Dysphonia induced by selective serotonin reuptake inhibitors.

To the Editor: Dysphonias are speech disorders resulting from voice disturbances, and iatrogenic dysphonias should be considered in the differential diagnosis of any patient presenting with a voice disorder. The most frequently cited medications that may cause dysphonia include corticosteroids, androgens, progesterone, diuretics, and tricyclic antidepressants. (1) We report two cases of dysphonia related to selective serotonin reuptake inhibitor (SSRI) intake, one involving paroxetine and the other, fluoxetine. Both were prescribed at the recommended daily dose. The main characteristic of these two cases is the complete cessation of vocal symptoms immediately after SSRI withdrawal.

A 46-year-old woman presented in January 2003 with a disturbing dysphonia. She had a history of posttraumatic cervical arthrodesis in 1994 and depressive episodes. She was treated with paroxetine (20 mg a day) from April to July 2002, and this treatment was reinitiated in September 2002. Her dysphonia was characterized by a shaking voice and breaks in pitch and phonation. It was associated with cervical and mediastinal paresthesias. She denied any symptoms of dyspepsia or pyrosis. Her thyroid was slightly painful on palpation. A digestive endoscopy and a cervicothoracic tomodensitometry with contrast media injection revealed no abnormality. ENT explorations revealed normal vocal fold morphology and mobility consistent with a neurodystonia. In February 2003, because of a possible drug-induced disorder, the patient was asked to stop her paroxetine treatment. Twelve days later the dysphonic symptoms had completely disappeared.

A 68-year-old woman with a spasmodic dysphonia presented in March 1999. She had a history of mammary radiation in 1986; arterial hypertension treated with hydrochlorothiazide, amiloride, and timolol since 1979; and depressive disorders treated with fluoxetine (20 mg daily) and zopiclone since April 1997. The patient's voice was throaty and hoarse with normal intensity and regular flow but with breaks in pitch and phonation and decreased modulation capacities. She also complained of thoracic dysesthesias. ENT explorations showed mobile but rather hypotonic vocal cords consistent with a dystonic origin. Because an iatrogenic dysphonia was suspected, fluoxetine was withdrawn in April 1999 whereas the other drugs were continued. Three days later, the spasmodic dysphonia completely disappeared. Due to the complete resolution of symptoms upon withdrawal of the SSRI, these cases strongly suggest drug-induced dysphonia.

SSRIs can induce neurologic disorders such as acute dystonia, dyskinesia, (2) dysarthria (3) and stuttering. (4) With the exception of a single case of dysphonic laryngeal dystonia reported by Murray et al (5) with chlorpromazine, fluoxetine, and alcohol overdose in a 14-year-old child, no case of dysphonia induced by SSRI at the recommended daily dosage has been reported.

These two reported cases of dysphonia widen the spectrum of the different kinds of dystonias, which may be induced by SSRIs, such as dysphonia and especially spasmodic dysphonia. With their increased usage, an association between SSRIs and dysphonia should therefore be kept in mind.

Nadine Petitpain, PHD

Nicolas Gambier, PHD

Pierre Gillet, PHD, MD

Department of Clinical Pharmacology

CHU Nancy

Crehange, France

Jean-Claude Muller, MD

General Practitioner

Crehange, France

Eric de Romemont, MD

General Practitioner

Nancy, France

References

1. Spiegel JR, Hawkshaw M, Thayer Sataloff R. Dysphonia related to medical therapy. Otolaryngol Clin North Am 2000;33:771-784.

2. Nielsen AS, Mors O. Choreiform dyskinesia with acute onset and protracted course following fluoxetine treatment. J Clin Psychiatry 1999;60:868-869.

3. Guthrie S, Grunhaus L. Fluoxetine-induced stuttering. J Clin Psychiatry 1990;51:85.

4. Fox GC, Ebeid S, Vincenti G. Paroxetine-induced chorea. Br J Psychiatry 1997;170:193-194.

5. Murray V. Laryngeal dystonia. Br J Psychiatry 1995;167:698-699.

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