DISFONÍA ESPASMÓDICA

ASHA
¿Qué es la disfonía espasmódica?
La disfonía espasmódica es un trastorno crónico (a largo plazo) de la voz.
En la disfonía espasmódica el movimiento de las cuerdas vocales es tenso y
forzado y tiene como resultado una voz que suena quebrada, temblorosa, ronca,
tensa o entrecortada. Se dan espasmos o interrupciones vocales, periodos
durante los cuales no se produce sonido alguno (afonía), y periodos durante los
cuales se produce una voz casi normal.

¿Cuáles son los síntomas o características observables de la disfonía

espasmódica?
Al principio, los síntomas pueden ser leves y pueden presentarse sólo de
vez en cuando. Más tarde, pueden empeorar y presentarse con mayor frecuencia
antes de nivelarse. Los síntomas pueden empeorar cuando la persona está
cansada o tensa. Y pueden también mejorar mucho o incluso desaparecer, por
ejemplo, cuando la persona ríe o canta.
La disfonía espasmódica es un trastorno que se caracteriza por el
movimiento involuntario de uno o más músculos de la laringe u órgano de la voz.
Los primeros síntomas de disfonía espasmódica se presentan con mayor
frecuencia entre las personas de los 30 a los 50 años de edad. Este trastorno
parece afectar con mayor frecuencia a las mujeres que a los hombres. La
gravedad de los espasmos de la voz fluctúa. Pueden disminuir durante horas e
incluso días.

¿Cómo se diagnostica la disfonía espasmódica?

No existe una simple prueba para diagnosticar la disfonía espasmódica. El
diagnóstico se basa en la presencia de las características y los síntomas típicos
descritos arriba y en la ausencia de otras condiciones que pudieran causar
problemas similares. La mejor evaluación del problema se lograría mediante el
trabajo en equipo de un grupo de profesionales que incluyera:
• un patólogo del habla y el lenguaje (también llamado en español logopeda,
fonoaudiólogo, terapeuta del habla o foniatra) para evaluar la producción y
el timbre de la voz,
• un otorrinolaringólogo (especialista en oído, nariz y garganta) para el
reconocimiento de las cuerdas vocales y su movimiento, y
• un neurólogo para la detección de síntomas de problemas neurológicos.

¿Cuáles son los tratamientos posibles para la disfonía espasmódica?

En la actualidad no existe cura para la disfonía espasmódica. Sin embargo,
sí existen varias opciones de tratamiento para mejorar la voz.
Con frecuencia se recomienda varias inyecciones de pequeñas dosis de
toxina botulínica (Botox) en una o ambas cuerdas vocales. La toxina botulínica
debilita los músculos laríngeos y tiene como resultado una voz más suave y
menos forzada, porque las cuerdas vocales se cierran con menos fuerza. Es
posible que durante un corto periodo de tiempo después de ser administradas, las
inyecciones causen temporalmente voz entrecortada o dificultad al tragar.
También podría recomendarse que se obtenga tratamiento con un patólogo del
habla y el lenguaje después de las inyecciones para optimizar la producción de la
voz.
Cuando los objetivos son que el paciente acepte el trastorno y aprenda las
técnicas necesarias para vivir con el mismo y sobrellevarlo con éxito, la atención
psicológica y psiquiátrica es de gran utilidad. También podría ser necesario
recomendar asesoría de desarrollo vocacional o de carrera para las personas que
teman que este trastorno amenace su ocupación. La participación en los grupos
locales de apoyo para autoayuda puede también fomentar el ajuste al problema y
brindar acceso a excelentes fuentes de información.

NATIONAL SPASMODIC DISPHONIA ASSOCIATION

Maybe you have heard someone whose voice sounds tight, strangled,
broken, whispery, or otherwise “not quite right.” It may be your own voice or that of
someone you know. You may be trying to determine what is wrong, or a doctor
may have already diagnosed the condition as spasmodic dysphonia (SD).
Spasmodic dysphonia belongs to a family of neurological disorders called
dystonias. A dystonia is a movement disorder that causes muscles to contract and
spasm involuntarily. Dystonias can be generalized, affecting the entire body, or
focal, affecting only a specific area of the body or group of muscles. Following
Parkinson’s disease and essential tremor, dystonia is the third most common
movement disorder. The most common focal dystonia, cervical dystonia, causes
the neck to twist or contort. Other dystonias can cause abnormal, involuntary
blinking or spasm of the eyelids (blepharospasm), inappropriate contractions of the
hand muscles (writer’s cramp), or uncontrolled movements from spasms in any of
the muscles of the face, jaw, or tongue (oromandibular dystonia).
Certain dystonias, including SD, are task-specific, meaning that the muscles
spasm only when they are used for particular actions and not when they are at
rest. When a person with SD attempts to speak, involuntary spasms in the tiny
muscles of the larynx cause the voice to break up, or sound strained, tight,
strangled, breathy, or whispery. The spasms often interrupt the sound, squeezing
the voice to nothing in the middle of a sentence, or dropping it to a whisper.
However, during other activities, such as breathing and swallowing, the larynx
functions normally.
Spasmodic dysphonia is estimated to affect approximately 50,000 people in
North America, but this number may be somewhat inaccurate due to ongoing
misdiagnosis or undiagnosed cases of the disorder. Although it can start at any
time during life, SD seems to begin more often when people are middle-aged. The
disorder affects women more often than men. Onset is usually gradual with no
obvious explanation. Symptoms usually occur in the absence of any structural
abnormality of the larynx, such as nodules, polyps, carcinogens, or inflammation.
People have described their symptoms as worsening over an approximate 18-
month period and then remaining stable in severity from that point onward. Some
people have reported brief periods of remission, however this is very rare and the
symptoms usually return.
People with SD initially notice either a gradual or sudden onset of difficulty in
speaking. They may hear breaks in their voices during production of certain words
or speech sounds, breathy-sounding pauses on certain words or sounds, or a
tremulous shaking of the voice. They may feel that talking requires more effort than
before. Often people say that their voices sound as if they “have a cold or
laryngitis.” The symptoms of SD can vary from mild to severe. A person's voice can
sound strained, tight, strangled, breathy, or whispery. The spasms often interrupt
the sound, squeezing their voice to nothing or dropping it to a whisper. Stress does
not cause SD, but it can worsen the spasms.

SINTOMAS
Adductor Spasmodic Dysphonia
SD is generally catergorized into two primary forms: adductor spasmodic
dysphonia (AdSD) and abductor spasmodic dysphonia (AbSD).
Adductor SD, the most common form, affects approximately 80–90% of
people with SD. In this type, spasms, usually in the thyroarytenoid muscle (TA),
force the vocal folds together in adduction, or closing. AdSD may also affect the
lateral cricoarytenoid muscle (LCA) or interarytenoid (IA). These spasms occur
particularly on “voiced” speech sounds.
If the voice cuts out, or breaks when the voiced sound is at the beginning of
the word, as in “eels,” the speaker often strains over the spasm to get the word
started. If the troubling vowel occurs in the middle of the word, the voice often
breaks the word in two.
For example, the word “lawn” would come out as “la---awn.” When the
voiced vowel is at the end of the word, such as “pleasingly,” the word terminates
earlier than it should, causing the speaker to sound as if he or she is swallowing
words. The speaker usually has no effort or disruption with the non-voiced vowels
and unvoiced consonants. However, since most words and sentences contain
voiced sounds, an adductor voice can be very hard to understand as the spasms
continuously interrupt the flow of speech.
In very severe cases of AD, the speaker may need to use extreme effort to
produce any voice at all since vowels occur frequently in speech. People with
AdSD often complain of having to struggle to speak.

Abductor Spasmodic Dysphonia

AbSD, a less common form, occurs in approximately 10–20 percent of
cases and results from spasms when the posterior cricoarytenoid muscles (PCA)
abducts, or opens, the vocal folds. AbSD causes problems with the production of
“voiceless” speech sounds, which normally sound “airy” or “breathy” when
produced.
In AbSD, the spasms in the abductor muscles cause the vocal folds to
remain open for a longer duration than should normally occur on these sound
combinations. This results in the voice taking longer to complete the voiceless
sounds, which makes the speaker sound “breathy.” For example, a person with
AbSD might produce the word “he” as “h……….he.” The symptoms of AbSD can
occur on any voiceless sound at the beginning, middle, or end of the word.
As with AdSD, the symptoms in AbSD can range from mild to severe.
Significant overall breathiness or a whispered voice quality may occur in people
with a very severe form of the disorder where breaks occur on every voiceless
consonant. Because people with AbSD expend too much air as they produce
sound, they often describe feeling winded or out-of-breath during speaking.

Subtypes of Spasmodic Dysphonia

While most people with spasmodic dysphonia fall into these two categories,
researchers have identified several subtypes. A person may have a mixed form
with symptoms of both AdSD and AbSD. Some people with SD also have a tremor
in their voice. Typically, tremor affects muscle groups outside of the larynx and can
cause the voice to sound “shaky” or “quivery.” Like adductor and abductor
spasmodic dysphonia, the symptoms of vocal tremor can range from mild
(infrequent, periodic tremor) to severe (affecting all voicing and singing). A very
severe tremor with significant shaking can even cause the voice to cut out,
sounding similar to the voice breaks in AdSD. In addition, sometimes treatment of
the SD symptoms reveals a co-existing underlying tremor.

Muscle Tension Dysphonia

SD may also be accompanied by or misdiagnosed as muscle tension dysphonia
(MTD), which is sometimes also referred to as a “hyperfunctional” voice. Although
the MTD voice sounds tight or strained and sometimes similar to AdSD, MTD is
considered a functional condition rather than a neurological one. MTD occurs when
the speaker exerts too much pressure or effort on the laryngeal muscles. In some
cases, people with AdSD may try to hold their vocal folds tighter in an attempt to
control them. This compensatory mechanism can result in the person developing a
variant of MTD on top of the SD.

Examples of Symptom Provoking Sentences

During an evaluation by a healthcare professional, a specific series of
voicing and speaking tasks may be used to determine the type of SD.
People with AdSD will have more difficult with sentences with voiced sound such
as these:
• Albert eats eggs every Easter
• We mow our lawn all year long
• Early one morning a man and a woman were ambling along a one mile lane
• Whereas people with AbSD will find these sentences with voiceless sounds
more challenging:
• Harry hit the hammer hard
• She sells seashells by the seashore
• The puppy bit the tape
Other parts of the evaluation may include reciting numbers, singing, laughing and
shouting.
CAUSAS
Although the exact cause of SD is unknown, evidence suggests that the
problem starts at the base of the brain in the basal ganglia, which regulate
involuntary muscle movement. To oversimplify, this nervous system regulator does
not function properly and produces incorrect signals, which cause the muscles to
contract or relax more than they should or at the wrong time.
What makes finding the cause even more difficult is that the spasms do not
occur in all types of speech. Two studies conducted in 1968 by Aronson, et. al.,
and one conducted by Ludlow and Connor in 1987, have shown that the symptoms
of SD improve or disappear during laughing, crying, yelling, throat clearing,
coughing, whispering, and humming.\Generally, SD does not affect the emotional
aspects of speech. As described earlier, SD is task-specific and tends to affect only
normal conversational speech. Researchers consistently have identified
abnormalities in brainstem reflexes and other aspects of disordered neurological
function in people with spasmodic dysphonia.
Genetic factors may put some people at greater risk of developing
spasmodic dysphonia, particularly those who have family members with any form
of dystonia.
While anecdotal evidence may suggest that symptom onset follows illnesses
such as viral infection, head trauma, bronchitis, surgery, or a stressful event, such
linkages have not been scientifically proven and the medical community has not
reached agreement on whether illness or stress plays any part in the onset of SD.
Regardless of the cause, it is most important to make a correct diagnosis and then
consider the available treatment options.

DIAGNÓSTICO
Spasmodic dysphonia can be difficult to diagnose because the anatomy of
the larynx is normal. SD has no objective pathology that is evident through x-rays
or imaging studies like a CT or MRI scan, nor can a blood test reveal any particular
fault. In addition, several other voice disorders may mimic or sound similar to it.
The excessive strain and misuse of muscle tension dysphonia (MTD), the harsh
strained voice of certain neurological conditions, the weak voice symptoms of
Parkinson’s disease, certain psychogenic voice problems, acid reflux, or voice
tremor are often confused with SD. Therefore, the best way to diagnose the
problem is to find an experienced clinician with a good ear.

Who Treats Spasmodic Dysphonia?

Usually an otolaryngologist, a physician that specializes in diseases of the
ears, nose, and throat (ENT), diagnoses SD. Some otolaryngologists, called
laryngologists, have additional postgraduate training and specialize in voice
disorders. Many otolaryngologists work with a speech pathologist, a clinician who
has expertise in the evaluation and non-medical treatment of voice disorders. A
neurologist may also be part of the diagnostic team to evaluate a patient for other
forms of dystonia or other neurological conditions.
After taking the medical history, the physician and speech pathologist listen
carefully to the person’s speech to subjectively identify specific signs of SD, such
as voice breaks. To help differentiate the condition and subtype, they ask the
patient to read and speak specific sentences loaded with certain sounds. While
additional evaluations may help to support or refute the conclusion, the
experienced clinician’s expert perceptual analysis usually serves as the basis for
making the SD diagnosis.
The physical examination continues by looking at the larynx in action. Even
though the person with SD often has normal anatomy, the physician should look at
the larynx to rule out other common laryngeal disorders that can result in a hoarse
voice. These include conditions such as vocal nodules or chronic laryngitis.
One way to view the larynx is to insert a rigid endoscope, a straight, narrow
metal rod containing a camera, through the mouth and toward the back of the
throat while the person is saying “eeeee.” In this manner, the otolaryngologist can
obtain a close-up view of the structures of the larynx and the movement of the
vocal folds. Another approach to viewing the vocal folds involves the use of a
flexible endoscope. In this method, a very narrow, flexible tube is inserted through
one nostril and down through the throat, which allows the doctor to evaluate the
movements of the larynx while the person is speaking or singing. Often, these
endoscopic examinations are performed with a specialized flickering light called a
stroboscope which allows the clinician to further evaluate the rapid fine movement
of the vocal folds.
The otolaryngologist may recommend a laryngeal electro-myography (EMG)
test to obtain specific information about the muscles involved. EMG involves
inserting a thin needle electrode through the neck into the muscles of the larynx
and evaluating the electrical activity of the muscles at rest and during speaking.
With a confirmed diagnosis, the doctor and patient can find an appropriate course
of treatment.

TRATAMIENTO
Speech therapy offered by a speech language pathologist (SLP) involves
training the person to alter voicing techniques. For instance, the speech therapist
may point out that the patient is producing his or her voice with poor breath support
or poor tongue placement in the mouth. Through exercises and practice,
the patient can gain better insight into how to speak more efficiently and effectively.
Unfortunately, this approach often produces incremental benefit for the typical SD
patient since SD is a neurologic condition over which the patient has little or no
control. While some have suggested that SD can be cured through speech
therapy, few practitioners or patients have had this experience. Speech therapy is
generally seen as a possibly helpful adjunct to other therapies such as botulinum
toxin (BTX) injection and to help SD patients who have excess voice strain to
“unload” some vocal muscle tension.
Some people with spasmodic dysphonia benefit from the use of a voice
amplifier for the phone or that of a self-contained microphone used in conjunction
with any FM radio.
Understanding what causes the SD patient's voice to be better or worse is
an important step in managing symptoms of SD. Susan Shulman, MS, CCC-SLP
surveyed individuals with SD regarding what affects voice quality, and the
following findings were presented:
Related Questions
What often helps make voice quality better?
ü Vocal exercise (humming, speaking slowly, reciting nursery rhymes)
ü Volume control (talking softly or loudly)
ü Feeling relaxed
ü Breathing deeper breaths, exhaling before speaking, not holding onto the
breath
ü Environmental control (talking one-on-one, not being interrupted)
ü Using voice early in the morning
ü Sensory gestures (neck muscle massage, covering eyes, pinching nose)
ü Physical exercise
ü Mental aspects ("not thinking about it", keeping a good attitude)
ü Miscellaneous (physical rest, vocal rest, warm liquids, laughing)

What often makes voice quality worse?

ü Stress (being tense, being in a hurry)
ü Speaking on the telephone
ü Speaking in a loud or large space
ü Trying to talk over noise
ü Lack of sleep
ü Negative thinking
ü Miscellaneous (overuse, weather changes, having a cold)