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Introduction: Adductor spasmodic dysphonia (ADSD) is one of the most disabling voice disorders with no permanent cure. Patients with ADSD suffer from poor voice quality and repeated interruption of phonation that leads to limitations in daily communication. Botox (BT) injection, considered the gold standard treatment for ADSD, reduces the amount of voice breaks and improves voice quality for a limited period. In this study, patients with ADSD were followed after a single BT injection to track the changes in QOL and perceptual voice quality over a 6-month period., Method: This is a prospective and longitudinal study. Fifteen patients with ADSD were evaluated preinjection and 1, 3, and 6 months postinjection. They completed the Voice Activity and Participation Profile-Persian Version (VAPPP) and read a passage at each recording period. Perceptual assessment was done by three expert speech-language pathologists with knowledge of ADSD using the grade, roughness, breathiness, asthenia, strain (GRBAS) scale. The data were analyzed using Friedman, Wilcoxon, and McNemar tests. The significance level was set at P < 0.05., Results: The VAPPP total score and each of the domain scores reached their peak scores at 3 months postinjection. At 6 months postinjection, the VAPPP scores increased significantly in comparison with the 3-month scores and but were lower than preinjection scores. GRBAS results also indicated that patients' voices at 1 and 3 months postinjection were significantly less severe in terms of strain and roughness (P = 0.01; P < 0.001, respectively)., Conclusion: BT injection resulted in improvement of subjects' QOL. The improvement was greatest at 3 months postinjection but remained above the preinjection values at 6 months after injection. The voice quality also improved but was not judged as normal., (Copyright © 2018 The Voice Foundation. All rights reserved.)

Objectives: This study aims to evaluate the effect of botulin toxin A in patients with multiple sclerosis (MS) affected by spasmodic dysphonia (SD) and to show the safety and effectiveness of this treatment in long-term observation., Materials and Methods: This is a pilot study on three relapsing-remitting MS patients with SD and their response to botulin toxin A., Results: None of the patients reported dysphagia or other adverse events. Significant improvement was observed in terms of both voice quality and laryngostroboscopy results. The treatment effect was durable for 6-8 months., Conclusions: Botulin toxin A is a safe treatment that can be successfully used to treat SD in patients with MS. Larger studies are necessary to confirm our results., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Botulinum toxin A (BtxA) injection is the mainstay treatment for laryngeal dystonias. BtxA product labeling states that reconstituted toxin should be used within 4 hours on a single patient despite several studies that have demonstrated multidose BtxA to be safe and effective. Many insurance carriers mandate the use of an outside pharmacy which necessitates a single-use approach. This study compares the cost savings of multidose BtxA for laryngeal dystonia compared to single-use., Study Design: This is a retrospective review and projected cost savings analysis., Methods: Records and billing information were reviewed for patients receiving BtxA for intralaryngeal injection at a single laryngology division in 2015. Inclusion criteria included CPT 64617 or J0585; exclusion criteria included CPT 64616. The price of BtxA 100 unit vial for calculation was $670., Results: A total of 142 patients were seen for intralaryngeal BtxA injection resulting in 337 visits over 1 year. The average BtxA dose per visit was 2.86 units with an average of 3.06 procedure visits per year. The calculated cost of BtxA treatment using a single vial approach was found to be $2,050 per patient per year. If billed instead for $7/unit with 5 units wastage charge per visit, the yearly per patient charge is $168. Single vial-use of BtxA injection thus represents a 1,118% price increase versus multidose use. When estimated for yearly prevalence of spasmodic dysphonia, multidose BtxA use would save almost $100 million annually., Conclusions: Multidose botulinum toxin A application utilizing per unit billing is significantly less expensive than per single-use vial billing and would save the health-care system significant amount of money without any sacrifice in safety or effectiveness., (Copyright © 2019. Published by Elsevier Inc.)

Objective: Contact granulomas are benign, exophytic inflammatory lesions of the larynx that typically arise on or near the vocal process of the arytenoid cartilage. The most common management options include voice therapy and antireflux pharmacotherapy, intralesional steroid injections, botulinum toxin injections, and surgical excision. In-office Botox injection into the lateral cricoarytenoid (LCA) muscle can be effective even for recurrent granulomas., Study Design: This is a retrospective chart review and literature review., Method: We reviewed more than 400 charts and included two patients, who underwent in-office injection with botulinum toxin A into LCA muscles bilaterally, after previously failing both conservative and surgical management., Results: Both cases showed significant improvement of the laryngeal granulomas after 6 months and a single botulinum toxin injection. Both cases were initially grade III granuloma that improved to grade I., Conclusions: In-office injection of botulinum toxin A targeting the LCA muscle appears to be a safe and effective treatment modality in refractory laryngeal granuloma., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to describe the presentation of pharyngeal dystonia (PD), which can occur as a focal or segmental dystonia with a primarily pharyngeal involvement for the discussion of treatment methods for controlling consequent symptoms. PD is specific to speech-related tasks., Methods: A retrospective medical record review of four patients with PD was performed., Results: All patients were initially misdiagnosed with adductor spasmodic dysphonia and failed standard treatment with botulinum toxin type A (BTX). On laryngoscopy, the patients were discovered to have segmental or focal dystonia primarily affecting the pharyngeal musculature contributing to their vocal manifestations. A novel treatment regimen was designed, which involved directing BTX injections into the muscles involved in spasmodic valving at the oropharyngeal level. After titrating to an optimal dose, all patients showed improvement in their voice and speech with only mild dysphagia. These patients have maintained favorable results with repeat injections at 6- to 12-week intervals., Conclusions: PD, or dystonia with predominant pharyngeal involvement, is a rare entity with vocal manifestations that are not well described. It can be easily mistaken for spasmodic dysphonia. PD is specific to speech-related tasks. A novel method of BTX injections into the involved muscles results in a significant improvement in voice without significant dysphagia., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Botulinum toxin (BTX) has been widely used to treat adductor spasmodic dysphonia (ADSD). Most commercially available forms of BTX require reconstitution before use, which may increase the risk of contamination and requires careful titration. Recently, a liquid-type BTX type A (BTX-A) has been developed, which should simplify the procedure and enhance its efficacy. Herein, we present a prospective pilot study to investigate the efficacy and safety of liquid-type BTX-A in the treatment of ADSD., Methods: Twenty-six consecutive liquid-type BTX-A injections were performed in 12 patients with ADSD. We included as a control group 34 consecutive patients with ADSD who had previously undergone 52 vocal fold injection procedures with freeze-dried-type BTX-A., Results: All patients in both groups had improvement of symptoms related to ADSD and period of normal voice. Most patients experienced breathiness, and the onset time, the peak response time, and the duration of breathiness were similar in both groups. The duration of effect (days) was 96.96 ± 18.91 and 77.38 ± 18.97 in the freeze-dried-type and the liquid-type groups, and the duration of benefit (days) was 80.02 ± 18.24 and 62.69 ± 19.73 in the freeze-dried-type and the liquid-type groups. To compare the efficacy between the freeze-dried-type and the liquid-type BTX-A, the sessions of the unilateral vocal fold injection were included and were categorized as group A (1 ~ 2 units BTX-A) and group B (2 ~ 3 units BTX-A), according to the dose per vocal fold. There was no significant difference of effect time between freeze-dried-type and liquid-type BTX-A groups. No adverse events related to BTX or vocal fold injection were reported., Conclusions: Liquid-type BTX-A is safe and effective for the treatment of spasmodic dysphonia. With the advantages of simple preparation, storage, and reuse and animal protein-free constituents, liquid-type BTX-A may be a good option in the treatment of spasmodic dysphonia., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The study aimed to compare and correlate perceptual-auditory analysis of vocal parameters and self-perception in individuals with adductor spasmodic dysphonia before and after the application of botulinum toxin., Study Design: This is a prospective cohort study., Methods: Sixteen individuals with a diagnosis of adductor spasmodic dysphonia were submitted to the application of botulinum toxin in the thyroarytenoid muscle, to the recording of a voice signal, and to the Voice Handicap Index (VHI) questionnaire before the application and at two time points after application. Two judges performed a perceptual-auditory analysis of eight vocal parameters with the aid of the Praat software for the visualization of narrow band spectrography, pitch, and intensity contour., Results: Comparison of the vocal parameters before toxin application and on the first return revealed a reduction of oscillation intensity (P = 0.002), voice breaks (P = 0.002), and vocal tremor (P = 0.002). The same parameters increased on the second return. The degree of severity, strained-strangled voice, roughness, breathiness, and asthenia was unchanged. The total score and the emotional domain score of the VHI were reduced on the first return. There was a moderate correlation between the degree of voice severity and the total VHI score before application and on the second return, and a weak correlation on the first return., Conclusions: Perceptual-auditory analysis and self-perception proved to be efficient in the recognition of vocal changes and of the vocal impact on individuals with adductor spasmodic dysphonia under treatment with botulinum toxin, permitting the quantitation of changes along time., (Copyright © 2017. Published by Elsevier Inc.)

Objectives: This study aimed to identify the changes in dosing of botulinum toxin-A for adductor spasmodic dysphonia (ADSD) over a prolonged period., Study Design: This is a retrospective chart review., Methods: One hundred thirteen subjects treated for ADSD from 2003 to 2013 were identified from a clinical database. Subject age, gender, and total injection dose amount were all recorded for all subjects who had at least 10 injections., Results: Fifty-four subjects met criteria for inclusion. There were no age or gender differences in the starting dose for subjects. Dosing decreased significantly compared with the second dose (5.05 ± 1.623 Units), by the sixth dose (4.26 ± 1.698 Units), and continued through the 10th dose (4.08 ± 2.019 Units) (P < 0.005 for all)., Conclusions: Botulinum toxin-A dosing for ADSD decreases consistently over subsequent injections after the initial two dose titrations., (Copyright © 2017. Published by Elsevier Inc.)

Objectives: The study aims to (1) identify the botulinum toxin (BTX) dosing trend in a cohort of patients who received at least 20 injections for the treatment of adductor spasmodic dysphonia (ADSD), (2) describe two distinct BTX dosing trends in treating ADSD (a "classic" dosing trend that initially decreases before stabilizing, and a "fluctuating" dosing trend), and (3) determine if patients with the "classic" dosing trend differed in age or in dosing intervals from those with the "fluctuating" dosing trend., Study Design: This is a retrospective case series., Methods: Of 149 patients who received a total of 2484 BTX injections for the treatment of spasmodic dysphonia in 1993-2013, 49 patients received at least 20 injections. The BTX dose and the interval between doses were recorded. The mean dose of injections 1-20 was determined. The age at initial injection, initial dose, and interval in days between treatments were compared for the "fluctuating" and "classic" groups., Results: The cohort exhibits a significant decrease in dose during the first 10-15 injections. The "fluctuating" group had a significantly shorter interval between injections (mean interval = 97.09 days, SD = 29.41; mean interval = 136.90 days, SD = 43.76, P = 0.002). The mean age at initial dose was not significantly different between the "classic" and "fluctuating" groups., Conclusions: The average BTX dose of patients with ADSD who receive long-term injections significantly decreases during the initial 10-15 injections before stabilizing. Patients who exhibit the "fluctuating" dosing pattern have a significantly shorter interval between injections than those with the "classic" dosing pattern., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Contact granuloma has been associated with voice abuse, laryngopharyngeal reflux, and habitual throat clearing. It has a high propensity for persistence and recurrence. Treatment options included voice therapy and antireflux measures. Surgical excision has been considered in patients who do not respond to medical management. In this research, we aimed to present our experience with botulinum toxin injection only., Studydesign: Retrospective case series of a tertiary referral center., Methods: Our series consisted of 22 patients, who underwent botulinum toxin injection only as an office procedure to bilateral thyroarytenoid and lateral cricoarytenoid muscles in 2 × 1.25 to 2 × 2.5 U. No other treatment was applied. The cases were followed up for at least 6 months ranging between 6 and 100 months with a mean of 28., Results: Seventeen cases (77%) were cured of their granuloma. Eleven of the cured cases had grade 2, four cases had grade 1, and two patients had grade 3 granuloma., Conclusions: Botulinum toxin A injection only is an efficient treatment modality in contact granuloma, especially for grade 1, 2, and 3 cases, and it can be used as a first-line treatment., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To demonstrate the utility of electromyography (EMG) in the evaluation and management of treatment-resistant dysphonia., Method: We report a case of refractory dysphonia in which EMG was used to identify and treat isolated cricothyroid (CT) dystonia., Results: The patient, a healthy 43-year-old woman, presented with 9 months of progressive hoarseness. Her symptoms were present across vocal tasks but were particularly bothersome while dictating. On presentation, her voice was rated grade 3, roughness 3, breathiness 1, asthenia 0, and strain 3 (G3R3B1A0S3). Videostroboscopy was remarkable for hyperfunction. Voice therapy was not beneficial despite appropriate effort. Microdirect laryngoscopy revealed no evidence of structural pathology. The patient was referred for EMG because of her normal examination and failure to improve with therapy. The CT muscle demonstrated an increased latency of 750 ms in all vocal tasks. One month after CT injection with 3 units of botulinum toxin (BTX), her voice was improved. Perceptual voice evaluation was rated G1R1B0A0S1. Voice Handicap Index improved from 87 to 35., Conclusions: In the absence of structural pathology, EMG can be a useful adjunct in the diagnosis of dysphonia that persists despite adequate trials of voice therapy. To our knowledge, this is the only report of laryngeal dystonia due to isolated CT dysfunction successfully treated with BTX., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Bilateral vocal fold paralysis most commonly results from iatrogenic trauma to the recurrent laryngeal nerve during surgical procedures in the anterior neck. Patients may require tracheostomy because of acute or gradual onset of dyspnea and airway compromise. The intralaryngeal injection of Botox has been considered as a possible therapy for these airway symptoms of bilateral vocal fold paralysis. Chronic unopposed activity of intact cricothyroid muscles could potentially result in gradual medialization of the vocal folds in patients with bilateral recurrent laryngeal nerve paralysis. This case series describes three patients who successfully underwent injections of botulinum toxin into the bilateral cricothyroid muscles to offer sustained relief of dyspnea resulting from bilateral vocal fold paralysis., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)