Stridor in Parkinson's disease: a case of ‘dry drowning’?

Negative pressure pulmonary edema due to upper airway obstruction after general anesthesia in a patient with Parkinson's disease: A case report

In a patient with Parkinson's disease (PD) who underwent spine surgery 13 h after the last anti-Parkinson medications, negative pressure pulmonary edema from upper airway obstruction developed immediately after extubation. Although oxygenation improved with high-flow nasal cannula therapy, such complications might develop due to abrupt discontinuation of medication for PD.

Breathing disorders in neurodegenerative diseases

Neurodegenerative disorders are a diverse group of conditions caused by progressive degeneration of neurons resulting in cognitive, motor, sensory, and autonomic dysfunction, leading to severe disability and death. Pulmonary dysfunction is relatively common in these conditions, may be present early in the disease, and is less well recognized and treated than other symptoms. There are variable disorders of upper and lower airways, central control of ventilation, strength of respiratory muscles, and breathing during sleep which further impact daily activities and quality of life and have the potential to injure vulnerable neurons. Laryngopharyngeal dysfunction affects speech, swallowing, and clearance of secretions, increases the risk of aspiration pneumonia, and can cause stridor and sudden death. In Parkinson's disease, L-Dopa benefits some pulmonary symptoms but there are limited pharmacological treatment options for pulmonary dysfunction. Targeted treatments include strengthening of respiratory muscles, positive airway pressure in sleep and techniques to improve cough efficacy. Well-designed clinical trials are needed to evaluate the long-term benefits of these interventions. Challenges for the future include earlier identification of pulmonary dysfunction in the clinic, institution of the most effective treatments (based on clinical trials that measure long-term meaningful outcomes) and the development of neuroprotective treatment.

Upper airway obstruction during extubation after general anesthesia, in a patient with Parkinson disease: A case report

RATIONALE

Parkinson disease (PD) is a chronic neurodegenerative condition often suffered by the elderly. Upper airway obstruction, though rare in patients with PD, can be life threatening and is associated with vocal cord paralysis, laryngeal spasm, and dystonia of jaw and neck muscles.

PATIENT CONCERNS

We describe a life-threatening upper airway obstruction caused by bilateral vocal cord paralysis, in an elderly man with PD, during extubation after general anesthesia.

DIAGNOSES

Based on clinical presentation and visual laryngoscopy, the patient was diagnosed with laryngeal spasm and bilateral vocal cord paralysis after extubation.

INTERVENTIONS

Re-intubation was carried out and dopamine hydrazine tablets were administered via a nasal feeding tube.

OUTCOMES

After re-intubation and further treatment, the endotracheal tube was successfully removed and no symptoms of respiratory distress were observed.

LESSONS

Patients with PD may be at a risk of life-threatening upper airway obstruction after extubation, which should be prevented systematically.

Extubation and the Risks of Coughing and Laryngospasm in the Era of Coronavirus Disease-19 (COVID-19)

The coronavirus disease-19 (COVID-19) pandemic has prompted new interest among anesthesiologists and intensivists in controlling coughing and expectoration of potentially infectious aerosolized secretions during intubation and extubation. However, the fear of provoking laryngospasm may cause avoidance of deep or sedated extubation techniques which could reduce coughing and infection risk. This fear may be alleviated with clear understanding of the mechanisms and effective management of post-extubation airway obstruction including laryngospasm. We review the dynamic function of the larynx from the vantage point of head-and-neck surgery, highlighting two key concepts:

1. The larynx is a complex organ that may occlude reflexively at levels other than the true vocal folds;

2. The widely held belief that positive-pressure ventilation by mask can “break” laryngospasm is not supported by the otorhinolaryngology literature.

We review the differential diagnosis of acute airway obstruction after extubation, discuss techniques for achieving smooth extubation with avoidance of coughing and expectoration of secretions, and recommend, on the basis of this review, a clinical pathway for optimal management of upper airway obstruction including laryngospasm to avoid adverse outcomes.

Various Motor and Non-Motor Symptoms in Early Multiple System Atrophy

BACKGROUND

Multiple system atrophy (MSA) patients pre-sent a variety of symptoms other than autonomic dysfunctions, parkinsonism, and cerebellar ataxia. The aim of this study was to evaluate the frequency of various motor and non-motor symptoms including so-called "red flags" in patients with early MSA and to determine whether the frequency of these symptoms was different between the parkinsonian (MSA-P) and cerebellar (MSA-C) subtypes.

METHODS

Sixty-one probable or possible MSA patients with disease duration of 3 years or less were included. Patients were classified into MSA-P, MSA-C, and MSA-PC. The frequency of 13 features including various motor and non-motor symptoms that commonly occur in MSA was assessed.

RESULTS

Dysarthria was the most prevalent feature (98.4%) followed by sexual dysfunction (95.1%). Probable REM sleep behavior disorder was present in 90.2%. The frequency of constipation (82.0%), dysphagia (68.9%), and snoring (70.5%) was also high. Stridor was present in 42.6% and more common in MSA-C than in MSA-P.

CONCLUSIONS

Increasing awareness of various motor and non-motor symptoms may assist clinicians to make an early, accurate diagnosis and to improve management of patients with MSA. We suggest that the diagnostic accuracy can be improved if these features are appropriately reflected in the new diagnostic criteria for MSA.

Prevalence and characterisation of vocal fold motion impairment (VFMI) in patients with Multiple system atrophy compared with Parkinson's disease

INTRODUCTION

Multiple system atrophy (MSA) is a neurodegenerative disorder in which vocal fold mobility can be affected, sometimes leading to life-threatening situations. Our aim was to know if laryngeal examination could help differentiate MSA from Parkinson's disease (PD).

MATERIALS AND METHODS

Between 2004 to 2014, all consecutive patients diagnosed with probable MSA were included in this retrospective, monocentric study. Flexible laryngoscopy was obtained in 51 MSA patients and compared with 27 patients with Parkinson's disease (PD). Laryngeal muscles EMG was available in 6 MSA patients.

RESULTS

Vocal fold motion impairments (VFMI) was found in 35 (68.6%) MSA patients: 15 (29.4%) had uni- or bilateral vocal fold abnormal movement (VFAM), 13 (25.5%) had uni- or bilateral vocal fold abductor paresis (VFABP), 4 (7.8%) had uni- or bilateral vocal fold adductor paresis (VFADP), 10 (19.6%) had bilateral vocal fold paralysis (BVFP). VFMI was found in 13 PD patients (48.1%) all of whom had VFADP. Presence of BVFP was found associated with stridor (P<0.001) and dysphagia (P=0.002). In all muscles examined in 6 MSA patients, the EMG showed neuropathic patterns.

CONCLUSIONS

Our data support that VFMI may be encountered in two-thirds of MSA with a variable degree of gravity. Laryngological examination should be considered as a supplementary tool for the diagnosis and prognosis of MSA. VFMI in particular VFAM, VFABD and BVFP should be discussed as an additional possible red flag even at an early stage of MSA and could help discriminate MSA from PD.

Bilateral vocal cord paralysis during emergence from general anesthesia in a patient with Parkinson's disease

Parkinson's disease (PD) is a neurodegenerative disorder that affects the extrapyramidal system, and respiratory dysfunction has also been noted in patients with PD. However, acute upper airway obstruction due to bilateral vocal cord paralysis is a very rare finding in PD. Here, we describe a rare life-threatening respiratory failure caused by bilateral vocal cord paralysis in an elderly woman with PD during emergence from general anesthesia. The tracheostomy was performed on the postoperative period because the condition persisted. The general anesthesia in PD may have aggravated vocal cord impairment. We recommend when a patient with PD is scheduled for general anesthesia that the anesthesiologist performs careful preoperative examinations, strictly monitors respiratory function, and rapidly manages acute upper airway obstruction.

Acute Postobstructive Pulmonary Edema Following Laryngospasm in Elderly Patients: A Case Report

Only a few cases regarding postobstructive pulmonary edema following laryngospasm in older patients aged more than 60 years have been reported; however, acute pulmonary edema or pulmonary hemorrhage would be more deadly to elderly patients who have cerebrovascular disease than young healthy adults. After review of the literature, we report an unusual case of a 67-year-old man with ischemic cerebrovascular disease, who underwent carotid angioplasty and stenting and experienced severe pulmonary edema and hemorrhage secondary to laryngospasm after general anesthesia with laryngeal mask airway. The patient required positive-pressure ventilation, supportive treatment, and active cerebroprotection in the intensive care setting for 3 days before the edema resolved, and subsequently made a complete recovery without new onset of neurologic sequelae. The possible pathophysiological mechanisms, precaution, and preventative strategy of postobstructive pulmonary edema in older patients are discussed.

Postoperative Stridor and Acute Respiratory Failure After Parkinson Disease Deep Brain Stimulator Placement: Case Report and Review of Literature

BACKGROUND

Parkinson disease (PD), a neurodegenerative disorder characterized by loss of dopaminergic neurons in the substantia nigra of the midbrain, is commonly thought of as a motion disorder, but it can have significant effect on the respiratory system. Respiratory failure is the most common cause of death in these patients, but it can also affect laryngeal function causing dysphonia, dysphagia, and dysarthric speech. Acute upper airway obstruction is a rare finding in PD, especially in the perioperative settings. In this article we report a PD patient who developed upper respiratory obstruction postoperatively. We also review the literature and highlight the importance of preoperative evaluation to identify patients who may be at risk of this complication.

CASE DESCRIPTION

We describe a PD patient presenting for brain stimulation electrode implantation under general anesthesia, who postoperatively developed stridor and near complete upper airway obstruction despite maintenance of oral anti-Parkinson medication regimen intraoperatively. The patient was reintubated in post-anesthesia-care unit, and tracheostomy was performed after 1 week due to persistent vocal cord dysfunction.

CONCLUSIONS

Baseline vocal cord impairment in PD patients can be acutely aggravated perioperatively. Symptoms such as dysphagia and dysarthria, which can indicate susceptibility to postoperative upper airway obstruction, may not be well recognized by the patient and family. Surgical candidates should be carefully interviewed preoperatively, and watchful monitoring of respiratory function intraoperatively and postoperatively is of paramount importance. Neurosurgical and neuroanesthesia team should be aware of, and prepared to manage, this potentially life-threatening airway obstruction in PD patients.

Effects of deep brain stimulation on vocal fold immobility in Parkinson's disease

Background:

Vocal fold (VF) immobility is a rare, potentially fatal complication of advanced Parkinson's disease (PD). Previous reports suggest that subthalamic nucleus deep brain stimulation (STN-DBS) may influence laryngeal function, yet the role of STN-DBS on VF immobility remains unexplored.

Case Description:

We report a case of a patient with advanced PD and bilateral VF immobility ultimately requiring a tracheostomy. To assess the effects of STN-DBS on vocal cord function and to correlate these effects with peripheral motor symptoms at different stimulation settings, the patient was evaluated before and after initiation of bilateral STN-DBS. Measures included direct observation of VF mobility via transnasal laryngoscopy, levodopa equivalent dose of anti-PD medication, and motor scores. High frequency (150 Hz) STN-DBS resulted in improved motor scores, reduced medication requirement, and modestly improved right VF abduction although insufficient for safe decannulation. Low frequency (60 Hz) stimulation resulted in lower motor scores, but without worsening VF abduction.

Conclusions:

STN-DBS may play an important role in the neuromodulation of PD-induced laryngeal dysfunction, including VF mobility. Characterization of these axial symptoms is important when programming and evaluating responsiveness to DBS.

Levodopa reverse stridor and prevent subsequent endotracheal intubation in Parkinson disease patients with bilateral vocal cord palsy: A case report

BACKGROUND

Respiratory abnormalities are often overlooked; however, because of their potential comorbidity, they must be analyzed to determine the most effective treatment for patients with Parkinson disease (PD). Among various theories on respiratory abnormalities in PD, "upper airway obstruction" and "restrictive respiratory disorders" are 2 of the most accepted etiologies; both appear to be related to basal ganglia dysfunction. Complex vocal cord muscle dysfunction contributes to stridor, which can be a manifestation of nigrostriatal dopaminergic dysfunction. Stridor is a lethal form of upper airway obstruction in PD patients; its most frequent causes are bilateral vocal cord palsy, laryngeal spasms, and dystonia of the supra-laryngeal muscle. Several previous studies have suggested that levodopa administration induces a significant improvement of both lung function and symptoms of parkinsonian syndrome.

CASE SUMMARY

We reported a 77-year-old gentleman PD patient admitted for acute levodopa-responsive stridor resulting from bilateral vocal cord palsy. Dopaminergic therapy prevented the need for subsequent endotracheal intubation and tracheostomy treatment.

CONCLUSION

It is vital to understand that complex vocal cord muscle dysfunction may be related to nigrostriatal dopaminergic dysfunction in PD patients. The strategy of levodopa up-titration should be considered an option because it may be beneficial in relieving both stridor and parkinsonian syndrome, and in preventing respiratory failure.

Meta-analyses of seven GIGYF2 polymorphisms with Parkinson's disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder that affects ~2% of the global population aged ≥65 years. Grb10-interacting GYF protein-2 (GIGYF2) can influence the development of PD through the regulation of insulin-like growth factor-1. The aim of the present meta-analysis study was to establish the contribution of GIGYF2 polymorphisms to PD. The study was conducted based on nine eligible studies consisting of 7,246 PD patients and 7,544 healthy controls. The results indicated that the GIGYF2 C.3630A>G polymorphism increased the risk of PD by 37% [P=0.008; odds ratio (OR), 1.37; 95% confidence interval (CI), 1.08-1.73] and that the GIGYF2 C.167G>A polymorphism was significantly associated with PD (P=0.003; OR, 3.67; 95% CI, 1.56-8.68). The meta-analyses of the other five GIGYF2 polymorphisms (C.1378C>A, C.1554G>A, C.2940A>G, C.1370C>A and C.3651G>A) did not reveal any significant associations. The present meta-analyses of the GIGYF2 genetic polymorphisms may provide a comprehensive overview of this PD candidate gene for future studies.

Polymorphisms of DRD2 and DRD3 genes and Parkinson's disease: A meta-analysis

Parkinson's disease (PD) is the second most common neurodegenerative disorder that affects ~2% of the population aged ≥65 years. The degeneration of dopamine neurons in the substantia nigra contributes to the pathogenesis of PD. Dopamine receptor D2 (DRD2) and dopamine receptor D3 (DRD3) are two key subtypes of dopamine receptors. The aim of our study was to evaluate the association between the polymorphisms of DRD2 and DRD3 genes and PD. Meta-analyses were conducted from 16 studies (46 stages) among 4,279 cases and 5,661 controls between PD and 9 polymorphisms (DRD2: rs1800497, rs1079597, rs6278, rs6279, rs273482, rs1799732 and rs1076563; DRD3: rs6280 and rs2134655). A significant association was observed between DRD3 rs2134655 polymorphism and PD [P=0.01, odds ratio (OR)=1.17, 95% confidence interval (CI): 1.03-1.32] and a borderline association was observed between DRD2 rs1800497 polymorphism and PD in Europeans (P=0.05, OR=1.13, 95% CI: 1.00-1.27). Findings of the current meta-analysis suggested that DRD3 rs2134655 polymorphism was associated with a 17% increased risk of PD and that DRD2 rs1800497 polymorphism had a potential to increase the risk of PD by 13% in Europeans. Future large-scale studies are required to confirm the ethnic difference of DRD2 rs1800497 polymorphism and to determine whether there were significant associations of PD with other polymorphisms in DRD2 and DRD3 genes.

Premotor signs and symptoms of multiple system atrophy

Diagnostic criteria for multiple system atrophy are focused on motor manifestations of the disease, in particular ataxia and parkinsonism, but these criteria often cannot detect the early stages. Non-motor symptoms and signs of multiple system atrophy often precede the onset of classic motor manifestations, and this prodromal phase is estimated to last from several months to years. Autonomic failure, sleep problems, and respiratory disturbances are well known symptoms of established multiple system atrophy and, when presenting early and preceding ataxia or parkinsonism, should be regarded as evidence of premotor multiple system atrophy. An early and accurate diagnosis is becoming increasingly important as new neuroprotective agents are developed.