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Botulinum toxin is a biological substance used in the management and treatment of voice and speech disorders. This activity describes the evaluation and treatment of various functional laryngeal disorders and explains the role of the interprofessional team in using botulinum toxin in managing patients with this condition. Objectives: Summarize the etiology of laryngeal disorders. Describe the management considerations for patients with laryngeal disorders. Review the presentation of a patient with spasmodic dysphonia. Outline some interprofessional team approaches that will improve outcomes for patients with laryngeal disorders. Access free multiple choice questions on this topic.

Botulinum toxin is a neurotoxin produced from Clostridium botulinum, an anaerobic, gram-positive bacteria.[1] Injection of botulinum toxin into a muscle temporarily denervates the targeted muscle. It also reduces secretory function when injected into a gland. Although botulinum toxin has traditionally been utilized in facial cosmetics/aesthetics to address rhytids, it is also a useful tool in addressing laryngeal pathology. Before introducing botulinum toxin, laryngeal dystonia was historically treated with psychotherapy and speech therapy, both of which were significantly limited in their effectiveness for this disorder.[2] The use of botulinum toxin has been described in the management of both adductor and abductor laryngeal dystonia/spasmodic dysphonia (SD), vocal tremor, vocal process granuloma, and cricopharyngeal muscle dysfunction. By selectively denervating targeted laryngeal musculature, the surgeon can strategically address these pathologies. The vast majority (65%) of SD patients are female, with an average age of onset of 45 years. The prevalence of SD is 1 per 100,000.[3] In adductor spasmodic dysphonia (ADSD), the thyroarytenoid (TA) muscle is targeted for chemodenervation. Botulinum toxin chemodenervation, initiated in the 1980s by Blitzer and colleagues, is now considered the gold standard for the treatment of ADSD.[2]

Complications of the treatment of spasmodic dysphonia with botulinum toxin injections include dysphagia, excessive breathiness, and aspiration of fluids.[11] Other disadvantages include the need for repeat procedures and a lack of a uniform dose-response relationship between patients.[2]

Voice disorders are a significant issue in the general population, with a prevalence of 16.9% in a Stockholm public health cohort. Prevalence increases in female and elderly populations, among individuals who are in high-stress positions and those who use their voice significantly as part of their profession.[13]Interprofessional communication is paramount in the management of patients with laryngeal disorders. Primary care clinicians may act as the first line of detection for voice disorders, and effective referral and communication will allow the patient to find the appropriate multidisciplinary voice team. Speech-language pathologists (SLPs) and otolaryngologists/laryngologists play an important role in making a diagnosis, educating patients about their diagnosis, and providing management options. SLPs may serve as the first line of treatment for patients in whom conservative measures, such as speech therapy and vocal hygiene, are indicated. As the patient progresses through their care, shared decision making, and revisiting progress goals will direct the future of care. Once a decision is made to employ invasive treatments such as laryngeal botulinum toxin, the laryngologist must work closely with an assistant to provide high-quality care. The assistant, typically a trained nurse, may steady and advance the flexible video laryngoscope while the surgeon maneuvers the botulinum toxin needle. With EMG-guided injections, the assistant is typically a neurologist, trained to read the EMG monitor and advise the otolaryngologist on how they should maneuver. Laryngeal botulinum toxin is unique in that the procedure can be both diagnostic and therapeutic. They should effectively communicate this to the patient. It is important to relay that, although temporary, laryngeal botulinum toxin can help guide future decision making. The patient and provider may agree on repeat botulinum toxin injections vs. more definitive treatment with a shared decision-making process. Considerations for continued care may include patient tolerability of the procedure and the likelihood of tolerating repeat injections every 6 to 12 months. The time to recurrence of symptoms is another factor to consider.