tremor. JAMA Otolaryngol Head Neck Surg. 2015 Dec 10. 1-5. [Medline].
Busenbark K, Ramig L, Dromey C, Koller WC. Methazolamide for essential voice tremor. Neurology. 1996 Nov. 47(5):1331-2. [Medline].
Barkmeier-Kraemer J, Lato A, Wiley K. Development of a speech treatment program for a client with essential vocal tremor. Semin Speech Lang. 2011 Feb. 32(1):43-57. [Medline].