A new paradigm for the management of essential vocal tremor with botulinum toxin

Gurey, Lowell E.; Sinclair, Catherine F.; Blitzer, Andrew

doi:10.1002/lary.24073

Cited by 57 publications

(84 citation statements)

References 26 publications

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“…Again, only a few studies specifically focused on treatment of voice tremor. Overall, fewer than 50 % patients with voice tremor respond to oral medication [101]. Botulinum toxin may be helpful, and a treatment algorithm for botulinum toxin use in vocal tremor has recently been proposed [101].…”

Section: Treatment Of Voice Tremormentioning

confidence: 99%

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The Treatment of Tremor

Schneider

Deuschl

2014

Neurotherapeutics

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Tremor is a hyperkinetic movement disorder characterized by rhythmic oscillations of one or more body parts. It can be disabling and may impair quality of life. Various etiological subtypes of tremor are recognized, with essential tremor (ET) and Parkinsonian tremor being the most common. Here we review the current literature on tremor treatment regarding ET and head and voice tremor, as well as dystonic tremor, orthostatic tremor, tremor due to multiple sclerosis (MS) or lesions in the brainstem or thalamus, neuropathic tremor, and functional (psychogenic) tremor, and summarize main findings. Most studies are available for ET and only few studies specifically focused on other tremor forms. Controlled trials outside ET are rare and hence most of the recommendations are based on a low level of evidence. For ET, propranolol and primidone are considered drugs of first choice with a mean effect size of approximately 50 % tremor reduction. The efficacy of topiramate is also supported by a large double-blind placebocontrolled trial, while other drugs have less supporting evidence. With a mean effect size of about 90 % deep brain stimulation in the nucleus ventralis intermedius or the subthalamic nucleus may be the most potent treatment; however, there are no controlled trials and it is reserved for severely affected patients. Dystonic limb tremor may respond to anticholinergics. Botulinum toxin improves head and voice tremor. Gabapentin and clonazepam are often recommended for orthostatic tremor. MS tremor responds only poorly to drug treatment. For patients with severe MS tremor, thalamic deep brain stimulation has been recommended. Patients with functional tremor may benefit from antidepressants and are best be treated in a multidisciplinary setting. Several tremor syndromes can already be treated with success. But new drugs specifically designed for tremor treatment are needed. ET is most likely covering different entities and their delineation may also improve treatment. Modern study designs and long-term studies are needed.

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Section: Treatment Of Voice Tremormentioning

confidence: 99%

“…Overall, fewer than 50 % patients with voice tremor respond to oral medication [101]. Botulinum toxin may be helpful, and a treatment algorithm for botulinum toxin use in vocal tremor has recently been proposed [101]. Also, DBS does improve voice tremor [99].…”

Section: Treatment Of Voice Tremormentioning

confidence: 99%

The Treatment of Tremor

Schneider

Deuschl

2014

Neurotherapeutics

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“…(3,9) In addition to BoNT, the VT component may also be treated with primidone and propanolol with variable efficacy. (10) Lastly an alternative to these treatments in some patients is surgery, particularly selective laryngeal adductor denervation -reinnervation (SLAD -R) surgery. (11) Features of the aetiology, pathophysiology and phenomenology of SD are still poorly understood.…”

Section: Introductionmentioning

confidence: 99%

“…The hypothesis is that there will be distinct brain abnormalities present in SD versus SD/VT patients, not only because SD/VT patients are clinically different to SD patients, but also because they usually have a poorer response to BoNT treatment. (9,10) Ultimately an improved understanding of the neuropathophysiology of SD and SD/VT will result in both the optimized diagnosis and management of these patients.…”

Section: Introductionmentioning

confidence: 99%

“…This has been acknowledged in the literature in patients with VT alone but not in SD. (9,10) Unfortunately in other movement disorders it has been documented that this has led to the misuse of alcohol in order to self manage this range of conditions, but once again no data regarding SD exists. (16) Therefore the second part of this Masters, attempts to formalize these anecdotal findings by conducting a prospective cross sectional survey of SD and SD/VT patients.…”

Section: Introductionmentioning

confidence: 99%

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Spasmodic dysphonia and voice tremor: an analysis of the neuropathophysiology, clinical features and treatment options

Kirke¹

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Spasmodic dysphonia (SD) is a focal laryngeal dystonia that affects speech production. It is a rare disease that can remain undiagnosed and untreated in many. It usually develops in midlife and is socially and occupationally disabling. It can be sub-classified into adductor SD (ADSD), abductor SD (ABSD) and mixed SD. In one -third of patients, SD is also associated with vocal tremor (SD/VT). This further complicates the diagnosis, as this element of the disease has a more variable response to the gold standard of management Botulinum toxin (BoNT) than SD alone. The reasons for this are unclear, but a lack of the full understanding of the aetiology, pathophysiology and clinical features of SD with or without VT (SD+/-VT) certainly contribute.Whilst there has been some recent progress made in understanding the brain functional and structural alterations of SD, there has been no commensurate progress in understanding the VT component of SD/VT. As such this prevents the true understanding of the nature of SD+/-VT, and thus improved management of the disorder. Therefore the first aim of this work was to determine specific brain abnormalities contributing to both SD and SD/VT, via examining functional and structural brain abnormalities in 20 SD vs. 20 SD/VT vs. healthy controls (HV), using functional MRI (fMRI) during symptomatic speech production, voxel based morphometry (VBM) and diffusion weighted imaging (DWI). This revealed that both SD and SD/VT groups showed increased activation in the sensorimotor cortex, inferior frontal (IFG) and superior temporal gyri (STG), putamen and ventral thalamus, as well as deficient activation in the inferior parietal cortex and middle frontal gyrus (MFG). Common structural alterations were observed in the IFG and putamen, which were further coupled with functional abnormalities in both patient groups (Coordinates at the peak of significant clusters are given in the AFNI standard Talairach-Tournoux space at an FWE-corrected p ≤ 0.05). Abnormal activation in the left putamen was correlated with SD onset (r = 0.61, p = 0.004), whereas SD/VT onset was associated with right putaminal volumetric changes (r = -0.48, p = 0.032). These and further findings explored in the thesis demonstrate that SD and SD/VT, are heterogeneous disorders at different ends of the same clinical spectrum, with each disorder carrying a characteristic neural signature, which may potentially help the development of differential markers for these two conditions.The secondary aim of this Masters, was to explore some of the clinical characteristics of SD+/-VT. It has been acknowledged anecdotally that the symptoms of both SD and SD/VT respond positively to the consumption of alcohol. This has been published in the setting of VT alone, however it has never been formally explored in the setting of SD. Therefore the secondary aim of this work was to conduct a cross sectional online survey of patients with SD and SD/VT in order to 3 ascertain their degree of alcohol consumption and the effect it has on their sym...

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