Diagnosis and management with botulinum toxin in 11 cases of laryngeal synkinesis

Vocal Fold Motion Impairment in Neurodegenerative Diseases

Vocal fold motion impairment (VFMI) is the inappropriate movement of the vocal folds during respiration, leading to vocal fold adduction and/or abduction problems and causing respiratory and vocal impairments. Neurodegenerative diseases (NDDs) are a wide range of disorders characterized by progressive loss of neurons and deposition of altered proteins in the brain and peripheral organs. VFMI may be unrecognized in patients with NDDs. VFMI in NDDs is caused by the following: laryngeal muscle weakness due to muscular atrophy, caused by brainstem and motor neuron degeneration in amyotrophic lateral sclerosis; hyperactivity of laryngeal adductors in Parkinson's disease; and varying degrees of laryngeal adductor hypertonia and abductor paralysis in multiple system atrophy. Management of VFMI depends on whether there is a presence of glottic insufficiency or insufficient glottic opening with/without severe dysphagia. VFMI treatment options for glottic insufficiency range from surgical interventions, including injection laryngoplasty and medialization thyroplasty, to behavioral therapies; for insufficient glottic opening, various options are available based on the severity and underlying cause of the condition, including continuous positive airway pressure therapy, botulinum toxin injection, tracheostomy, vocal fold surgery, or a combination of interventions. In this review, we outline the mechanisms, clinical features, and management of VFMI in NDDs and provide a guide for physicians who may encounter these clinical features in their patients. NDDs are always progressive; hence, timely evaluation, proper diagnosis, and appropriate management of the patient will greatly affect their vocal, respiratory, and swallowing functions as well as their quality of life.

Voice Rehabilitation After Laryngeal Transplantation: Own Experience

BACKGROUND AND PURPOSE

Laryngeal transplantation (LT) remains an infrequently performed procedure due to well-defined and limited medical indications. The challenges include a very complicated surgery, continuous immunosuppressive treatment, as well as post-transplant rehabilitation of voice, speech, and swallowing. The aim of this paper is to describe a model of voice and speech rehabilitation after LT, based on our own experience.

STUDY DESIGN

Observational study.

METHOD

Presented here are the rehabilitation processes of two patients who had previously undergone LT as well as their pre- and postrehabilitation voice outcomes. Both patients underwent voice, speech, and swallowing rehabilitation in the fifth month after LT.

RESULTS

One of the patients had a significant improvement in voice quality. While, the other did not regain his natural, sonorous voice, but he scored very high on a voice self-assessment test.

CONCLUSION

Voice rehabilitation after LT is a complex and long-term process that requires the involvement of a team of specialists. The optimal anatomical conditions restored during surgery, the patient's motivation and the support of professionals make it possible to return to normal verbal communication.

Ultrasound-guided injection into the lateral crico-arytenoid muscle: a pilot study

OBJECTIVES

The anterior, percutaneous Botulinum neurotoxin (BoNT) injection in the lateral cricoarytenoid muscle (LCA) guided by laryngeal electromyography (LEMG) is considered the golden standard treatment for several neurolaryngological disorders. The study presented in this article aims to assess the effectiveness of an alternative approach by which the injection is performed laterally under ultrasound monitoring.

STUDY DESIGN

Anatomical dissection study in human cadavers.

SETTINGS

Academic health care center.

METHODS

Ultrasound-guided bilateral dye (0.1 mL of dye solution containing cold-curing polymers, latex, acrylates, acrylic esters, alcohol, and green color) injection in the LCA was performed by means of 24G needles and 1 mL syringes using the lateral approach. The dye location and distribution were assessed by anatomic dissection, performed immediately after the injection.

RESULTS

In 9/10 specimens, the dye was exclusively detectable in the LCA. In 1/10 case (left side), the dye could not be delivered in the LCA because of unintended penetration of the thyroid cartilage by the needle during injection. Anatomic dissection confirmed that the dye spread neither into the thyroarytenoid (TA) nor the cricothyroid muscle (CT).

CONCLUSIONS

The anatomic dissection following lateral dye injection in the LCA under ultrasound guide confirmed the precision of this approach in delivery a substance exclusively in a pre-determined target. This feature makes this method an interesting addition or alternative to the standard LEMG-guided BoNT injection at least when the LCA is its target.

LEVEL OF EVIDENCE

III.

Vocal Fold Paresis

This article discusses vocal fold paresis as a separate and distinct condition from vocal fold paralysis. The signs and symptoms of paresis may be different and less obvious than those for paralysis, so this condition is often misdiagnosed or underdiagnosed. Elements necessary to heighten clinical suspicion are included to assist in educating practitioners on these subtle findings. Once paresis is suspected, associated respiratory or sensory abnormalities also should be sought, because these may change the treatment plan when recognized. Utility of laryngeal electromyography is discussed along with potential treatment options for both the motor and often-present sensory symptoms.

Botulinum toxin injection in laryngeal dyspnea

Data, regarding the use of botulinum toxin (BT-A) in laryngeal dyspnea, are scarce, coming from some cases reports in the literature, including Vocal fold paralysis, laryngeal dystonia, vocal cord dysfunction also called paradoxical motion of the vocal fold (PMVF), and post-neuroleptic laryngeal dyskinesia. There is no consensus regarding the muscles and the doses to inject. The aim of this study is to present a retrospective review of patients treated in our ENT Department by BT-A injection in this indication. This study is a retrospective study describing patients who underwent an injection of botulinum toxin for laryngeal dyspnea in the ENT Department from 2005 to 2015 years. The inclusion criteria were a dyspnea associated with a laryngeal dysfunction, confirmed by flexible fiberoptic nasopharyngolaryngoscopy. Information concerning the causes of the dyspnea, the botulinum toxin BT-A injections procedure, post-injection follow-up, and respiratory outcome were collected for all patients included. In the group of 13 patients included, the main cause identified as principal factor linked with the short breath was: a bilateral VF paralysis (Patel et al., Otolaryngol Head Neck Surg 130:686-689, 7), laryngeal dystonia (Balkissoon and Kenn, Semin Respir Crit Care Med 33:595-605, 2), Anxiety syndrome associated with unilateral vocal fold paralysis or asthma (Marcinow et al., Laryngoscope 124:1425-1430, 3), and an isolated asthma (Zwirner et al., Eur Arch Otorhinolaryngol 254:242-245, 1). Nine out of the thirteen patients were improved by the injections. A BT-A-induced stable benefit for four patients led them to stop the injections in the follow-up. Good outcome was observed in five other patients (main cause: bilateral VP paralysis), allowing a progressive lengthening of the delay between BT-A injections. Four patients did not report a positive risk/benefit ratio after BT-A injections; two of them (with bilateral VF paralysis), because of respiratory side effects and lack of benefit without the side effects for the two others. This failure of effect was not related with BT-A doses injected. This study provides support for using BT-A injections as a symptomatic treatment of periodic laryngeal dyspnea, regardless of the etiologic context. From our data, we suggest that a small starting dose (of around 4 U BT-A Botox^®) could be enough for a first injection to obtain a good benefit. The target muscle should be determined by the EMG analysis.