- Email: [email protected]
Deep Brain Stimulation for Treatment of Voice Disorders
Deep Brain Stimulation for Treatment of Voice Disorders Mary J. Hawkshaw and Robert T. Sataloff, Philadelphia, Pennsylvania Summary: Objectives. Vocal tremor is a common, troublesome disorder that is difficult to treat. Efficacy of deep brain stimulation (DBS) was reported more than a decade ago. Most laryngologists are not familiar with the technique or its potential. This review was undertaken to assemble relevant literature written over the past decade and assess the clinical implications of that literature. Design. Literature review. Methods. PubMed search from 2002 through 2011. Results. A small number of articles on the topic have been identified, some of which appear to provide information of potential clinical importance for voice patients. Conclusion. A review of the literature from 2002 through 2011 has revealed several studies supporting the efficacy of DBS as well as adverse consequences of specific technical approaches (such as high-frequency DBS). In the aging population, the prevalence of this voice tremor is likely to increase. We suspect that DBS may be underused; and laryngologists should collaborate with neurosurgeons, speech-language pathologists, and voice scientists to study more extensively the safety and efficacy of DBS for treatment of voice disorders. Key Words: Deep brain stimulation–Dysphonia–Vocal fold tremor.
In 2002, we published our experience with deep brain stimulation (DBS) in the treatment of two patients with vocal tremor.1 Our results not only suggested that DBS may be helpful in controlling vocal tremor but also that more research was needed. In 2002, when we examined the literature, we found that very little had been published on the use of DBS on vocal tremor. The purpose of this review was to evaluate the published data since 2002 on DBS in the treatment of voice and potentially related disorders. A PubMed literature search was done using the keywords: DBS, voice disorders, dystonias, laryngeal dystonia, thalamic DBS, voice tremor, and spasmodic dysphonia. Thalamic stimulation for the reduction of tremor was first reported in 1991 by Benabid et al.2 Since that time, many reports have been published on the successful use of DBS for neurological movement disorders, including Parkinson’s disease, essential tremor, and dystonias.3–24 In addition to treating severe motor disorders, DBS has been used in the management of chronic pain, and recent studies suggest its application potential for treating psychiatric illnesses, including obsessivecompulsive disorder and depression.3,4 DBS has proven to be effective in the management of patients with hyperkinetic movement disorders, such as Gilles de la Tourette’s syndrome and tardive dyskinesia, tics, and in cervical dystonia refractory to medical treatment.5–9,24 In 2010, Thevathasan and Gregory25 reported that DBS is now used routinely as a treatment option for patients with advanced Parkinson’s disease, primary dystonias, secondary dystonias, and essential tremor. Accepted for publication May 15, 2012. From the Department of Otolaryngology—Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania. Address correspondence and reprint requests to Robert T. Sataloff, Department of Otolaryngology—Head and Neck Surgery, Drexel University College of Medicine, 1721 Pine Street, Philadelphia, PA 19103. E-mail: [email protected] Journal of Voice, Vol. 26, No. 6, pp. 769-771 0892-1997/$36.00 Ó 2012 The Voice Foundation doi:10.1016/j.jvoice.2012.05.004
Focal dystonias are specific to the body part affected: blepharospasm (eyes), writer’s cramp (hand), cervical (neck), spasmodic dysphonia (larynx), and oromandibular dystonia (lower face and mouth). The most common task-specific dystonias are laryngeal and writer’s cramp. DBS has been used and proven effective in the treatment of medically intractable focal dystonias. Cho et al26 found DBS effective in the treatment of writer’s cramp. Researchers in Korea reported their experience in treating 11 patients with Meige’s syndrome refractory to medical management.27 They reported postsurgical improvement in oromandibular dystonia, blepharospasm, and speech and swallowing. In 2010, Romito et al28 reported their experience in treating one patient with severe Meige’s syndrome with cervical brachial involvement. This patient underwent a bilateral ventroposterolateral globus pallidus internus implant followed by low voltage brain stimulation. Follow-up in 38 months showed sustained improvement and control of the dystonia without changing the electrical settings of the implants postoperatively. Researchers at the University of Kansas Medical Center reported their findings on the effect of DBS of the ventral intermediate nucleus (VIM) of the thalamus on the voice tremor in seven patients implanted primarily for management of hand tremor.29 They reported reduction of the voice tremor in four of the seven patients. However, they also reported that the gains in voice improvement did not parallel improvements of the upper extremities. In 1999, Taha et al30 evaluated their results using bilateral thalamic DBS in treating head, voice, and bilateral limb tremor associated with Parkinson’s disease (six patients), essential tremor (15 patients), and multiple sclerosis (two patients). Ninety percent of the patients with severe head tremor and 86% of the patients with voice tremor showed improvement within a mean follow-up of 10 months. These researchers suggested that head and voice tremors are the primary indications for this surgical procedure.
770 Moringlane et al31 reported the case of an 81-year-old female disabled by head, voice, and upper extremity tremor. She was treated with bilateral thalamic, intermediate nucleus (VIM) stimulation. With the stimulator on, they achieved complete normalization of her voice and improved vocal fold vibration. Their acoustic and electroglottographic analysis revealed hyperfunctional voicing with the stimulator both on and off. In 2010, researchers in the Netherlands reported their findings in a group of patients with DYT6 dystonia and their response to DBS. Four patients had segmental dystonia, oromandibular and laryngeal involvement. With DBS, these patients achieved moderate-to-good improvement in motor function and only marginal improvement in speech.32 Parkinson’s disease is a progressively debilitating neurological disease that results in impaired motor control of extremities and deficits of voice, speech, and swallowing. Earlier, DBS management of Parkinson’s disease has included medications to treat the symptoms and speech therapy. In 2000, researchers at the University of Florida/Gainesville33 reviewed the literature and examined the treatment options for patients with Parkinson’s disease and the effects on speech. They found that combined treatment with medications and speech therapy improved both the speaking voice and speech. They suggested that pallidotomy and DBS might be effective in the management of Parkinson’s but that further research and experience was needed. They also stressed that efforts should focus on combined therapy approaches. Over the past decade, other researchers have studied the effects of electrostimulation of the subthalamic nucleus (STN) on the speech subsystems and on the respiratory/phonatory subsystems in patients with Parkinson’s disease.34–37 D’Alatri et al38 studied the effect of bilateral STN stimulation and medication on Parkinson’s disease and dysarthria in 12 patients (11 male and one female). Neurological assessments and acoustic recordings of the voice were made. They found that STN improved motor function and voice tremor noting a ‘‘major stability to glottal vibration.’’ Similar to other reports, they noted that STN had a greater effect on the motor dysfunction of extremities than on the voice dysfunction. However, they reported no adverse effect on speech intelligibility. In 2010, Hammer et al39 published their research findings on the changes in speech, respiratory, and laryngeal control in 18 patients with Parkinson’s disease after STN-DBS. They used aerodynamic measures of speech and respiration to assess changes after DBS. Their findings showed that high-frequency STN-DBS often caused ‘‘respiratory overdrive and excessive vocal fold closure’’ and thus might be less helpful in controlling speech and laryngeal symptoms. Their article also provides an extensive list of references that highlights the number of other published reports on the effects of DBS on speech and voice. In 2008, Zealear’s group proposed another potential use for DBS. They studied the effects of DBS in canines with vocal fold paralysis. They assessed the effects in animals with complete denervation and those with synkinetic reinnervation and found DBS to be effective at reanimating the posterior cricoarytenoid muscle in both conditions.40
Journal of Voice, Vol. 26, No. 6, 2012
DBS is a neurosurgical procedure and, like all others, is associated with risks as well as benefits. Hardware complications, venous air emboli, intracranial bleeding, infection, electrode malposition, and erosion have been reported.41–43 Blomstedt et al44 reported moderate dysarthria and severe dysphonia in three of five patients after DBS. Tripoliti et al45 noted decreased speech intelligibility after high-voltage DBS that resulted in improved motor function. They cautioned that strict parameters are needed in speech motor control. Interestingly, acquired stuttering induced by thalamic DBS also has been reported.46,47 Literature over the last decade has supported the efficacy of DBS for treatment of vocal tremor. However, there have been few studies, and the number of patients treated remains small. Voice tremor can be a troublesome symptom; and it sometimes can be disabling. Medical treatment and voice therapy are often not sufficient to control symptoms especially in patients with severe tremor. The good results reported in some cases suggest that this treatment modality may be underused. Patients have an intuitive reluctance to undergo ‘‘brain surgery.’’ However, DBS is a common, reasonably safe procedure; and additional research should be encouraged to determine its safety and efficacy in treatment of patients with voice tremor. REFERENCES 1. Sataloff RT, Heuer RJ, Munz M, Yoon MS, Spiegel JR. Vocal tremor reduction with deep brain stimulation: a preliminary report. J Voice. 2002;16: 132–135. 2. Benabid AL, Pollak P, Dongming G, et al. Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders. J Neurosurg. 1996;84:203–214. 3. Dowling J. Deep brain stimulation: current and emerging indications. Mo Med. 2008;105:424–428. 4. Clausen J. Ethical brain stimulation—neuroethics of deep brain stimulation in research and clinical practice. Eur J Neurosci. 2010;32:1152–1162. 5. Welter ML, Grabli D, Vidailhet M. Deep brain stimulation for hyperkinetics disorders: dystonia, tardive dyskinesia, and tics. Curr Opin Neurol. 2010;23:420–425. 6. Gruber D, Trottenberg T, Kivi A, et al. Long-term effects of pallidal deep brain stimulation in tardive dystonia. Neurology. 2009;73:53–58. 7. Sako W, Goto S, Shimazu H, et al. Bilateral deep brain stimulation of the globus pallidus internus in tardive dystonia. Mov Disord. 2008;23:1929–1931. 8. Kefalopoulou Z, Paschali A, Markaki E, Vassilakos P, Ellul J, Constantoyannis C. A double-blind study on a patient with tardive dyskinesis treated with pallidal deep brain stimulation. Acta Neurol Scand. 2009; 119:269–273. 9. Cacciola F, Farah JO, Eldridge PR, Byrne P, Varma TK. Bilateral deep brain stimulation for cervical dystonia: long-term outcome in a series of 10 patients. Neurosurgery. 2010;67:957–963. 10. Torres CV, Moro E, Dostrovsky JO, Hutchinson WD, Poon YY, Hodale M. Unilateral pallidal deep brain stimulation in a patient with cervical dystonia and tremor. J Neurosurg. 2010;113:1230–1233. 11. Krauss JK. Surgical treatment of dystonia. Eur J Neurol. 2010;17(suppl 1): 97–101. 12. Oropilla JQ, Diesta CC, Itthimathin P, Suchowesky O, Kiss ZH. Both thalamic and pallidal deep brain stimulation for myoclonic dystonia. J Neurosurg. 2010;112:1267–1270. 13. Albanese A, Asmus F, Bhatia KP, et al. EFNS guidelines on diagnosis and treatment of primary dystonias. Eur J Neurol. 2011;18:5–18. 14. Valldeoriola F, Regidor I, Minguez-Castellanos A, et al. Efficacy and safety of pallidal stimulation in primary dystonia: results of the Spanish multicentric study. J Neurol Neurosurg Psychiatry. 2010;81:65–69. 15. Shanker V, Bressman SB. What’s new in dystonia? Curr Neurol Neurosci Rep. 2009;9:278–284.
Mary J. Hawkshaw and Robert T. Sataloff
DBS for Treating Voice Disorders
16. Huh R, Han IB, Chung M, Chung S. Comparison of treatment results between selective peripheral denervation and deep brain stimulation in patients with cervical dystonia. Stereotact Funct Neurosurg. 2010;88:234–238. 17. Cloud LJ, Jinnah HA. Treatment strategies for dystonia. Expert Opin Pharmacother. 2010;11:5–15. 18. Vasques X, Cif L, Hess O, Gavarini S, Mennessier G, Coubes P. Prognostic value of globus pallidus internus volume in primary dystonia treated by deep brain stimulation. J Neurosurg. 2009;110:220–228. 19. Walter U, Wolters A, Wittstock M, Benecke R, Schroeder HW, M€uller JU. Deep brain stimulation in dystonia: sonographic monitoring of electrode placement into the globus pallidus internus. Mov Disord. 2009;24: 1538–1541. 20. Woehrle JC, Blahak C, Kekelia K, et al. Chronic deep brain stimulation for segmental dystonia. Stereotact Funct Neurosurg. 2009;87:379–384. 21. Apetauerova D, Schirmer CM, Shils JL, Zani J, Arle JE. Successful bilateral deep brain stimulation of the globus pallidus internus for persistent status dystonicus and generalized chorea. J Neurosurg. 2010;113:634–638. 22. Cersosimo MG, Raina GB, Benarroch EE, Piedimonte F, Aleman GG, Micheli FE. Micro lesion effect of the globus pallidus internus and outcome with deep brain stimulation in patients with Parkinson disease and dystonia. Mov Disord. 2009;24:1488–1493. 23. Capelle HH, Blahak C, Schrader C, et al. Chronic deep brain stimulation in patients with tardive dystonia without history of major psychosis. Mov Disord. 2010;25:1477–1481. 24. Schrader C, Peschel T, Petermeyer M, Dengler R, Hellwig D. Unilateral deep brain stimulation of the internal globus pallidus alleviates tardive dyskinesia. Mov Disord. 2004;19:583–585. 25. Thevathasan W, Gregory R. Deep brain stimulation for movement disorders. Pract Neurol. 2010;10:16–26. 26. Cho CB, Park HK, Lee KJ, Rha HK. Thalamic deep brain stimulation for writer’s cramp. J Korean Neurosurg soc. 2009;46:52–55. 27. Ghang JY, Lee MK, Jun SM, Ghang CG. Outcome of pallidal deep brain stimulation in Meige syndrome. J Korean Neurosurg soc. 2010;48: 134–138. 28. Romito LM, Elia AE, Franzini A, Bugiani O, Albanese A. Low-voltage bilateral pallidal stimulation for severe meige syndrome in a patient with primary segmental dystonia: case report. Neurosurgery. 2010;67(3 suppl operative):E308. 29. Carpenter MA, Pahwa R, Miyawaki KL, Wilkinson SB, Searl JP, Koller WC. Reduction in voice tremor under thalamic stimulation. Neurology. 1998;50: 796–798. 30. Taha JM, Janszen MA, Favre J. Thalamic deep brain stimulation for the treatment of head, voice, and bilateral limb tremor. J Neurosurg. 1999; 91:68–72. 31. Moringlane JR, P€ utzer M, Barry WJ. Bilateral high-frequency electrical impulses to the thalamus reduce voice tremor: acoustic and electroglottographic analysis. A case report. Eur Arch Otorhinolaryngol. 2004;261: 334–336.
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32. Groen JL, Ritz K, Contarino MF, et al. DYT6 dystonia: mutation screening, phenotype, and response to deep brain stimulation. Mov Disord. 2010;25: 2420–2427. 33. Schulz GM, Grant MK. Effects of speech therapy and pharmacologic and surgical treatments on voice and speech in Parkinson’s disease: a review of the literature. J Commun Disord. 2000;33:59–88. 34. Wang E, Verhagen Metman L, Bakay R, Arzbaecher J, Bernard B. The effect of unilateral electrostimulation of the subthalamic nucleus on respiratory/phonatory subsystems of speech production in Parkinson’s disease— a preliminary report. Clin Linguist Phon. 2003;17:283–289. 35. Rousseaux M, Krystkowiak P, Kozlowski O, Ozsancak C, Blond S, Destee A. Effects of subthalamic nucleus stimulation on parkinsonian dysarthria and speech intelligibility. J Neurol. 2004;251:327–334. 36. Putzer M, Barry WJ, Moringlane JR. Effects of deep brain stimulation in different speech subsystems in patients with multiple sclerosis. J Voice. 2007;21:741–753. 37. Putzer M, Barry WJ, Moringlane JR. Effect of bilateral stimulation of the subthalamic nucleus on different speech subsystems in patients with Parkinson’s disease. Clin Linguist Phon. 2008;22:957–973. 38. D’Alatri L, Paludetti G, Contarino MF, Galla S, Marchese MR, Bentivoglio AR. Effects of bilateral subthalamic nucleus stimulation and medication on Parkinsonian speech impairment. J Voice. 2008;22:365–372. 39. Hammer MJ, Barlow SM, Lyons KE, Pahwa R. Subthalamic nucleus deep brain stimulation changes in speech respiratory and laryngeal control in Parkinson’s disease. J Neurol. 2010;257:1692–1702. 40. Katada A, Van Himbergen D, Kunibe I, et al. Evaluation of a deep brain stimulation electrode for laryngeal pacing. Ann Otol Rhinol Laryngol. 2008;117:621–629. 41. Chan DT, Zhu XL, Yeung JH, et al. Complications of deep brain stimulation: a collective review. Asian J Surg. 2009;32:258–263. 42. Jeong SG, Lee MK, Kang JY, Jun SM, Lee WH, Ghang CG. Pallidal deep brain stimulation in primary cervical dystonia with phasic type: clinical outcome and postoperative course. J Korean Neurosurg Soc. 2009;46: 346–350. 43. Hooper AK, Okun MS, Foote KD, Haq IU, Fernandez HH, Hegland D, Robicsek SA. Venous air embolism in deep brain stimulation. Stereotact Funct Neurosurg. 2009;87:25–30. 44. Blomstedt P, Hariz GM, Hariz MI. Pallidotomy versus pallidal stimulation. Parkinsonism Relat Disord. 2006;12:296–301. 45. Tripoliti E, Zrinzo L, Martinez-Torres I, et al. Effects of contact location and voltage amplitude on speech and movement bilateral subthalamic nucleus deep brain stimulation. Mov Disord. 2008;23:2377–2383. 46. Nebel A, Reese R, Deuschl G, Mehdom HM, Volkmann J. Acquired stuttering after pallidal deep brain stimulation for dystonia. J Neural Transm. 2009;116:167–169. 47. Allert N, Kelm D, Blahak C, Capelle HH, Krauss JK. Stuttering induced by thalamic deep brain stimulation for dystonia. J Neural Transm. 2010;117: 617–620.
In 2002, we published our experience with deep brain stimulation (DBS) in the treatment of two patients with vocal tremor.1 Our results not only suggested that DBS may be helpful in controlling vocal tremor but also that more research was needed. In 2002, when we examined the literature, we found that very little had been published on the use of DBS on vocal tremor. The purpose of this review was to evaluate the published data since 2002 on DBS in the treatment of voice and potentially related disorders. A PubMed literature search was done using the keywords: DBS, voice disorders, dystonias, laryngeal dystonia, thalamic DBS, voice tremor, and spasmodic dysphonia. Thalamic stimulation for the reduction of tremor was first reported in 1991 by Benabid et al.2 Since that time, many reports have been published on the successful use of DBS for neurological movement disorders, including Parkinson’s disease, essential tremor, and dystonias.3–24 In addition to treating severe motor disorders, DBS has been used in the management of chronic pain, and recent studies suggest its application potential for treating psychiatric illnesses, including obsessivecompulsive disorder and depression.3,4 DBS has proven to be effective in the management of patients with hyperkinetic movement disorders, such as Gilles de la Tourette’s syndrome and tardive dyskinesia, tics, and in cervical dystonia refractory to medical treatment.5–9,24 In 2010, Thevathasan and Gregory25 reported that DBS is now used routinely as a treatment option for patients with advanced Parkinson’s disease, primary dystonias, secondary dystonias, and essential tremor. Accepted for publication May 15, 2012. From the Department of Otolaryngology—Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania. Address correspondence and reprint requests to Robert T. Sataloff, Department of Otolaryngology—Head and Neck Surgery, Drexel University College of Medicine, 1721 Pine Street, Philadelphia, PA 19103. E-mail: [email protected] Journal of Voice, Vol. 26, No. 6, pp. 769-771 0892-1997/$36.00 Ó 2012 The Voice Foundation doi:10.1016/j.jvoice.2012.05.004
Focal dystonias are specific to the body part affected: blepharospasm (eyes), writer’s cramp (hand), cervical (neck), spasmodic dysphonia (larynx), and oromandibular dystonia (lower face and mouth). The most common task-specific dystonias are laryngeal and writer’s cramp. DBS has been used and proven effective in the treatment of medically intractable focal dystonias. Cho et al26 found DBS effective in the treatment of writer’s cramp. Researchers in Korea reported their experience in treating 11 patients with Meige’s syndrome refractory to medical management.27 They reported postsurgical improvement in oromandibular dystonia, blepharospasm, and speech and swallowing. In 2010, Romito et al28 reported their experience in treating one patient with severe Meige’s syndrome with cervical brachial involvement. This patient underwent a bilateral ventroposterolateral globus pallidus internus implant followed by low voltage brain stimulation. Follow-up in 38 months showed sustained improvement and control of the dystonia without changing the electrical settings of the implants postoperatively. Researchers at the University of Kansas Medical Center reported their findings on the effect of DBS of the ventral intermediate nucleus (VIM) of the thalamus on the voice tremor in seven patients implanted primarily for management of hand tremor.29 They reported reduction of the voice tremor in four of the seven patients. However, they also reported that the gains in voice improvement did not parallel improvements of the upper extremities. In 1999, Taha et al30 evaluated their results using bilateral thalamic DBS in treating head, voice, and bilateral limb tremor associated with Parkinson’s disease (six patients), essential tremor (15 patients), and multiple sclerosis (two patients). Ninety percent of the patients with severe head tremor and 86% of the patients with voice tremor showed improvement within a mean follow-up of 10 months. These researchers suggested that head and voice tremors are the primary indications for this surgical procedure.
770 Moringlane et al31 reported the case of an 81-year-old female disabled by head, voice, and upper extremity tremor. She was treated with bilateral thalamic, intermediate nucleus (VIM) stimulation. With the stimulator on, they achieved complete normalization of her voice and improved vocal fold vibration. Their acoustic and electroglottographic analysis revealed hyperfunctional voicing with the stimulator both on and off. In 2010, researchers in the Netherlands reported their findings in a group of patients with DYT6 dystonia and their response to DBS. Four patients had segmental dystonia, oromandibular and laryngeal involvement. With DBS, these patients achieved moderate-to-good improvement in motor function and only marginal improvement in speech.32 Parkinson’s disease is a progressively debilitating neurological disease that results in impaired motor control of extremities and deficits of voice, speech, and swallowing. Earlier, DBS management of Parkinson’s disease has included medications to treat the symptoms and speech therapy. In 2000, researchers at the University of Florida/Gainesville33 reviewed the literature and examined the treatment options for patients with Parkinson’s disease and the effects on speech. They found that combined treatment with medications and speech therapy improved both the speaking voice and speech. They suggested that pallidotomy and DBS might be effective in the management of Parkinson’s but that further research and experience was needed. They also stressed that efforts should focus on combined therapy approaches. Over the past decade, other researchers have studied the effects of electrostimulation of the subthalamic nucleus (STN) on the speech subsystems and on the respiratory/phonatory subsystems in patients with Parkinson’s disease.34–37 D’Alatri et al38 studied the effect of bilateral STN stimulation and medication on Parkinson’s disease and dysarthria in 12 patients (11 male and one female). Neurological assessments and acoustic recordings of the voice were made. They found that STN improved motor function and voice tremor noting a ‘‘major stability to glottal vibration.’’ Similar to other reports, they noted that STN had a greater effect on the motor dysfunction of extremities than on the voice dysfunction. However, they reported no adverse effect on speech intelligibility. In 2010, Hammer et al39 published their research findings on the changes in speech, respiratory, and laryngeal control in 18 patients with Parkinson’s disease after STN-DBS. They used aerodynamic measures of speech and respiration to assess changes after DBS. Their findings showed that high-frequency STN-DBS often caused ‘‘respiratory overdrive and excessive vocal fold closure’’ and thus might be less helpful in controlling speech and laryngeal symptoms. Their article also provides an extensive list of references that highlights the number of other published reports on the effects of DBS on speech and voice. In 2008, Zealear’s group proposed another potential use for DBS. They studied the effects of DBS in canines with vocal fold paralysis. They assessed the effects in animals with complete denervation and those with synkinetic reinnervation and found DBS to be effective at reanimating the posterior cricoarytenoid muscle in both conditions.40
Journal of Voice, Vol. 26, No. 6, 2012
DBS is a neurosurgical procedure and, like all others, is associated with risks as well as benefits. Hardware complications, venous air emboli, intracranial bleeding, infection, electrode malposition, and erosion have been reported.41–43 Blomstedt et al44 reported moderate dysarthria and severe dysphonia in three of five patients after DBS. Tripoliti et al45 noted decreased speech intelligibility after high-voltage DBS that resulted in improved motor function. They cautioned that strict parameters are needed in speech motor control. Interestingly, acquired stuttering induced by thalamic DBS also has been reported.46,47 Literature over the last decade has supported the efficacy of DBS for treatment of vocal tremor. However, there have been few studies, and the number of patients treated remains small. Voice tremor can be a troublesome symptom; and it sometimes can be disabling. Medical treatment and voice therapy are often not sufficient to control symptoms especially in patients with severe tremor. The good results reported in some cases suggest that this treatment modality may be underused. Patients have an intuitive reluctance to undergo ‘‘brain surgery.’’ However, DBS is a common, reasonably safe procedure; and additional research should be encouraged to determine its safety and efficacy in treatment of patients with voice tremor. REFERENCES 1. Sataloff RT, Heuer RJ, Munz M, Yoon MS, Spiegel JR. Vocal tremor reduction with deep brain stimulation: a preliminary report. J Voice. 2002;16: 132–135. 2. Benabid AL, Pollak P, Dongming G, et al. Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders. J Neurosurg. 1996;84:203–214. 3. Dowling J. Deep brain stimulation: current and emerging indications. Mo Med. 2008;105:424–428. 4. Clausen J. Ethical brain stimulation—neuroethics of deep brain stimulation in research and clinical practice. Eur J Neurosci. 2010;32:1152–1162. 5. Welter ML, Grabli D, Vidailhet M. Deep brain stimulation for hyperkinetics disorders: dystonia, tardive dyskinesia, and tics. Curr Opin Neurol. 2010;23:420–425. 6. Gruber D, Trottenberg T, Kivi A, et al. Long-term effects of pallidal deep brain stimulation in tardive dystonia. Neurology. 2009;73:53–58. 7. Sako W, Goto S, Shimazu H, et al. Bilateral deep brain stimulation of the globus pallidus internus in tardive dystonia. Mov Disord. 2008;23:1929–1931. 8. Kefalopoulou Z, Paschali A, Markaki E, Vassilakos P, Ellul J, Constantoyannis C. A double-blind study on a patient with tardive dyskinesis treated with pallidal deep brain stimulation. Acta Neurol Scand. 2009; 119:269–273. 9. Cacciola F, Farah JO, Eldridge PR, Byrne P, Varma TK. Bilateral deep brain stimulation for cervical dystonia: long-term outcome in a series of 10 patients. Neurosurgery. 2010;67:957–963. 10. Torres CV, Moro E, Dostrovsky JO, Hutchinson WD, Poon YY, Hodale M. Unilateral pallidal deep brain stimulation in a patient with cervical dystonia and tremor. J Neurosurg. 2010;113:1230–1233. 11. Krauss JK. Surgical treatment of dystonia. Eur J Neurol. 2010;17(suppl 1): 97–101. 12. Oropilla JQ, Diesta CC, Itthimathin P, Suchowesky O, Kiss ZH. Both thalamic and pallidal deep brain stimulation for myoclonic dystonia. J Neurosurg. 2010;112:1267–1270. 13. Albanese A, Asmus F, Bhatia KP, et al. EFNS guidelines on diagnosis and treatment of primary dystonias. Eur J Neurol. 2011;18:5–18. 14. Valldeoriola F, Regidor I, Minguez-Castellanos A, et al. Efficacy and safety of pallidal stimulation in primary dystonia: results of the Spanish multicentric study. J Neurol Neurosurg Psychiatry. 2010;81:65–69. 15. Shanker V, Bressman SB. What’s new in dystonia? Curr Neurol Neurosci Rep. 2009;9:278–284.
Mary J. Hawkshaw and Robert T. Sataloff
DBS for Treating Voice Disorders
16. Huh R, Han IB, Chung M, Chung S. Comparison of treatment results between selective peripheral denervation and deep brain stimulation in patients with cervical dystonia. Stereotact Funct Neurosurg. 2010;88:234–238. 17. Cloud LJ, Jinnah HA. Treatment strategies for dystonia. Expert Opin Pharmacother. 2010;11:5–15. 18. Vasques X, Cif L, Hess O, Gavarini S, Mennessier G, Coubes P. Prognostic value of globus pallidus internus volume in primary dystonia treated by deep brain stimulation. J Neurosurg. 2009;110:220–228. 19. Walter U, Wolters A, Wittstock M, Benecke R, Schroeder HW, M€uller JU. Deep brain stimulation in dystonia: sonographic monitoring of electrode placement into the globus pallidus internus. Mov Disord. 2009;24: 1538–1541. 20. Woehrle JC, Blahak C, Kekelia K, et al. Chronic deep brain stimulation for segmental dystonia. Stereotact Funct Neurosurg. 2009;87:379–384. 21. Apetauerova D, Schirmer CM, Shils JL, Zani J, Arle JE. Successful bilateral deep brain stimulation of the globus pallidus internus for persistent status dystonicus and generalized chorea. J Neurosurg. 2010;113:634–638. 22. Cersosimo MG, Raina GB, Benarroch EE, Piedimonte F, Aleman GG, Micheli FE. Micro lesion effect of the globus pallidus internus and outcome with deep brain stimulation in patients with Parkinson disease and dystonia. Mov Disord. 2009;24:1488–1493. 23. Capelle HH, Blahak C, Schrader C, et al. Chronic deep brain stimulation in patients with tardive dystonia without history of major psychosis. Mov Disord. 2010;25:1477–1481. 24. Schrader C, Peschel T, Petermeyer M, Dengler R, Hellwig D. Unilateral deep brain stimulation of the internal globus pallidus alleviates tardive dyskinesia. Mov Disord. 2004;19:583–585. 25. Thevathasan W, Gregory R. Deep brain stimulation for movement disorders. Pract Neurol. 2010;10:16–26. 26. Cho CB, Park HK, Lee KJ, Rha HK. Thalamic deep brain stimulation for writer’s cramp. J Korean Neurosurg soc. 2009;46:52–55. 27. Ghang JY, Lee MK, Jun SM, Ghang CG. Outcome of pallidal deep brain stimulation in Meige syndrome. J Korean Neurosurg soc. 2010;48: 134–138. 28. Romito LM, Elia AE, Franzini A, Bugiani O, Albanese A. Low-voltage bilateral pallidal stimulation for severe meige syndrome in a patient with primary segmental dystonia: case report. Neurosurgery. 2010;67(3 suppl operative):E308. 29. Carpenter MA, Pahwa R, Miyawaki KL, Wilkinson SB, Searl JP, Koller WC. Reduction in voice tremor under thalamic stimulation. Neurology. 1998;50: 796–798. 30. Taha JM, Janszen MA, Favre J. Thalamic deep brain stimulation for the treatment of head, voice, and bilateral limb tremor. J Neurosurg. 1999; 91:68–72. 31. Moringlane JR, P€ utzer M, Barry WJ. Bilateral high-frequency electrical impulses to the thalamus reduce voice tremor: acoustic and electroglottographic analysis. A case report. Eur Arch Otorhinolaryngol. 2004;261: 334–336.
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