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is not masculinized, ie, there is a failure in the spurt of growth (length) of the vocal cords that ordinarily occurs in pubertal boys Voice training has been helpful Paresis of respiratory movements, as in myasthenia gravis, Guillain-Barre syndrome, and severe pulmonary disease, may af fect the voice because insuf cient air is provided for phonation Also, disturbances in the rhythm of respiration may interfere with the uency of speech This is particularly noticeable in extrapyramidal diseases, where one may observe that the patient tries to talk during part of inspiration Another common feature of the latter diseases is the reduction in volume of the voice (hypophonia) due to limited excursion of the breathing muscles; the patient is unable to shout or to speak above a whisper Whispering speech is also a feature of advanced Parkinson disease, stupor, and occasionally concussive brain injury and frontal lobe lesions, but strong stimulation may make the voice audible With paresis of both vocal cords, the patient can speak only in whispers Since the vocal cords normally separate during inspiration, their failure to do so when paralyzed may result in an inspiratory stridor If one vocal cord is paralyzed as a result of involvement of the tenth cranial nerve by tumor, for example the voice becomes hoarse, low-pitched, rasping, and somewhat nasal in quality The pronunciation of certain consonants such as b, p, n, and k is followed by an escape of air into the nasal passages The abnormality is sometimes less pronounced in recumbency and increased when the head is thrown forward Prolonged tracheal intubation that causes pressure necrosis of the posterior cricoarytenoid cartilage and the underlying posterior branch of the laryngeal nerve is an increasingly common iatrogenic cause Spasmodic (Spastic) Dysphonia This is a relatively common condition about which little is known Spasmodic dysphonia is a better term than spastic dysphonia, since the adjective spastic suggests corticospinal involvement, whereas the disorder is probably of extrapyramidal origin The authors, like most neurologists, have seen many patients, middle-aged or elderly men and women, otherwise healthy, who lose the ability to speak quietly and uently.

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Any attempt to speak results in simultaneous contraction of all the speech musculature, so that the patient s voice is strained and speaking requires a great effort The patient sounds as though he were trying to speak while being strangled Shouting is easier than quiet speech, and whispering is unaltered Other actions utilizing approximately the same muscles (swallowing and singing) are usually unimpeded Spasmodic dysphonia is usually nonprogressive and occurs as an isolated phenomenon, but we have observed exceptions in which it occurs in various combinations with blepharospasm, spasmodic torticollis, writer s cramp, or some other type of segmental dystonia The nature of spasmodic dysphonia is unclear As a neurologic disorder, it is akin to writer s cramp, ie, a restricted dystonia (see Chap 6) We have at times had great dif culty differentiating a severe essential tremor of voice from spasmodic dysphonia (fortunately, the treatments are similar) Treatment Speech therapists, observing such a patient strain to achieve vocalization, often assume that relief can be obtained by making the patient relax, and psychotherapists believed at rst that a search of the patient s personal life around the time when the dysphonia began would enable the patient to understand the problem and regain a normal mode of speaking But both these methods have failed without exception Drugs useful in the treatment of Parkinson disease and other extrapyramidal diseases are practically never effective Crushing of one recurrent laryngeal nerve can be bene cial, but recurrence is to be expected The most effective treatment, comparable to treatment of other segmental dystonias, consists of the injection of 5 to 20 U of botulinum toxin, under laryngoscopic guidance, into each thyroarytenoid or cricothyroid muscle Relief lasts for several months An anatomic abnormality has not been demonstrated, but careful neuropathologic studies have not been made Glottic spasm as in tetanus, tetany, and certain hereditary metabolic diseases results in crowing, stridorous phonation Hoarseness and raspiness of the voice may also be due to structural changes in the vocal cords, the result of cigarette smoking, acute or chronic laryngitis, polyps, edema after extubation, etc.

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ALEXANDER MP, BENSON DF: The aphasias and related disturbances, in Joynt RJ (ed): Clinical Neurology Vol 1 New York, Lippincott, 1991, chap 10 ALEXANDER MP, NAESER MA, PALUMBO CL: Correlation of subcortical CT lesion sites and aphasia pro les Brain 110:961, 1987 ANDERSON JM, GILMORE R, ROPER S, et al: Conduction aphasia and the arcuate fasciculus: A reexamination of the Wernicke-Geschwind model Brain Lang 70:1, 1999 ASSAL G, REGLI F, THUILLARD A, et al: Syndrome de l isolement de la zone du language Rev Neurol 139:417, 1983 BALTER M: Speech gene tied to modern humans Science 297:1105, 2002 BASSO A, TABORELLI A, VIGNOLO LA: Dissociated disorders of reading and writing in aphasia J Neurol Neurosurg Psychiatry 41:556, 1978 BEAUVOIS MF, SAILLANT B, MEININGER V, LHERMITTE F: Bilateral tactile aphasia: A tacto-verbal dysfunction Brain 101:381, 1978 BENSON DF: Aphasia, Alexia, and Agraphia New York, Churchill Livingstone, 1979 BRAIN R: Speech Disorders Aphasia, Apraxia and Agnosia Washington, DC, Butterworth, 1961 BROCA P: Portee de la parole: Ramollisement chronique et destruction partielle du lobe anterieur gauche du cerveau Paris Bull Soc Anthropol 2:219, 1861 BUCHMAN AS, GARRON DC, TROST-CARDOMONE JE, et al: Word deafness: One hundred years later J Neurol Neurosurg Psychiatry 49:489, 1986 CIABARRA AM, ELKIND MS, ROBERTS JK, MARSHALL RS: Subcortical infarction resulting in acquired stuttering J Neurol Neurosurg Psychiatry 69:546, 2000 CRITCHLEY M: Aphasiological nomenclature and de nitions Cortex 3:3, 1967 CROISILE B, LAURENT B, MICHEL D, et al: Pure agraphia after a deep hemisphere haematoma J Neurol Neurosurg Psychiatry 53:263, 1990 DAMASIO AR: Aphasia N Engl J Med 326:531, 1992 DAMASIO AR, DAMASIO H: The anatomic basis of pure alexia Neurology 33:1573, 1983 DAMASIO AR, GESCHWIND N: Anatomical localization in clinical neuropsychology, in Vinken PJ, Bruyn GW, Klawans HL (eds): Handbook of Clinical Neurology Vol 45 Amsterdam, Elsevier, 1985, chap 2, pp 7 22.

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