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.

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.

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]

Medication

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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Gillivan-Murphy P, Carding P, Miller N. Vocal tract characteristics in Parkinson's disease. Curr Opin Otolaryngol Head Neck Surg. 2016 Jun. 24 (3):175-82. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Perez KS, Ramig LO, Smith ME. The Parkinson larynx: tremor and videostroboscopic findings. J Voice. 1996 Dec. 10(4):354-61. [QxMD MEDLINE Link].
Adler CH, Bansberg SF, Hentz JG. Botulinum toxin type A for treating voice tremor. Arch Neurol. 2004 Sep. 61(9):1416-20. [QxMD MEDLINE Link].
de Lima Xavier L, Simonyan K. Neural Representations of the Voice Tremor Spectrum. Mov Disord. 2020 Dec. 35 (12):2290-300. [QxMD MEDLINE Link].
Hemmerich AL, Finnegan EM, Hoffman HT. The Distribution and Severity of Tremor in Speech Structures of Persons with Vocal Tremor. J Voice. 2017 May. 31 (3):366-77. [QxMD MEDLINE Link].
Paige C, Hopewell BL, Gamsarian V, et al. Characterizing the Normative Voice Tremor Frequency in Essential Vocal Tremor. JAMA Otolaryngol Head Neck Surg. 2018 Dec 1. 144 (12):1169-73. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Bove M, Daamen N, Rosen C, et al. Development and validation of the vocal tremor scoring system. Laryngoscope. 2006 Sep. 116(9):1662-7. [QxMD MEDLINE Link].
Nida A, Alston J, Schweinfurth J. Primidone Therapy for Essential Vocal Tremor. JAMA Otolaryngol Head Neck Surg. 2015 Dec 10. 1-5. [QxMD MEDLINE Link].
Busenbark K, Ramig L, Dromey C, Koller WC. Methazolamide for essential voice tremor. Neurology. 1996 Nov. 47(5):1331-2. [QxMD MEDLINE Link].
Van Doren M, Faudoa E, Carroll TL. Treatment of Patients with Vocal Fold Atrophy and Comorbid Essential Voice Tremor: Long-Term Injection Augmentation Outcomes After Successful Diagnostic Vocal Fold Injection Augmentation. J Voice. 2018 Nov 29. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Nelson RC, Silva Merea V, Tierney WS, Milstein C, Benninger MS, Bryson PC. Laryngeal Botulinum Toxin Injection for Vocal Tremor: Utility of Concurrent Strap Muscle Injection. Laryngoscope. 2019 Jun. 129 (6):1433-7. [QxMD MEDLINE Link].

Media Gallery

Laryngeal cartilages, posterior view.

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Author

Thomas L Carroll, MD Instructor, Department of Otolaryngology, Harvard Medical School; Director, Brigham and Women's Voice Program, Brigham and Women's Hospital

Thomas L Carroll, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American Laryngological Association, American Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Pentax Medical, Merck and Co., Bellus Health<br/>Scientific advisory board, stock options for Sofregen Medical ad N-Zyme for: Book Royalties from Plural Publishing.

Coauthor(s)

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, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Soly Baredes, MD Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School; Director of Otolaryngology-Head and Neck Surgery, University Hospital

Soly Baredes, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Laryngological Association, The Triological Society, American Medical Association, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, Triological Society, New York Head and Neck Society, New York Laryngological Society, New Jersey Academy of Otolaryngology-Head and Neck Surgery, The New Jersey Academy of Facial Plastic Surgery, International Skull Base Society

Disclosure: Nothing to disclose.

Brian E Benson, MD, FACS Founding Chair, Department of Otolaryngology-Head and Neck Surgery, Hackensack Meridian School of Medicine; Chief, Division of Laryngeal Surgery, Interim Chair, Department of Otolaryngology-Head and Neck Surgery, Attending Surgeon, Hackensack University Medical Center; Co-Chief, Division of Head and Neck Oncology, The John Theurer Cancer Center at Hackensack University Medical Center

Brian E Benson, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, New York Head and Neck Society, New York Laryngological Society

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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Ryte; Neosoma; MI10<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10.

Acknowledgements

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