ACP InternistMKSAP Quiz: Evaluation of Strained, Strangled Voice

Could it be chorea, dystonia, a functional disorder, myoclonus, or a tic?

A 56-year-old woman presents with a year-long history of a strained and strangled voice, difficulty expressing certain consonants, and intermittent throat tightness. She reports no pain, shortness of breath, other symptoms, or medical problems and takes no medications. Vital signs are normal. Her voice is hoarse, and she speaks with a strained and pressured voice disrupted by sudden pauses, but she can sing without any problems. The remainder of the neurologic examination is normal. Video laryngoscopy reveals slow, sustained, and nonrhythmic pulling of vocal cords toward midline with intermittent relaxations.

Dystonia, the third most common movement disorder after Parkinson’s disease and essential tremor, affects more than 300,000 people in North America.

Question

What is the most likely diagnosis?

• Chorea: Characterized by random flowing movements.
• Dystonia: Characterized by sustained or intermittent muscle contractions that are slow, repetitive, and directional.
• Functional disorder: Can present with variability, distractibility, and inconsistency with organic disorders.
• Myoclonus: Characterized by fast jerky movements that can involve various body parts.
• Tic: Usually present as sudden utterances or words that disrupt otherwise normal speech.

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