This article is an interesting report of a case of persistent voice problems affecting a 43-year-old physician that significantly compromised her ability to converse and communicate at work. Specifically, she had a fluctuating voice quality that would ‘choke off’, combined with an elevated pitch that made her ‘sound like Minnie Mouse’. No significant abnormalities were noted on videostroboscopy other than mild laryngeal hyperfunction in the lateral dimension, and as such she was diagnosed with a functional dysphonia and referred for voice therapy. The patient’s initial VHI was 87 with a GRBAS score of G3R3B1A0S3. Prolonged voice therapy failed to improve her symptoms, and steroids and voice rest were also unhelpful. A formal operative microlaryngoscopy procedure revealed no sulcus, mucosal bridge or other subtle submucosal pathology. A laryngeal EMG was therefore ordered. This revealed a prolonged latency of 750ms for the cricothyroid muscle alone, with normal latencies for the other muscles tested (thyroarytenoid and interarytenoid). Given the EMG results, botulinum toxin injection of the cricothyroid muscles was performed. Approximately 48 hours after injection of three units into each cricothyroid, pronounced improvement was noted by the patient. Her VHI markedly improved to 35 with a post-treatment voice rating of G1R1B1A0S1. Clinical benefit was sustained for five to six months after the initial injection, following which repeat injections have been performed with further benefit. This case report is a helpful reminder about the potential diagnostic benefits of laryngeal EMGs in patients with dysphonia that is refractory to both medical and speech therapy and for which no obvious structural cause can be identified. 

Refractory dysphonia due to isolated cricothyroid muscle dystonia.
Kraft S, Childes J, Hillel A, Schindler J.
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Christopher Burgess

Musgrove Park Hospital, Taunton, UK.

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