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Purpose: The main objective of this study was to compare laryngeal dystonia (LD) and vocal tremor's (VT) response to botulinum toxin injection. Methods: Retrospective study including every patient with LD or VT injected with botulinum toxin guided by electromyography, from January 1, 2010, to September 30, 2022, at a tertiary hospital centre. Improvement was assessed with the VHI-10, grade of dysphonia in a visual analogue scale (VAS; 0–10), GRBAS(I) scale (0–3) and maximum phonation time (MPT). Results: A total of 77 patients were included, 44 patients with LD and 33 with VT. There were no differences between groups on pre-treatment VHI-10, grade of dysphonia in the VAS, MPT and G, R, B, A and I at diagnosis (p > 0.05). S was significantly higher in patients with LD (p < 0.001). After the first injection, both groups showed an increase in the grade of dysphonia on the VAS and a decrease in VHI-10, G, S and I (p < 0.05), with a higher variation in the VAS and S parameters in the LD group compared to VT (p < 0.05). In the 54 patients that performed two or more injections, G, S and I had a higher decrease in patients with LD when compared to patients with VT (p < 0.05). Conclusion: BTX injection was successful in improving the VHI-10, grade of dysphonia on the VAS and G, S and I in the GRBAS-I scale for both DT and VT. LD seems to have a better response to BTX in comparison to VT. [ABSTRACT FROM AUTHOR]

Objectives: There is an absence of data in the literature regarding methods to improve the patient experience during the performance of awake in‐office laryngeal injections. This study sought to evaluate whether the use of local anesthetic or a vibrating instrument decreased overall pain experienced by patients with laryngeal dystonia, frequently referred to as spasmodic dysphonia (SD), undergoing transcervical botulinum toxin injections. Methods: This was an unblinded, prospective randomized control trial with a crossover design where each patient received transcutaneous transcricothyroid injection of botulinum toxin with alternating use of no anesthesia, local anesthesia (2% lidocaine in 1:100,000 epinephrine), and vibrating instrument in three consecutive laryngeal injections to treat adductor SD. Patients were randomized to the order they received these treatments. Patients measured pain on a 0–10 visual analogue scale (VAS) and selected their preferred technique after receiving all three analgesic modalities. Results: Thirty‐two patients completed the study. There was no statistically significant difference in pain between the three analgesic techniques (p = 0.38). The most preferred analgesic technique was the vibrating wand (44% (14/32)). Lidocaine was the second most preferred (37% (12/32)) and 19% (6/32) of patients preferred nothing. When combining the wand and nothing groups, 63% of patients preferred one of these two methods (95% exact CI: 44%–79%). Conclusion: There was no statistically significant difference in median pain experienced by patients during laryngeal botulinum toxin injection between these different analgesic modalities. More than half of the patients selected a preference for a technique that did not include lidocaine. This data supports individualization of analgesia during transcutaneous laryngeal injections. Level of Evidence: 2 Laryngoscope, 134:2277–2281, 2024 [ABSTRACT FROM AUTHOR]

Objectives: The primary objective of this study was to determine whether two neurosurgical procedures, deep brain stimulation (DBS) and focused ultrasound (FUS), to treat essential tremor (ET) of the upper limb also reduce vocal tremor (VT) in patients with comorbid dysphonia. Methods: Twelve patients with ET and concomitant VT scheduled for neurosurgical intervention (FUS or DBS) or returning for follow‐up after DBS implantation were assessed. FUS patients were assessed pre‐ and post‐intervention and DBS patients were assessed with the electrodes turned on and off post‐implantation. Three voice recordings of a sustained /a/ were obtained for each participant condition. Percent fundamental frequency variability (FFV) was calculated for each recorded sustained vowel. Additionally, blinded expert perceptual VT rating (VTR) was performed to assess subjective changes in tremors. Results: Of the 12 patients, seven underwent unilateral FUS, and five underwent bilateral DBS. Mean FFV without neurosurgical intervention was 18.3%, SD = 7.8 and with neurosurgical intervention was 6.3%, SD = 3.0 (t (70) =8.7, p < 0.001). Mean FFV decreased in the FUS cohort from 22.0%, SD = 7.1 pre‐ablation to 6.7%, SD = 2.4 post‐ablation (t (40) = 7.7, p < 0.001). Mean FFV also decreased in the DBS cohort from 15.7%, SD = 7.0 to 6.0%, SD = 3.3 when stimulation was turned on (t (28)=5.7 p < 0.001). In the FUS group, mean VTR decreased from 4.0 to 1.4 post‐ablation (Z = 7.8, p < 0.001). In the DBS group, mean VTR decreased from 3.3 to 2.1 with stimulation (Z = 4.1, p < 0.001). Conclusion: Neurosurgical interventions for ET (bilateral DBS and unilateral FUS) demonstrate acoustic and perceptual benefits for VT. Level of Evidence: 4 Laryngoscope, 134:367–373, 2024 [ABSTRACT FROM AUTHOR]

Background: Despite many available patient‐reported outcome measures (PROMs) for laryngeal movement disorders, there is a lack of patient input regarding which PROM most accurately and conveniently captures aspects related to their vocal disease. This study aimed to assess patients' preferences among a selection of voice‐related PROMs (Voice Handicap Index‐10 [VHI‐10], OMNI‐Vocal Effort Scale [OMNI‐VES], Communicative Participation Item Bank‐General Short Form [CPIB‐10], and Visual Analog Scales [VAS]) within the laryngeal movement disorder population and investigate associations between selected instruments. Methods: Prior to botulinum toxin A injection, patients with laryngeal dystonia and/or essential tremor of the vocal tract were administered the VHI‐10, OMNI‐VES, CPIB‐10, and three novel VAS questions in a randomized order. Patients rank ordered the four PROMs based on the PROMs' reflection of their voice problems. Pearson's correlation coefficients evaluated pairwise associations among PROM scores. Fisher's exact test compared the preferred PROM rankings. Results: Seventy patients (53 female, mean age = 60.7 years) participated. The VHI‐10 and CPIB‐10 were most preferred at 33.9% and 27.4% respectively. The OMNI‐VES and VAS scales were less favored (19.4%, each). When analyzed by age ≥60 years, the CPIB‐10 was most favored (33.3%), but for age <60 years, VHI‐10 was most preferred (42.3%). There was a strong correlation between scores of all administered PROMs (strongest correlation between OMNI‐VES and VAS, r = 0.8, p < 0.001; the weakest correlation between OMNI‐VES and VHI‐10, r = 0.6, p < 0.001). Conclusions: With an increasing trend in PROMs usage and a strong correlation between all evaluated outcome instruments, insight regarding patients' PROM preferences is an area for further consideration. Level of Evidence: NA Laryngoscope, 133:1448–1454, 2023 For patients with laryngeal dystonia (formally called spasmodic dysphonia) and vocal tremors, there is no universally accepted outcome metric to assess and compare disease severity or response to treatment. Our study looks to determine which of the currently used tools/questionnaires are most preferred by patients themselves. [ABSTRACT FROM AUTHOR]

Background: There is a paucity of literature examining the effect of Ventral Intermediate Nucleus (VIM) deep brain stimulation (DBS) on voice in patients with vocal tremor (VT). Objective: Investigate the effect of unilateral and bilateral VIM DBS on voice in patients with Essential Tremor (ET) and VT. Methods: All patients receiving VIM DBS surgery underwent voice evaluation pre- and six-months post-operatively. We collected patient-reported quality-of-life outcome measures and acoustic voice measures of sustained phonation and connected speech. Acoustic measures specific to VT included amplitude tremor intensity index (ATRI), frequency tremor intensity index (FTRI), rate and extent of F0 modulation, and rate and extent of intensity modulation. Results: Five patients, age 72.8 ± 2.6 years, 4 female, 1 male with mean disease duration of 29 ± 26.2 years met the inclusion criteria and were included. Two subjects had bilateral procedure and three had unilateral. We observed significant improvements in measures of vocal tremor including ATRI, FTRI, rate of F0 modulation, rate of intensity modulation, and extent of intensity modulation, as well as patient reported voice-related quality of life measured by VHI-10. Bilateral VIM DBS cases showed greater improvement in VT than unilateral cases. Conclusion: Both unilateral and bilateral VIM DBS resulted in significant improvement of VT, with more improvement demonstrated in patients having bilateral as compared to unilateral VIM DBS. In addition, patients also reported significant improvements in voicerelated quality of life. If larger studies confirm our results, VIM DBS has the potential to become a treatment specifically for disabling VT. [ABSTRACT FROM AUTHOR]

Deep brain stimulation (DBS) is a treatment for medically refractory essential tremor (ET), but there is a paucity of literature examining the effects of DBS on voice in patients with ET pre-DBS and post-DBS. This study aimed to report a comprehensive evaluation of voice in patients with ET pre-DBS and 6-months post-DBS. Case series. Five patients receiving DBS for ET underwent voice evaluations pre-DBS and 6-months post-DBS. One patient had concurrent ET of the vocal tract (ETVT). The evaluation included patient-reported, perceptual, acoustic, and phonatory aerodynamic analyses of voice. Voice Handicap Index-10, Grade, Roughness, Breathiness, Asthenia, Strain Scale, perturbation measures, cepstral spectral index of dysphonia, cepstral peak prominence, and mean phonatory airflow measures were also among the data collected. Patients with ET presented with minimal changes in perceptual, acoustic, and phonatory aerodynamic parameters. Perceived vocal roughness significantly increased 6-months post-DBS (P = 0.047). The patient with ETVT presented with clinically significant improvement in almost all collected voice parameters 6-months post-DBS. This is the first study to provide data encompassing auditory perceptual voice analysis, voice-specific patient-reported quality of life measures, acoustic, and phonatory aerodynamic outcomes in patients pre-DBS and 6-months post-DBS for ET. The results of our preliminary study have implications for the use of a comprehensive voice assessment to identify and measure change in voice outcomes in patients with ET and ETVT pre- and postsurgery. [ABSTRACT FROM AUTHOR]

Objectives: This study aims to evaluate the demographic differences between those with adductor spasmodic dysphonia with vocal tremor (AdSD(+)VT) and those without vocal tremor (AdSD(-)VT) and to analyze their response to treatment with botulinum neurotoxin (BoNT-A)., Study Design: Retrospective cohort study., Methods: A database review of all spasmodic dysphonia patients treated with BoNT from 1989 to 2018 at the Mayo Clinic in Arizona was performed. Only patients who had received ≥4 injections of BoNT-A for AdSD were included. Patients were divided into two cohorts: those with coexistent vocal tremor (AdSD(+)VT) and those without vocal tremor (AdSD(-)VT)., Results: The final analysis included 398 patients, with 210 AdSD(+)VT patients (53%) and 188 AdSD(-)VT patients (47%). The length of follow-up and median number of treatments were similar between cohorts. AdSD(+)VT patients were more likely to be female (P < 0.001), and older at onset (P < 0.001) and first injection (P < 0.001). The mean maximal benefit was significantly lower for the AdSD(+)VT cohort (P < 0.01), however the mean length of benefit was similar (P = 0.70)., Conclusions: Demographic differences exist between AdSD(+)VT and AdSD(-)VT patients. AdSD(+)VT patients benefit from BoNT-A treatment; however, our analysis suggests that the degree of their maximal benefit is less than in those without VT., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The main objective of this study was to compare the demographic and clinical characteristics of patients with laryngeal dystonia (LD), dystonic tremor (DT), and vocal tremor (VT)., Study Design: This was a retrospective longitudinal study., Methods: Data analysis from every patient diagnosed with LD, DT, or VT from January 1, 2010, to September 30, 2022, at a tertiary hospital center. Differential diagnosis between these entities was clinical (clinical history, voice assessment, and endoscopy) and confirmed by laryngeal electromyography., Results: A total of 87 patients were included in this study: 50 patients with LD, 23 with DT, and 14 with VT. Age at diagnosis was significantly lower in patients with LD, with a mean age of 56.2 years when compared to DT (67.6 years; P = 0.002) and VT (70.5 years; P = 0.009). Furthermore, VT had a higher female prevalence (92.9%) when compared with LD (52%; P = 0.011). LD was mainly adductor, with only two patients diagnosed with abductor LD, and DT was adductor in every case. Tremor direction in patients with VT was horizontal in 50% and mixed (horizontal + vertical) in 50%, while in DT was mixed in 65.2% and horizontal in 34.8%. LD was more commonly an isolated laryngeal movement disorder (78%) when compared to DT (47.8%; P = 0.015) or VT (28.5%; P < 0.001), which were more often secondary to generalized neurological disorders. There were no differences between groups on Voice Handicap Index-10, self-reported grade of dysphonia on a visual analogic scale (0-10), maximum phonation time, and G, R, B, A, and I in the GRBAS-I scale at diagnosis (P > 0.05). S was significantly higher in LD when compared to VT (P < 0.001) and nonsignificantly higher than in DT (P = 0.075)., Conclusions: LD, DT, and VT seem to be different entities with different demographics and clinical characteristics., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors have no conflicts of interest to declare., (Copyright © 2023 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The effectiveness of deep brain stimulation (DBS) in treating vocal tremors is currently a subject of debate. To assess the efficacy of DBS therapy in adults with vocal tremors (VT), we analyzed its impact on voice tremor severity, voice-related quality of life, fundamental frequency, voice intensity, and emotional state., Methods: We conducted a systematic review with meta-analysis to investigate the impact of DBS therapy on voice tremor severity, voice-related quality of life, fundamental frequency, voice intensity, and emotional state in adults with vocal tremors (PROSPERO/CRD42023420272). The PubMed, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials databases were searched up to September 20, 2022. Primary outcome measures included voice tremor severity and voice-related quality of life (V-RQOL), while fundamental frequency (F0) and voice intensity, along with emotional state, were selected as secondary outcome indicators. We employed the Cochrane Collaboration's tool for assessing bias risk in randomized trials. Meta-analysis (standardized difference of means and weighted mean differences) and heterogeneity analysis (I2) were performed., Results: Our search identified 1186 studies, of which nine studies involving 61 patients met the inclusion criteria. The severity of voice tremor (SMD = -1.08; 95% CI: -1.80 to 0.35; P = 0.02) and V-RQOL (SMD = -1.39; 95% CI: -2.68 to -0.09; P = 0.04) in patients with vocal tremor significantly improved after DBS "on". Subgroup analyses revealed that the stimulation site may contribute to high heterogeneity. Specifically, Vim DBS showed significant improvement in voice tremor severity (SMD = -0.97; 95% CI: -1.84 to -0.09; I2 = 51.01%), while STN DBS did not demonstrate a clear benefit in addressing vocal tremor. There was no significant difference between DBS "on" and DBS "off" in terms of F0, voice intensity, or emotional status., Conclusion: DBS therapy is effective in enhancing voice quality and voice-related quality of life in patients with vocal tremors. Notably, Vim DBS demonstrates a significant improvement in voice tremor severity, particularly in VT patients with ET and SD., Competing Interests: Declaration of Competing Interest Authors have no conflict of interest to declare., (Copyright © 2023 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Essential vocal tremor is a difficult disease entity to treat with a poor response to existing medical management and limited options for surgical management of the disease. Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is an emerging treatment modality with encouraging results for limb tremor in patients with essential tremor, but data are limited for the treatment of vocal tremor., Observations: This is the case of a 69-year-old male with a history of essential vocal tremor severely limiting his ability to perform his occupation as an opera singer. He underwent staged bilateral ventral intermediate nucleus of the thalamus thalamotomy with MRgFUS for the treatment of his bilateral upper extremity tremor with near complete resolution of his vocal tremor after a second procedure., Lessons: Bilateral MRgFUS may be a safe and efficacious option for the treatment of essential vocal tremor. Further research into optimal patient selection, precise target location, and treatment parameters is needed.

Objectives/hypothesis: Laryngeal dystonia and vocal tremor can be debilitating conditions with suboptimal treatment options. Botulinum toxin chemodenervation is typically the first-line treatment and is considered the gold standard. However, patient response to botulinum toxin varies widely. There is anecdotal evidence for the use of cannabinoids in treating laryngeal dystonia with a scarcity of research investigating this potential treatment option. The primary objective of this study is to survey patients with laryngeal dystonia and vocal tremor to gauge how some people are using cannabinoids to treat their condition and to ascertain patient perceptions of cannabinoid effectiveness., Study Design: This is a cross-sectional survey study., Methods: An eight-question anonymous survey was distributed to people with abductor spasmodic dysphonia adductor spasmodic dysphonia, vocal tremor, muscle tension dysphonia, and mixed laryngeal dystonia via the Dysphonia International (formerly National Spasmodic Dysphonia Association) email listserv., Results: 158 responses: 25 males and 133 females, (mean [range] age, 64.9 [22-95] years). 53.8% of participants had tried cannabinoids for the purposes of treating their condition at some point, with 52.9% of this subset actively using cannabis as part of their treatment. Most participants who have used cannabinoids as a treatment rank their effectiveness as somewhat effective (42.4%) or ineffective (45.9%). Participants cited a reduction in voice strain and anxiety as reasons for cannabinoid effectiveness., Conclusions: People with laryngeal dystonia and/or vocal tremor currently use or have tried using cannabinoids as a treatment for their condition. Cannabinoids were better received as a supplementary treatment than as a stand-alone treatment., (Copyright © 2023 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)