Analgesia in Transcutaneous Laryngeal Botulinum Toxin Injections: A Randomized Crossover Trail

William Karle, MD | Northwell Health

Dr. William Karle is a recipient of the 2023 Dysphonia International Research Travel Award in partnership with The Voice Foundation. Dr. Karle participated in the 2023 Voice Foundation Conference and presented research entitled, “Analgesia in Transcutaneous Laryngeal Botulinum Toxin Injections: A Randomized Crossover Trail”. When asked what it meant for him to attend The Fall Voice Conference, he stated that “It was great sharing ideas for treatment of patients with laryngeal dystonia (spasmodic dysphonia).”

Below is an abstract of Dr. Karle’s podium presentation.


Additional Authors: Richard Heyes MD; Charles H. Adler MD, PhD; Claire Yee PhD; David G. Lott MD

Objectives: There is an absence of data in the literature regarding methods to improve the patient experience during the performance of awake in-office laryngeal injections. This study sought to evaluate whether the use of local anesthetic or a vibrating instrument decreased overall pain experienced by patients with laryngeal dystonia, frequently referred to as spasmodic dysphonia (SD), undergoing transcervical botulinum toxin injections.   

Methods: This was an unblinded, prospective randomized control trial with a crossover design where each patient received transcutaneous transcricothyroid injection of botulinum toxin with alternating use of no anesthesia, local anesthesia (2% lidocaine in 1:100,000 epinephrine), and vibrating instrument in three consecutive laryngeal injections to treat adductor SD. Patients were randomized to the order they received these treatments. Patients measured pain on a 0-10 visual analogue scale (VAS) and selected their preferred technique after receiving all three analgesic modalities.   

Results: Thirty-two patients completed the study. There was no statistically significant difference in pain between the three analgesic techniques (p = 0.38). The most preferred analgesic technique was the vibrating wand (44% (14/32)). Lidocaine was the second most preferred (37% (12/32)) and 19% (6/32) of patients preferred nothing. When combining the wand and nothing groups, 63% of patients preferred one of these two methods (95% exact CI: 44% – 79%).   

Conclusions: There was no statistically significant difference in median pain experienced by patients during laryngeal botulinum toxin injection between these different analgesic modalities. More than half of the patients selected a preference for a technique that did not include lidocaine. This data supports individualization of analgesia during transcutaneous laryngeal injections.

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Sponsoring Organizations

The Fall Voice Conference is designed to encourage and educate professionals on a multi-disciplinary approach to the management of vocal disorders. The focus of this conference is the clinical care of patients with voice-related difficulties and how clinical and basic science research guide clinical care. For more information:

Dysphonia International is dedicated to improving the lives of people with spasmodic dysphonia and related voice conditions through research, education, awareness, and research.