Your voice catches, breaks, or squeezes shut in the middle of a sentence, yet you can laugh, whisper, or sometimes sing without trouble. If a doctor has called that spasmodic dysphonia, the next question is what actually treats it.
There is no cure yet, but spasmodic dysphonia treatment works well for most people. The three main options are Botox injections, voice therapy, and, for selected patients, surgery. Botox is the standard: the National Institute on Deafness and Other Communication Disorders reports that injections generally improve the voice for three to four months before they need repeating.
This article compares the three paths, what each involves, and who each one suits. Dr. Aaron Feinstein, a fellowship-trained laryngologist, treats spasmodic dysphonia at Los Angeles Voice Center in Tarzana.
What spasmodic dysphonia is
Spasmodic dysphonia is a neurological voice disorder, a localized form of dystonia that is also called laryngeal dystonia. The brain sends faulty signals to the muscles of the voice box during speech, so the vocal cords spasm. The problem sits in the brain's movement control, not in the vocal cords themselves, which look normal on exam.
It is rare. Symptoms usually start between ages 30 and 50, and it affects more women than men. There are two main types:
Adductor spasmodic dysphonia, the most common form, where the cords squeeze together and the voice sounds strained, choked, or broken.
Abductor spasmodic dysphonia, where the cords spasm open and the voice drops into breathy, whispered gaps.
The type matters, because the main treatments work better for one than the other.
How spasmodic dysphonia is diagnosed
Spasmodic dysphonia is diagnosed by listening and watching, not by a blood test or scan. A laryngologist examines the vocal cords with a camera while you read and speak, and listens for the specific breaks that certain sounds trigger. Patients undergo a videostroboscopy exam, which shows the vocal folds moving in slow motion, to carefully assess the voice.
The work-up also rules out conditions that sound similar, such as muscle tension dysphonia, vocal tremor, and vocal cord paralysis. Each of these is treated differently, which is why the diagnosis comes before any treatment decision. NIDCD notes that the evaluation often involves an otolaryngologist, a speech-language pathologist, and sometimes a neurologist.
Botox injections: the standard treatment
Botox for spasmodic dysphonia works by weakening the overactive voice muscles just enough to stop the spasms. A very small dose is injected through the skin of the neck into the muscle that drives the spasm. At Los Angeles Voice Center, the injection is an in-office procedure done while you are awake, and it takes minutes.
The effect builds over a few days. Some people have a few days to a couple weeks of breathiness or mild trouble swallowing liquids before the voice settles, according to the American Academy of Otolaryngology's patient guide. The benefit then lasts about three to four months, and most patients come back for repeat injections every three months or so.
Who it suits
Botox works best for adductor spasmodic dysphonia and less predictably for the abductor type. Dose and timing are adjusted visit by visit. Patients who use their voice professionally often schedule injections so the breathy phase falls in a quiet week, not before a performance or presentation.
Voice therapy: helpful, rarely enough on its own
Spasmodic dysphonia voice therapy helps you speak with less effort and get more out of each Botox cycle. A voice-specialized speech-language pathologist works on breath support, easier onset of sound, and the strain habits that build up when speaking feels like a fight.
For mild cases, therapy may reduce symptoms on its own. For most people it works alongside injections rather than replacing them, because therapy cannot change the brain signal behind the spasm. At Los Angeles Voice Center, therapy is led by Paige Plotkin, M.S., CCC-SLP, the center's Director of Voice Rehabilitation, and the same team approach applies to voice therapy for professional singers.
Spasmodic dysphonia surgery
Surgery is an option for some patients who want to stop repeating injections. The best-known procedure for adductor spasmodic dysphonia is selective laryngeal adductor denervation-reinnervation, or SLAD-R surgery. The surgeon cuts the nerve branches that carry the faulty signal to the closing muscles and reconnects them to a nearby nerve, so the muscles keep their bulk without the spasm.
Dr. Feinstein trained in SLAD-R with Dr. Gerald Berke at UCLA, who developed the procedure. Around 85% of patients experience a good result, but some patients have severe breathiness. It is not for abductor spasmodic dysphonia, and recovery of the voice takes months rather than days.
Other surgical options exist, including type II thyroplasty and thyroarytenoid myomectomy. Dysphonia International keeps a plain-language summary of each spasmodic dysphonia treatment option. These surgeries are usually a conversation after injections have been tried. Because the SLAD-R surgery is only done before age 65, the TA myomectomy is a more frequent option beyond age 65.
Botox vs. voice therapy vs. surgery
Botox injection is an in-office treatment repeated about every three months. It gives the most reliable improvement for adductor spasmodic dysphonia, with a short breathy phase after each dose. It is the first choice for most patients.
Voice therapy is a series of sessions with a voice-specialized speech-language pathologist. It improves ease and efficiency and supports Botox, and it may be enough alone in mild cases.
SLAD-R surgery is a one-time operation under general anesthesia for selected adductor patients who want to stop injections. The voice improves gradually over months, and it does not treat the abductor type.
Frequently asked questions
Is there a cure for spasmodic dysphonia?
Not yet. Treatment controls the symptoms, and Botox injections give most patients a clearer, easier voice for three to four months at a time.
How often do you need Botox for spasmodic dysphonia?
Most patients need repeat injections about every three months, though the interval varies from person to person.
Can you sing with spasmodic dysphonia?
Often, yes. Singing, laughing, and whispering are frequently less affected than speaking, which is one of the clues that points to the diagnosis.
Is spasmodic dysphonia caused by stress?
No. It is a neurological condition. Stress and fatigue can make symptoms more noticeable, but they do not cause it.
Getting the right spasmodic dysphonia treatment
Spasmodic dysphonia is treatable, and the right plan starts with an accurate diagnosis and the correct type. For most people that means Botox, with voice therapy to make each cycle work harder, and surgery as an option for selected adductor patients. If your voice has started to break or give out without a clear reason, an exam is the first step.
If you are looking for spasmodic dysphonia treatment in Los Angeles, Dr. Feinstein sees patients at Los Angeles Voice Center in Tarzana. Schedule an evaluation or call 818-609-0600.