How does my jaw move?

The functional anatomy of the jaw is essential to understand dystonic movements of the jaw when a patient is eating or speaking. The chewing movements are extremely complex and I will detail only the main posture of the jaw, following dystonic spasms.

The jaw can move in a vertical plan, with opening or closing the mouth

The jaw can move in a saggital plan, the jaw going forward ( protrusion) or backward ( retrusion)

The jaw can move in a lateral plan, the jaw going side to side or going down and to one side, called deviation of the jaw.

The masticatory muscles, responsible of these movements are 4 pairs of muscles ( masseters, temporalis, median pterygoid and lateral pterygoid muscles) and the mouth floor muscles ( supra-hyoid muscles).

image

image

A combination of these movements is usually involved in the dystonic spams of the jaw. The video recording of a patient when chewing can be very helpful for analysing in details the dystonic spasms.

Dr MH Marion at the London BTX centre, is specialised in the treatment of dystonia, and injects under electromyogram guidance the masticatory muscles involved in oro-mandibular dystonia.

Advertisements

Strangulated and whispery voice due to laryngeal dystonia. What does it mean for the patient?

               Our voice, like our handwriting, is an individual signature.

Just answering Hello on the phone is enough for our relatives or closed friends to identify who is speaking.

The daughter or the son of a friend, who speaks just like their parents, sometimes mistakes us. Study on monozygotic twins showed that the voice pitch can be a familial characteristic, which can be useful in the identification of twins.

 Also our voices may express our emotions, such as anger, stress, and happiness like our facial muscles do, mainly through the pitch of our voice. There are studies in the world of forensic science on vocal stress analysis. But none of them have found so far a reliable way of detecting lie based on recording laryngeal micro-tremor.

 Also our accent told people where we come from geographically and socially.

 So, presenting with a voice disorder can be emotionally difficult as not only the oral communication become laborious, but also the way of expressing our emotions is impaired, and part of our identity is lost.

 –Spasmodic dysphonia, is a dystonic spasm of the vocal cords when speaking and there are 2 main types of spasmodic dysphonia.

1-In the adductor type, the most common form the voice is strained, strangled, frequently interrupted by voiceless pauses, because the vocal cords have difficulties to spread apart when speaking, In that case, the dystonic muscles are the thyro-arythenoids muscles or adductor muscles, which are responsible of getting the vocal cords closed to each other’s.

2-In the abductor type, the less common form, the voice is breathy, with prolonged voiceless consonants because of difficulties with voice onset following voiceless sounds such as /h/, /s/, /f/, /p/, /t/, and /k/. The muscles, which are responsible of spreading apart the vocal cords, are the Crico-pharyngeal muscles or abductor muscles.

 

-Emotional factors can influence spasmodic dysphonia

Stress can precede the onset, or worsen the symptoms, but surprisingly patients report that screaming, crying, laughing, and singing can be normal. This variability of the symptoms can be disconcerting for the patient and raise suspicion of psychogenic pathology (due to psychological problems) in the entourage of the patients and even the doctors. The capricious nature of the dystonic symptoms has to be explained for a better acceptation of the condition .

Botulinum toxin injections into the vocal cords are the most efficient treatment of this condition, which curiously not only restore the voice fluidity in case of adduction dysphonia but also the voice personality with pitch and accent. Repeated injections every 3 to 6 months are required to maintain a good voice.

-References:

Voice similarity in identical twins. Van Gysel WD, Vercammen J, Debruyne F. Acta Otorhinolaryngol Belg. 2001;55(1):49-55.

 Voice Onset Time Production in Older and Younger Female Monozygotic Twins
Jack Ryalls, Heather Shaw, Marni Simon. 
Folia Phoniatr Logop 2004;56:165-169.

 Voice stress evaluators and lie detection. Hollien H, Geison L, Hicks JW Jr. J Forensic Sci. 1987 Mar;32(2):405-18.

 Voice – How humans communicate? Manjul Tiwari and Maneesha Tiwari , J Nat Sci Biol Med June 2012

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361774/

Free article

 Patient perceptions of factors leading to spasmodic dysphonia: a combined clinical experience of 350 patients. Childs L, Rickert S, Murry T, Blitzer A, Sulica L. Laryngoscope. 2011 Oct;121(10):2195-8.

Few words about me… Dr Marie-Hélène Marion

Few words about me…

Dr Marie-Hélène Marion, specialist in Botox treatment for 25 years.

My name is Marie-Hélène Marion and I am a consultant neurologist, specialized in the use of Botulinum toxin (also called Botox) in Neurology. I started blogging 2 months ago about Botox, Dystonia and Hyperhydrosis and I enjoyed every minute of it. Of course at the beginning I had some hesitations, but quickly I realized that blogging for patients and talking to patients during a clinic, have a lot in common, except that you don’t know and you don’t see the reactions of your readers.

My training

I studied medicine at the University of Clermont-Ferrand in the heart of the beautiful volcanic region of Auvergne. Then went to Paris to study Neurology as an “ Interne des Hopitaux de Paris” in the most prestigious departments of that time and in parallel studied Neuro-pharmacology (how the drugs work in the brain)

Then I started to have itchy feet and went to London to specialize in movement disorder as a research fellow under Professor David Marsden for 2 years. His passion for Parkinson’s disease, Dystonia and the all field of involuntary movement was contagious and never left me since.

My work as a movement disorder specialist on both sides of the channel

I went back to Paris in September 1986 to work as a Chef de Clinique and pioneer in France the use of Botulinum toxin in Neurology. Then in 1998 I crossed again the channel to follow my Australian husband and worked for 12 years at St George’s hospital, in London, running Movement disorders clinics and various Botulinum toxin clinics. At St George’s I still run a clinic specialized in excessive sweating, in particular facial sweating and hands sweating, and a clinic for voice disorders and severe bent neck.

The London BTX Centre

Now my main clinical activity is at the London BTX Centre in Sloane Square that I founded 6 years ago, dedicated to the treatment of focal dystonia, (Blepharospasm, Cervical dystonia, Jaw dystonia, Writer’s cramp, Musician’s cramp), Hemifacial spasm, Facial palsy, Tremor, Bruxism and excessive sweating.

A special mention for patients with voice disorders who are seen in a joint clinic, unique in London, with an ENT-voice specialist (Ms Lucy Hicklin) and a neurologist (MH Marion).

Dr Marie-Helene Marion (neurologist) and MS Lucy Hicklin ( ENT surgeon, Voice specialist)

Academic interests

In parallel, I pursue academic projects in the movement disorders field and published this year on Parkinson’s disease and also on complex cervical dystonia with my junior colleagues at St George’s Hospital. I recently organized the British Neurotoxin Network (BNN)  which gathered all the clinicians over UK who are running Botox services for neurological conditions.

I am a regular invited speaker in international meetings on the field of movement disorders and organized workshops on the use of Botox treatment in neurology, as European expert in the field.