Spasmodic Dysphonia and Essential Vocal Tremor

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Spasmodic dysphonia and essential vocal tremor are neurological voice disorders that are often misunderstood and misdiagnosed. They can be mistaken for simple voice strain. Duke laryngologists -- ear, nose, and throat (ENT) doctors who specialize in voice disorders -- and speech-language pathologists are experts in diagnosing spasmodic dysphonia and essential vocal tremor. We offer customized treatments and therapy to help you find relief. 

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About Spasmodic Dysphonia

Spasmodic dysphonia causes involuntary spasms of the vocal cords (also known as vocal folds). It can make your voice sound hoarse, jerky, quivering, strangled, tight, or breathy, sometimes to the point where it is difficult to speak. The vocal spasms are due to a faulty connection between a nerve and the muscle that controls your larynx (voice box). 

There are two types of spasmodic dysphonia. Some people have characteristics of both.

  • Abductor spasmodic dysphonia occurs when the vocal cords spasm open, which results in a breathy voice that can sound like a whisper.
  • Adductor spasmodic dysphonia occurs when the vocal cords spasm shut, which causes a strained and strangled voice.

While there is currently no cure, our laryngologists and speech-language pathologists can offer a combination of proven treatments and voice therapy to alleviate and manage your symptoms.

About Essential Vocal Tremor

Essential vocal tremor is also an involuntary voice disorder, and it can cause rhythmic voice shaking. The voice of someone with essential vocal tremor might sound labored, unstable, and as if they are nervous. Whereas spasmodic dysphonia specifically affects the vocal cords, vocal tremor can involve muscles in the throat and those used for breathing and articulation, such as the tongue, jaw, and palate. Some people may have both essential vocal tremor and spasmodic dysphonia, so accurate diagnosis by skilled voice experts is crucial to making sure you receive appropriate treatment.

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Duke Health offers locations throughout the Triangle. Find one near you.


Comprehensive Evaluation

We will assess how you use your voice and what it sounds like. When spasmodic dysphonia or essential vocal tremor is suspected, your speech-language pathologist will complete a detailed evaluation of your speaking patterns, with a particular focus on the signs of spasmodic dysphonia or tremor. Your laryngologist will evaluate the role of any medical conditions that can cause voice changes, such as surgeries or recent illness. We will perform a head and neck examination and a visual examination of your voice box.


Videolaryngostroboscopy is essential for reaching an accurate diagnosis and determining the best treatment for your voice. This detailed visual exam helps us evaluate how your vocal cords vibrate while you make sounds. A tiny camera attached to a small tube called an endoscope is inserted through your nose and allows us to see your vocal cords and larynx (voice box). A flashing strobe light simulates slow motion video, and the camera captures images of your vocal cords. The exam takes about a minute. Your nose may be sprayed with topical anesthetic for your comfort.

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Botulinum Toxin (Botox) Injection

A laryngologist injects botulinum toxin (Botox) into the vocal cord through the neck or mouth. This temporarily weakens overactive vocal cord muscles to allow you to speak more easily and clearly.

If the injection approach is through the neck, a neurologist provides electromyographic (EMG) guidance. This detects electrical activity in the muscle and helps ensure accurate placement of the injection. Repeat injections are usually needed every four to six months. 

If the injection approach is through the mouth, a speech-language pathologist will assist by directing an endoscope through the nose and into the throat. This allows the laryngologist to visualize the voice box and ensure accurate placement of the injection. Repeat injections are usually needed every eight to twelve weeks. 


Although Botox is often considered the gold standard of treatment for spasmodic dysphonia, there are also some oral medications that can lessen the symptoms. Specific medications can also provide some relief of vocal tremor symptoms.

Voice Therapy

A speech-language pathologist guides you through vocal exercises to improve your breathing, reduce throat strain, and minimize your symptoms. Depending on the severity of your condition, voice therapy can be used alone or with Botox injections (and/or medication).

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Duke University Hospital is proud of our team and the exceptional care they provide. They are why we are once again recognized as the best hospital in North Carolina, and nationally ranked in 11 adult and 9 pediatric specialties by U.S. News & World Report for 2023–2024.

Why Choose Duke

A Team of Experts
Your care team will include laryngologists with advanced training and years of experience in diagnosing and treating spasmodic dysphonia and essential vocal tremor. They work closely with speech-language pathologists who are specially trained to evaluate and treat people with voice problems and have expertise in managing neurological voice disorders.

Latest Technology and Treatments
We use sophisticated technology designed to enhance your treatment's accuracy and effectiveness. 

Coordinated Care
Because spasmodic dysphonia and essential vocal tremor are neurological conditions, we may also partner with Duke Health neurologists to ensure you receive the best therapies to minimize your symptoms and improve your voice.

Active Research to Advance Care
Our ongoing research ensures you receive the best, most up-to-date care for your spasmodic dysphonia and essential vocal tremor.

This page was medically reviewed on 03/08/2023 by