Laryngeal Tremor Treatment & Management

Updated: Apr 06, 2021
  • Author: Thomas L Carroll, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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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, 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. While systemic tremor symptoms can improve, the efficacy of other pharmacologic interventions for ETV is typically poor. [8]  Vocal fold augmentation for ETV does not always relieve the tremor but can improve other symptoms, such as effort, strain, and fatigue, and can ameliorate social restrictions; this treatment may offer a permanent option for symptom alleviation, but rarely symptom elimination.


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.


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 vocal fold injections, has had mixed results.

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. [14]

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. [15]

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.

Vocal fold augmentation in the setting of vocal fold atrophy and comorbid ETV has been shown to offer some sustained improvement in patient symptoms. [16]

Additionally, newer voice therapy techniques have shown promise with the behavioral management of ETV. [17]