The Laryngoscope V C 2011 The American Laryngological, Rhinological and Otological Society, Inc. Patient Perceptions of Factors Leading to Spasmodic Dysphonia: A Combined Clinical Experience of 350 Patients Lesley Childs, MD; Scott Rickert, MD; Thomas Murry, PhD; Andrew Blitzer, MD, DDS; Lucian Sulica, MD Purpose: Spasmodic dysphonia (SD) is an idiopathic voice disorder that is characterized by either a strained, strangled voice quality or a breathy voice with aphonic segments of connected speech. It has been suggested that environmental factors play a role in triggering the onset. Clinical observation suggests that some patients associate onset with specific events or fac- tors while others do not. The purpose of this study was to examine a large database of SD patients to determine if specific triggers are associated with the onset of SD. Procedures: Retrospective chart review. Results: A total of 350 charts of patients with SD were identified and were categorized as either ‘‘sudden onset’’ or ‘‘gradual onset.’’ One hundred sixty-nine recalled their circumstances surrounding onset. Forty-five percent of these patients described the onset as sudden. Patient perceptions of inciting events in the sudden onset group were identified 77% of the time and 2% of the time in the gradual onset group. The most common factors identified were stress (42%), upper respira- tory infection (33%), and pregnancy and parturition (10%). Conclusions: Thirty-five percent of SD patients perceive their disorder to have a sudden onset with identified inciting events. This prevalence raises questions regarding possible behavioral and environmental factors surrounding the onset of this disorder. Key Words: Spasmodic dysphonia, sudden onset, gradual onset. Laryngoscope, 121:2195–2198, 2011 INTRODUCTION Spasmodic dysphonia (SD), or focal laryngeal dysto- nia, is an idiopathic disorder in which voice production is impaired by irregular and uncontrolled contractions of the laryngeal muscles. Typically, it is divided into two types—adductor (82%) and abductor (17%)—based on the predominant effect of inappropriate muscle contrac- tion. 1 Adductor SD patients experience intermittent hyperadduction of the vocal folds, which results in a choked or strangled voice quality. Those with abductor SD exhibit a breathy voice quality with aphonic or whis- pered breaks in phonation. SD is a chronic condition, which interferes with patients’ daily communication, resulting in significant occupational disability and social isolation. 2 Historically, SD was considered a psychiatric condi- tion highly related to stress, despite the conspicuous lack of success of psychiatric treatment. The early work of Dedo 3 involving recurrent laryngeal nerve block and section demonstrated beyond a doubt that the disorder was neurologic in nature. Others have reported success- ful temporary relief of symptoms with botulinum toxin injections to the laryngeal musculature. 4,5 Despite these therapeutic successes, knowledge regarding causes and predisposing factors remains extremely limited. To date, six ‘‘DYT’’ gene loci characterized by dystonia have been designated, although none have been specifically linked to SD. Additionally, no genetic studies have been reported in families with SD. Most cases occur sporadi- cally and are not associated with other medical conditions. Women do appear more likely to be affected, but the implications of this for pathophysiology are not clear. Some affected individuals relate the onset of their voice disorder to specific events, whereas others do not. The Laryngeal and Speech Section of the NIH has emphasized that studies that identify associations with the onset of SD provide clues for animal models, 6 yet no large-scale study has yet examined the patient percep- tion regarding onset of SD. The lack of a large SD population in any one center, the assessment process, and/or the lack of a consistent case history format to study the disorder may explain this. The present study aims to examine patient perceptions regarding the onset of their disorder. MATERIALS AND METHODS Institutional review board approval was obtained. The clinical records of patients from two urban laryngology practices From the New York Head and Neck Institute (L.C., S.R., A.B.), Center for Voice and Swallowing Disorders, New York, New York, U.S.A.; Weill Medical College of Cornell University (L.C., S.R., T.M., L.S.), Department of Otorhinolaryngology, New York, New York, U.S.A. Editor’s Note: This Manuscript was accepted for publication June 3, 2011. Poster presentation at Combined Otolaryngological Spring Meet- ing, American Laryngological Association, Chicago, IL, April 27–28, 2011. The authors have no financial disclosures for this article. The authors have no conflicts of interest to disclose. Send correspondence to Lesley Childs, New York Head and Neck Institute, Center for Voice and Swallowing Disorders, 515 West 59th Street, #11A, New York, NY 10019. E-mail: childs.lesley@gmail.com DOI: 10.1002/lary.22168 Laryngoscope 121: October 2011 Childs et al.: Patient Perceptions of Factors Leading to SD 2195