Hello SteveI can relate to what you are reporting with the extremely breathy low-volume voice. By 'breathiness' in this context I don't mean any difficulty in breathing while at rest, but WASTING breath while talking, so that all you can manage in this state is 3-4 syllables before running out of breath. You can test this by holding your hand in front of your mouth as you talk and feel the blast of air being wasted as you exhale while talking.
I presume you have ADductor SD like I do - if not, ignore the rest of this.
In my case the breathy voice became more of a problem as my series of Botox injections continued. The doctors lowered the dose, but I still had the breathy voice, and the duration of effect shortened too.
Eventually my doctors, on advice from Dr Christy Ludlow of the NIH, decided to change the treatment to unilateral injections - that is, one side only. My doctors tried alternating the side injected each time, but improved the treatment by injecting the SAME side each time. Here is what I currently experience (I'm a veteran of 44 shots now over a period of 13-14 years).
I currently receive 10 units in the right cord only each time. Why the right side? Apparently the two vocal cords are marginally asymmetric because one wraps around the front of the other in places, and the right side is the easier to inject. It is, also, apparently, more prone to injury than the left one so it makes sense to leave the left one more functional and not inject it. This assumes my medical anatomy (or explanation from my doctor) is correct! But in my case - with experimentation over the years, when I tried unilateral alternating - what happened was that the uninjected cord was still weak from the time before, so didn't play its full part in voicing - and therefore the total dose needed to be kept lower, which didn't help with the longevity of the Botox shot. So, when having alternating unilateral, although better than low/medium dose bilateral, there was neither full relief from the SD or a good strong voice.
So, 6/7 years ago we decided to try unilateral same side each time, and in my case it's the best method (having tried low dose bilateral, and alternating unilateral).
My doctor gives two shots (5 units each) in the SAME cord each time. The reason for the two shots in the one cord are:
1 - an insurance policy in case the placement of a single shot isn't quite right
2 - better diffusion in the cord because two sites are involved
It adds about 20 seconds onto the treatment time, and the same needle can be used of course.
My advice would be to try unilateral one side only, and work your way up slowly to a slightly higher dose. I wouldn't try even 5 units first time because the other cord will still have some residual weakness. But after 3/4 times and the unilateral pattern is firmly established you might hopefully see an improvement. Working up to a higher dose over time should increase the good effect out considerably from just 3 months. I am currently getting 6-8 months. I won't pretend my voice is perfect (I'm always envious of people I know who go in for minor bilateral top-ups and sound wonderful all the time) but it is serviceable, with OK volume in quiet surroundings fairly soon after injection.
David Barton (AD/SD, Auckland, New Zealand)
