Chapter 35
Botulinum Toxin Injection
of the Larynx
35.1 Fundamental and Related Chapters
Please see Chaps. 7, 33, and 34 for further information.
35.2 Disease Characteristics
and Differential Diagnosis
35.2.1 Botulinum Toxin Fundamentals
Botulinum toxin is a naturally occurring clostridial neurotoxin
that reversibly inhibits release of acetylcholine into the synap-
tic cleft of the neuromuscular junction, thereby causing flaccid
paralysis. Clinically, this results in a reversible, dose-dependent
weakening of injected muscles. In addition to its muscle weak-
ening effect, botulinum toxin has been hypothesized to have
an effect on efferent feedback to the central nervous system,
although whether this is by means of a direct effect on intra-
muscular gamma motor neurons or an indirect consequence
of muscle weakening remain matters of speculation. This ef-
ferent effect may be an important part of the broad success of
botulinum toxin in the treatment of dystonia, particularly in
comparison to surgical denervation.
Although seven different serotypes of botulinum toxin are
known, only two are available for clinical use, type A (Botox®,
Allergan, Irvine, Calif., and Dysport®, Ipsen, Ltd., Slough, UK)
and type B (Myobloc®, Elan Pharmaceuticals, Dublin, Ireland).
Type A appears to have a slightly longer duration of effect (ap-
proximately 90 days) than has type B, and the Botox prepa-
ration diffuses less from the point of injection than the other
two, both factors with practical clinical consequences. Dose is
expressed in mouse units (U) and differs substantially among
the commercial preparations; the reader should note that dos-
ages discussed in this chapter refer to Botox.
Adverse effects of botulinum toxin treatment may result
from overweakening of the intended target muscle as well as
unintended weakening of surrounding muscles. Therefore,
both appropriate dosing and the tissue distribution of the
toxin are crucial. In general, dose is proportional to targeted
muscle mass, although the range of therapeutic dosing is typi-
cally highly variable. There is no standard botulinum toxin
dose for patients with spasmodic dysphonia. Some patients get
the best results from a unilateral dose and others from bilat-
eral treatment. In bilateral injections for adductor spasmodic
dysphonia, for example, therapeutic doses range from 0.3 to
15 U per thyroarytenoid muscle, although most dysphonia is
well controlled with doses of 0.625–2.5U. The distribution of
35
the toxin is affected by accuracy of needle placement as well as
by volume of the injectate, which can be varied as necessary.
Systemic effects from botulinum toxin are very unlikely, par-
ticularly at doses used to treat laryngeal diseases.
Development of antibody resulting in clinical resistance to
toxin is very rare with recent preparations of toxin, and may
be tested for with an antibody assay, or, more practically, with
an injection into an area where muscle effect is obvious, such
as the forehead. Technical issues rather than resistance remain
the most likely reason for an ineffective laryngeal injection. For
a more in-depth description of the pharmacology of botulinum
toxin, the reader is referred to article by Aoki cited in “Selected
Bibliography,” below.
35.2.2 Spasmodic Dysphonia
and Essential Tremor
Dystonia is a chronic neurologic disorder of central motor pro-
cessing characterized by task-specific, action-induced muscle
spasms. Spasmodic dysphonia is a focal dystonia involving
the larynx. It is usually classified into adductor, abductor, and
mixed forms, the first two characterized by hallmark clinical
features and the latter being a combination of the first two. Ad-
ductor spasmodic dysphonia, the more common form, causes
inappropriate glottic closure and as a result, produces strangled
breaks in connected speech. Abductor spasmodic dysphonia,
in contrast, causes inappropriate glottal opening that produces
breathy breaks and hypophonia. Although clinical features are
not always typical, the classification of spasmodic dysphonia
into adductor and abductor varieties remains essential to treat-
ment: Botulinum toxin is injected into the thyroarytenoid/lat-
eral cricoarytenoid muscles (TA-LCA) in adductor spasmodic
dysphonia, and into the posterior cricoarytenoid muscle in
abductor spasmodic dysphonia.
Essential voice tremor is an age-related disorder of invol-
untary muscle contraction, which can affect the voice to a de-
bilitating extent in some patients. Clinical examination reveals
rhythmic, oscillatory movement of the portions of the vocal
tract (i. e., velum, base of tongue, pharynx, larynx, vocal folds),
which typically involves a wide variety of muscles of the upper
aerodigestive tract. No pharmacologic intervention has been
documented to be effective in essential voice tremor, and botu-
linum toxin chemodenervation has provided symptomatic
relief in selected patients. Administered much as in adductor
spasmodic dysphonia, botulinum toxin symptom control is
usually not as dramatic in essential tremor, probably due to
differences in the pathophysiology of the two diseases. The
 222 Botulinum Toxin Injection of the Larynx
areas of tremor most responsive to the botulinum toxin injec-
tion from a symptom perspective are the true vocal folds and
the false vocal folds.
35.2.3 Different Botulinum Toxin
Injection Approaches
There are a variety of injection approaches to deliver botuli-
35 num toxin to the larynx:
■ Percutaneous injection with EMG guidance (most
traditional)
■ Percutaneous with laryngoscopic guidance
■ Supraglottic botulinum toxin injection with laryngo-
scopic guidance
Distinct advantages and disadvantages exist for these ap-
proaches (see below). Selection of the best injection approach
is determined by surgeon’s training, equipment availability,
patient’s disease characteristics and preference.
Percutaneous injection under EMG guidance is the quick-
est and most precise method of botulinum toxin delivery into
the larynx. However, this technique also has a learning curve
and can take a considerable amount of time and practice to
master. In addition, the technique requires the purchase of ad-
ditional equipment (EMG machine) and moderate technical
mastery of EMG interpretation. Given these barriers, some
surgeons who perform laryngeal botulinum toxin injections
on an infrequent basis may wish to consider an alternative
method, a percutaneous or peroral injection technique, us-
ing laryngoscopic (visual) guidance. Given that this approach
(without EMG guidance) is less precise, often the toxin dose
used is slightly higher than EMG-guided percutaneous injec-
tion.
Supraglottic botulinum toxin injection with laryngoscopic
guidance for spasmodic dysphonia offers the advantages of:
■ More gradual/smooth onset of action
■ Smoothing of vocal fold “peaks and troughs” associated
with true vocal fold injections
■ Less severe (minimal to none) breathy voice
■ Preserves singing voice/pitch control in many patients
The disadvantages of this approach include a shorter duration
(typically 6–8 weeks), less predictable voice results and more
involved injection procedure. The unreliable voice results most
likely occur from variable supraglottic muscular anatomy and
variable needle location during the supraglottic injection. Su-
praglottic botulinum toxin injection with laryngoscopic guid-
ance may be preferred in professional voice users afflicted with
adductor spasmodic dysphonia, given the reduced number of
days with a soft, weak, breathy voice.
 
35.3 Surgical Indications
and Contraindications
Indications comprise:
■ Spasmodic dysphonia
■ Essential voice tremor
■ Vocal fold granuloma
Muscle selection, injection strategies, and dosing involves the
following:
1. Spasmodic dysphonia
The standard treatment for adductor spasmodic dysphonia
(SD) is bilateral EMG-guided, percutaneous injections of
the TA-LCA muscles, using equal amounts of botulinum
toxin, based on the understanding that the motor control
disorder is bilateral and symmetric (see Blitzer et al. 1998).
In patients with abductor spasmodic dysphonia, bilateral
posterior cricoarytenoid muscles are treated, although in-
jections are staggered for reasons of airway safety. For both
forms of SD, the dose is adjusted based on the severity of
the disease and on response to treatment, and the value of
bilateral versus unilateral treatment is reassessed. It is clear
from reports in the literature that unilateral injection may
provide essentially equivalent symptomatic relief in patients
with adductor spasmodic dysphonia, although the dose is
usually increased and may not provide the same duration of
benefit.
A reasonable initial dose in adductor spasmodic dyspho-
nia is 1.25 U per side, which represents a low-average dose.
Dosing at subsequent treatment is adjusted based on pa-
tients response. For abductor spasmodic dysphonia, the
first posterior cricoarytenoid (PCA) muscle is injected with
5 U; voice result and vocal fold mobility is evaluated 2 weeks
later. The contralateral dose is determined in light of this,
so that the dose in inversely proportional to the degree of
muscle weakness observed. Asymmetric dosing is the rule
in abductor spasmodic dysphonia.
Botulinum toxin treatment results in an initial period of
marked muscle weakness lasting several days, followed by
a 3- to 4-month-long plateau of milder weakening, which
constitutes the principal therapeutic effect. This effect prob-
ably occurs because of the two-stage mechanism of neural
recovery from botulinum toxin administration. The tran-
sient, breathy dysphonia that usually follows bilateral TA-
LCA injections is a clinical manifestation of this pattern,
and is to some extent inevitable. In general, the length of
the period of breathiness and the length of the therapeutic
effect are approximately proportional, so that attempts to
shorten the breathiness may compromise the duration of
therapeutic effect. Naturally, patients prefer to minimize the
frequency of their injections, but each will have a different
tolerance for the initial breathy voice phase of their treat-
ment.
Dyspnea is the equivalent early treatment effect in abductor
SD. Because this may be life threatening, only one side is
treated at a time, to allow partial recovery of the first prior
to denervation of its counterpart. Alternate explanations
   Chapter 35 223

for greater difficulty and less satisfactory results in abductor

■ Ground and reference electrodes
SD patients are (1) the PCA muscle injection is technically
■ Tuberculin syringe
more difficult and/or (2) some patients thought to have ab-
■ (Optional) local anesthetic for skin (1% lidocaine with
ductor SD have mixed SD, a combination of adductor and
1:100,000 epinephrine) and tracheal use
abductor SD. Even so, the potential for dyspnea imposes
important treatment limitations in abductor spasmodic
dysphonia, which may account for the generally less satis- Additional equipment necessary for percutaneous injection
factory results in these patients. with laryngoscopic guidance and/or peroral supraglottic injec-
2. Essential voice tremor tion with laryngoscopic guidance:
Essential voice tremor is typically treated with bilateral
■ Flexible laryngoscope (with working channel or
symmetric muscle injections of the TA-LCA muscles in the
endosheath with channeled sheath (Vision Sciences,
similar manner of adductor spasmodic dysphonia. These
Orangeburg, New Jersey)
patients are more likely to be troubled by prolonged post­
■ C-mount camera (attaches to flexible laryngoscope)
injection breathiness; thus, a lower dose is preferred by
■ Videomonitor for visualization
most patients. Essential voice tremor usually involves the
■ Three to 6 ml of 4% plain lidocaine
muscles of the upper aerodigestive tract more broadly, but
■ 27-g needle, 37 mm in length (percutaneous injection
no systematic attempt to treat other involved muscles, such
with laryngoscopic guidance
as the strap muscles, has been made, and the functional re-
■ Orotracheal injector device for peroral injection ap-
quirements of swallowing prevent treatment of still others,
proach (Medtronic Xomed)
such as pharyngeal constrictors. When the tremor is found
■ Cetacaine spray (benzocaine/tetracaine topical)
to be predominantly at the level of the true and false vo-
■ Curved Abraham cannula
cal folds, botulinum toxin injection of the TA-LCA muscles
■ Fine-gauge injection needle for use with working chan-
and/or the supraglottis can be very effective.
nel in flexible laryngoscope
3. Vocal fold granuloma
Botulinum toxin injection has been advocated by some to
weaken the vocal adductory force of the arytenoid to al-
low better healing and resolution of vocal fold granuloma.
35.5 Procedure
Botulinum toxin is injected into ipsilateral or bilateral TA-
LCA muscles, in doses ranging from 1.25 to 20 U. Most
often 5 U injected unilaterally is adequate. In most cases, 1. Botulinum toxin reconstitution and dilution
a single application, either alone or in conjunction with Botox is supplied as a freeze-dried powder in 100-U vials.
surgical removal, has been sufficient to permit resolution It is reconstituted with preservative-free saline. The prod-
of the granuloma. It should be noted that patients treated uct insert provides dilution instructions to achieve a wide
with this approach will have a severe breathy, weak voice for variety of concentrations (1.25–10 U/0.1 ml). Injection vol-
several months, and this may have a major impact on the ume should be limited to minimize diffusion. Preferable
functional voice capacity (work and social). volume is 0.1 ml per vocal fold; however, a volume of 0.2 ml
is also acceptable. At that volume, there is virtually no risk
Contraindications to injection include: of airway difficulty from vocal fold engorgement. A needle
larger than 21 g should be used for reconstitution, dilution,
■ Pregnancy
and transfer from vial to injection syringe. After the correct
■ Breast feeding
dose is prepared, the insulated 26-g injection needle is at-
■ Impaired abduction of vocal fold for PCA injection
tached to the syringe.
(relative)
2. Percutaneous EMG-guided botulinum toxin injection
■ Neuromuscular diseases (e. g., myasthenia gravis)
a) Connecting EMG electrodes
■ Concurrent aminoglycoside treatment
A ground and a reference electrode are attached to the
patient’s skin at a convenient site so as not to obstruct
the injection or inconvenience the injector. The insulated
injection needle, which serves as a monopolar sampling
35.4 Equipment
electrode during the injection, is attached to an EMG re-
cording device.
Equipment for botulinum toxin injection: b) Thyroarytenoid–lateral cricoarytenoid muscle complex
localization and injection for Adductor SD
■ EMG device (AccuGuide® [Medtronic Xomed, Jackson-
The patient is positioned in a semirecumbent position,
ville, Fla.] is a hand-held device that offers principally
with the chin raised and the head back. If the neck is
acoustic output which may used as a lower-cost alterna-
thin and laryngeal landmarks are easily palpable, then
tive to more expensive traditional electromyography
a shoulder roll may be omitted. If the neck is short and
machines.)
stocky, or the larynx is canted forward, then a shoulder
■ Botulinum toxin
roll is helpful. Alternatively, the headpiece of the chair
■ Insulated 26-g needle electrode
can be positioned to allow neck extension (Fig. 35.1).
 224 Botulinum Toxin Injection of the Larynx
The patient is asked to breathe quietly and to try not to
swallow during the procedure. Both skin and intratra-
cheal anesthetic may be injected, the latter via a cricothy-
roid puncture.
The anesthetic approach is highly variable among expe-
rienced clinicians. Some argue that the discomfort to the
patient from the anesthetic injection is approximately
equivalent to that from the toxin injection itself, while
others will perform the skin injection (30-g needle using
1% lidocaine with 1:100,000 epinephrine and sodium bi-
35 carbonate).
Fig. 35.1  Position of patient for percutaneous TA-LCA muscle botu-
linum toxin injection
Fig. 35.2  Insertion of needle through cricothyroid membrane into the
TA-LCA muscle complex for botulinum toxin injection
 
It is helpful to bend the needle upward some 30–45°, es-
pecially when injecting the female larynx, as the shorter
anterior–posterior distance requires a more acute angle
of entry under the inferior rim of the thyroid cartilage.
The needle is inserted into the cricothyroid space some
2–3 mm off the midline toward the side to be injected
and advanced superiorly and laterally (Fig. 35.2). A
more lateral entry point is used to attempt to avoid the
airway, because traversing endolaryngeal mucosa is un-
comfortable for the patient and may cause cough or even
laryngospasm during the procedure. If it is possible to
remain entirely submucosal, then the patient finds the
procedure much less painful and stimulating to airway
reflexes. Entry into the airway produces a characteristic
“buzz” in the EMG signal, which should alert the injector
to redirect the needle more laterally, or even begin again.
The location where the needle penetrates the cricothy-
roid membrane from a superior–inferior perspective is
determined by the surgeon’s preference. Some will enter
the larynx at the junction of the inferior border of the
thyroid cartilage and the membrane while others prefer
to be at the halfway point of the membrane.
The needle is maneuvered within the tissue until the tip
lies in an area of crisp motor unit potentials. The pa-
tient is asked to phonate and a brisk recruitment and
a full interference pattern confirms placement, and the
botulinum toxin is injected. It is especially good to see
Fig. 35.3  Placement of EMG needle into the posterior cricoarytenoid
muscle, using a retrolaryngeal approach
 
a characteristic prephonatory burst of EMG activity for
optimal injection localization.
c) Posterior cricoarytenoid muscle localization and injec-
tion for Abductor SD
i. Retrolaryngeal approach
The patient is seated upright, and the injector places
his or her thumb at the posterior border of the thy-
roid cartilage on the side to be injected. Using coun-
terpressure on the opposite side of the thyroid carti-
lage from the other four fingers, the larynx is gently
rotated to expose its posterior aspect. The needle
pierces the skin along the lower half of the posterior
border of the thyroid cartilage and is advanced until
it stops against the posterolateral surface of the cri-
coid. The needle is then pulled back slightly, and the
patient is asked to sniff to confirm placement (Fig.
35.3). When this produces brisk recruitment, the
toxin is injected.
ii. Translaryngeal approach
In this approach, the needle must cross the endo­lar­
yngeal mucosa so an intratracheal injection of 4%
plain lidocaine is useful to prevent coughing and
discomfort. The needle is inserted through the cri-
cothyroid membrane in the midline, and directed
posteriorly across the lumen of the glottis (identified
by the characteristic airway buzz on EMG) angled
toward the side to be injected. Using gentle pres-
sure, it is pushed through the lamina of the cricoid
cartilage until the opposite side is reached (due to
cricoid cartilage calcification, this approach may not
be possible in the older patient). The first electrical
signal encountered on the far side represents poste-
rior cricoarytenoid muscle. Placement is confirmed
by muscle activation during sniffing, and the toxin is
injected (Fig. 35.4). It is often useful (especially when
learning the technique) to employ an assistant to pro-
vide flexible laryngoscopy visualization on a monitor
during PCA injections (see Chap. 33, “Peroral Vo-
cal Fold Augmentation in the Clinic Setting”). The
surgeon should be aware that fragments of cartilage
might plug the needle lumen as it crosses the cricoid,
and expelling them to permit injection may require
considerable force on the plunger of the syringe; a
luer-lock syringe will prevent toxin leakage around
the needle hub.
d) Botulinum toxin injection with laryngoscopic guidance
for Adductor SD
i. Local anesthesia is obtained by performing a punc-
ture through the cricothyroid membrane, and instill-
ing approximately 3 ml of 4% lidocaine into the air-
way.
ii. The nasal cavity is anesthetized and a flexible laryngo-
scope, attached to videomonitor, is inserted through
the nasal cavity and advanced to a level slightly above
the vocal folds. An assistant maintains the scope in
position in order to provide constant visual feedback
during the procedure.
Alternatively, the surgeon may use a rigid telescope
for laryngeal visualization (nondominant hand) while
Chapter 35 225
Fig. 35.4  Placement of EMG needle into the posterior cricoarytenoid
muscle, using a translaryngeal approach
manipulating the needle with the other. The patient
(or an assistant) must stabilize the tongue to facilitate
good transoral visualization.
iii. A 1-ml syringe filled with botulinum toxin is at-
tached to a 27-g needle. The needle is placed through
the cricothyroid membrane near the midline, using
videomonitoring to confirm the location of the nee-
dle tip in the subglottic airway.
iv. The needle is angled toward the posterior aspect
of the vocal fold, piercing the infraglottic mucosa,
and advancing the needle laterally into the adduc-
tor musculature of the vocal fold (TA-LCA complex)
(Fig. 35.2). The posterior third of the membranous
vocal fold is the targeted region for Botox placement.
A similar injection is then performed on the oppo-
site vocal fold through the same approach via the
cricothyroid membrane. Visual confirmation, via the
flexible laryngoscopic monitoring is used to confirm
correct placement and to insure that inadvertent
“loss” of the Botox does not occur.
e) Supraglottic botulinum toxin injection with laryngo-
scopic guidance for Adductor SD.
Supraglottic botulinum toxin injection with laryngo-
scopic guidance is effective for treatment of adductor
spasmodic dysphonia as well as essential tremor involv-
ing the supraglottis. Two different injection approaches
can be used to perform supraglottic botulinum toxin in-
jection, (1) peroral approach or (2) an approach using a
working channel of a flexible laryngoscope. Each of these
two approaches are equally efficacious, and the decision
to use one approach or the other is usually determined
by the availability of the equipment to the surgeon. From
a patient-comfort perspective, the injection through the
working channel of a flexible laryngoscope is better tol-
erated.
 226 Botulinum Toxin Injection of the Larynx
35
Fig. 35.5  False vocal fold site(s) for trans-oral botulinum toxin
injection
1. Topical anesthesia nasal/oropharynx
a) Topical oxymetazoline/Pontocaine 2% spray to
nasal cavities
b) Topical Cetacaine spray to oral cavity (palate/pos-
terior pharynx)
2. Videomonitoring/topical anesthesia of larynx
a) A video camera is attached to a flexible laryngo-
scope or a distal chip flexible laryngoscope, insert-
ed through the nasal cavity (typically the left side)
by an assistant, employing a “videocart system.”
The scope is generally maintained slightly below
the palate so that the tongue base and larynx can
be easily viewed on the video monitor.
b) Four percent lidocaine drip onto larynx under
flexible guidance (3–5 ml; see Chap. 33)
The patient is bent forward at the waist with the
neck extended in a “sniffing” position to maximize
laryngeal exposure. The tongue is grasped with a
4 × 4 gauze with the surgeon’s left hand. A 3-ml
syringe of 4% lidocaine (40 mg/ml) attached to an
Abraham cannula (Pilling, Fort Washington, Pa.)
is advanced into the oropharynx. Approximately
1 ml is deposited over the tongue base, and 2–4 ml
is dripped onto the vocal folds during phonation,
producing the characteristic “laryngeal gargle”.
The maximal recommended dose of 4% lidocaine
is approximately 7–8 ml (4.5 mg/kg; approximate-
ly 300 mg for a 70-kg patient).
3. Peroral passage of the needle into the endolaryngeal
region
a) The Botox is drawn up in a 1-ml syringe, and
secured into the orotracheal injector device
(Medtronic ENT, Jacksonville, FL) with the
 
Fig. 35.6  Characteristic submucosal bleb immediately after transoral
botulinum toxin injection
curved needle. Disposable 27-g needles are used
with this system.
b) The needle is advanced into the oropharynx un-
der direct visualization. The patient is instructed
to phonate /a/ as the needle enters the oral cavity,
which results in palatal raising, clearing the path
into the oropharynx. The assistant should posi-
tion the flexible scope just above the palate until
the needle is visualized in the oropharynx.
c) The injector is then advanced, and the needle tip
is then guided into the hypopharynx, under endo-
scopic visualization, as the assistant follows closely
behind with the flexible scope The assistant must
be adept at manipulating the scope; consistent
visualization of the injector can be challenging
in a narrow airway with copious secretions. The
flexible scope should be positioned a few millime-
ters above the false vocal folds providing a clear,
well-illuminated, magnified view of the false vo-
cal folds.
4. Laryngeal injection of Botox
a) The needle is guided into the posterolateral and/
or mid-lateral false vocal fold under laryngoscop-
ic visualization (Fig. 35.5).
b) Botox is injected into a superficial (submucosal)
plane, forming a characteristic bleb (Fig. 35.6).
c) Five to 7.5 U are typically deposited in both false
vocal folds (total of 10–15 U).
An alternative way to perform supraglottic botuli-
num toxin injection with laryngoscopic guidance
is to use a flexible laryngoscope with a working
channel, or a flexible laryngoscope with an en-
dosheath working channel apparatus. After ad-
equate anesthesia to the larynx has been achieved
   Chapter 35 227

via the approach described above, a fine-gauge in-

laryngeal injections infrequently because it is
jection needle can be passed through the working
easier to master and relies on visual confirma-
channel of the flexible laryngoscope (NM-9L-1,
tion of the target, rather than blind needle
Olympus America, Center Valley, Pa.) and the su-
placement. However, it does require an assistant
praglottic larynx can be injected with botulinum
to hold the flexible laryngoscope.
toxin as discussed above. ■ The response to botulinum toxin is similar with
this technique when compared to EMG guided
technique, except:
35.6 Postprocedure Care ■ Higher doses are required
and Complications ■ Delayed onset of action (up to 5 days) occurs
■ Toxin effect that is less consistent
■ Supraglottic botulinum toxin injection with flex-
Patients may be discharged immediately after the injection.
ible laryngoscope guidance
Patients receiving TA-LCA injections should be cautioned re- ■ Supraglottic peroral Botox injection with flex-
garding an initial period of (1) breathiness and (2) dysphagia,
ible laryngoscopic guidance is indicated in
especially to liquids, as discussed above. Patient receiving their
selected patients with adductor spasmodic
second posterior cricoarytenoid injection should be advised
dysphonia (especially professional voice users
regarding dyspnea and stridor.
and supraglottic-based essential tremor).
Patients that received laryngeal anesthesia should be ad- ■ Advantages of supraglottic botulinum toxin
vised to retrain from any peroral intake for 2 hours (or until
(over EMG-guided approach) for spasmodic
sensation returns to the larynx/pharynx) to avoid the risk of
dysphonia
aspiration. ■ Smoothing of the vocal “peaks and troughs”
associated with serial EMG-guided Botox
injections
Key Points ■ Less severe (minimal-to-no) breathy voice
after injection
■ Disadvantages of supraglottic botulinum toxin
■ Percutaneous, EMG-guided botulinum toxin injec- for spasmodic dysphonia
tion ■ Shorter duration of effect (6–8 weeks)
■ Effective administration of botulinum toxin ■ Variable patient response (variable supra-
depends on glottic muscular anatomy)
■ Accuracy of injection
■ Minimizing diffusion to neighboring muscles
■ Appropriate dosing
■ When using EMG, confirmation of needle place- Selected Bibliography
ment by muscle activation during appropriate
activity (e. g., sustained “ee” or Valsalva for the
1 Aoki KR (2004) Pharmacology of botulinum neurotoxins. Oper
thyroarytenoid, sniffing for the posterior crico-
Techniques Otolaryngol 15:81–85
arytenoid) is essential to accuracy.
2 Blitzer A, Brin MF, Stewart CF (1998) Botulinum toxin manage-
■ Diffusion is minimized by injecting a small vol-
ment of spasmodic dysphonia (laryngeal dystonia): a 12-year expe-
ume of solution, ideally 0.1 ml.
rience in more than 900 patients. Laryngoscope 108:1435–1441
■ Approximate dosing is determined by muscle
3 Blitzer A, Sulica L (2001) Botulinum toxin: basic science and
mass and experience treating a given muscle.
clinical uses in otolaryngology. Laryngoscope 111:218–226
Precise dosing for each patient is determined by
4 Bové M, Daamen N, Rosen C et al (2006) Development and
careful assessment of clinical result and adjust-
validation of the vocal tremor scoring system. Laryngoscope
ment of subsequent treatment.
116:1662–1668
■ Percutaneous injection of botulinum toxin with
5 Simpson CB, Amin MR (2004) Office-based procedures for the
laryngoscopic guidance
voice. Ear Nose Throat J 83(Suppl.):6–9
■ Percutaneous injection of Botox under flexible
6 Sulica L, Blitzer A (2004) Botulinum toxin treatment of spas-
(or rigid) laryngoscopic guidance is an ideal
modic dysphonia. Oper Tech Otolaryngol 15:76–80
technique for the practitioner who performs