Ami Otnl Rhinol Laryngol 94:1985 MAGNETIC RESONANCE IMAGING FINDINGS AND CORRELATIONS IN SPASMODIC DYSPHONIA PATIENTS STEVEN SCHAEFER, MD TERESE FINITZO, PHD ELLIOTT ROSS, MD LANNY CLOSE, MD JOAN REISCH, PHD DALLAS, TEXAS FRANCES FREEMAN, PHD MICHAEL CANNITO, MS KENNETH MARAVILLA, MD A sample of 19 spasmodic dysphonia (SD) patients was selected from a larger population of such patients to undergo magnetic resonance imaging (MRI), auditory brain stem response (ABR) testing, speech analysis, and extensive physical examination. Six patients had abnormal spin-echo MRI findings, ranging from infarcts within the basal ganglia to demyelinating lesions within the supralateral angles of the lateral ventricles. A weakly positive correlation was noted between the abnormal MRI findings and an abnormal ABR. The lack of a significant correlation between the MRI findings and other predictors of brain stem and midbrain disea.sc, and the current spatial resolution limitations of MRI, suggest that we are visualizing the associated lesions rather than the actual foci of SD. The range of MRI findings is consistent with the concept that SD is a voice disorder in a heterogeneous patient population. KEY WORDS — auditory brain .stem response, magnetic resonance imaging, single photon emission computed tomography, spasmodic dysphonia. INTRODUCTION Spasmodic dysphonia (SD) is a devastating voice disorder of unknown etiology, with variable clinical presentation and response to treatment. The voice of such patients is characterized by "staccato, jerky, squeezed, effortful, or groaning vocalizations."' Opinion has been polarized in the past century be- tween psychiatric and organic etiologies for the dis- order.'' This polarization has arisen from 1) histor- ically inadequate description and definition of the entity, 2) the trend to view SD as a pure disorder rather than a vocal behavior having multiple etiolo- gies, and 3) the inherent difficulties in documenting and developing a model for a voice disorder. Traube (1871) is credited as the first to report a "spastic form of psychogenic hoarseness" while con- trasting the various manifestations of "typhus ab- dominalis" upon the larynx. Die spastische Form der nervosen Heiserkeit beobachtete Pro- fessor Traube bei einem hysterischen jungen Madchen. Die sehr heisere, fast aphonische Patientin vermochte mit grosser An- strengung nur zuweilen sehr hohe, fistulirende Tone anzuschla- gen. Die laryngoscopische Untersuchung ergab einen krampfhaf- ten Verschluss der Stimmritze, wobei die linke Cartilago ary- thaenoidea sich vor die rechte schob und wahrscheinlich auch die Stimmbander zum Theil sich deckten. Das Verhalten dieser letz- teren war desshalb nicht zu eruiren, well die Epiglottis stark nach hinten geneigt war. Auch in diesem Falle hatte der electrische in- constante Strom keine Wirkung.' Translation: The spastic form of the nervous hoarseness was ob- served by Professor Traube in one hysterical young girl. The very hoarse, nearly aphonic patient could only rarely produce some high frequency falsetto tones with great effort. The laryngoscopic axamination gave a spastic closure of the vocal cord whereby the left arytenoid cartilage shifted in front of the right one while probably also the vocal cords particularly overlapped each other. The behavior of the vocal cords was not examined because the epiglottis was inclined strongly backwards. Also in this case, the electrical energy does not show any effectiveness [sic]. This casual reference to a young woman in a five page chapter on laryngeal afflictions caused by typhus is the origin of psychogenic theories of SD. Traube based his diagnosis on the short duration of the illness and assumed a hysterical etiology. In 1874 and in 1895, Schnitzler described two patients with "cramping of the vocal cords and forced voice."' These patients were noted to have synkinesis of facial muscles and abnormal movements of the arms and legs. He postulated an organic etiology and called this entity "aphonia spastica" or spastic dysphonia. A century after Traube's original de- scription, Aronson pointed out that this designation was clinically misleading, because spasticity arising from corticospinal (pyramidal) disease implies a form of rigidity,'' whereas extrapyramidal disor- ders characteristically "wax and wane from mo- ment to moment in a spasmodic fashion," and are best described as "spasmodic." For the past 25 years the concept that SD was a purely psychosomatic disorder has been seriously challenged. In 1960, Robe et al published the results of their EEG study of ten patients with SD of one half to 15 years duration.' Forty percent of the pa- From the Departments of Otorhinolaryngology (Schaefer. Close), Neurology (Ross), Radiology and the Medical Computing Resources Center (Maravil- la, Reisch), Southwestern Medical School, University of Texas Health Science Center at Dallas, and Callier Center for Communicative Disorders, Uni- versity of Texas at Dallas (Freeman, Finitzo, Cannito). Supported by grants from the National Institute of Neurological and Communicative Disorders and stroke (IROl NS18276-01A1). Presented at the meeting of the American Laryngological Association, Miami Beach, Florida, May 25-26, 1985. REPRINTS — Steven Schaefer, MD, Dept of Otorhinolaryngology, Southwestern Medical School, University of Texas Health Science Center, 5323 Harry Hines Blvd, Dallas, TX 75235. 595