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Mir MJ, Herndon NE, Wagle Shukla A, Wheeler‐Hegland K, McFarland NR. The Vocal Flutter of Multiple System Atrophy: A Parkinsonian-Type Phenomenon? Mov Disord Clin Pract 2024; 11:403-410. [PMID: 38314679 PMCID: PMC10982599 DOI: 10.1002/mdc3.13988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Early features of multiple system atrophy (MSA) are similar to those in Parkinson's disease (PD), which can challenge differential diagnosis. Identifying clinical markers that help distinguish MSA from forms of parkinsonism is essential to promptly implement the most appropriate management plan. In the context of a thorough neurological evaluation, the presence of a vocal flutter might be considered a potential feature of MSA-parkinsonian type (MSA-P). CASES This case series describes clinical histories of 3 individuals with MSA-P. In each case, vocal flutter was detected during neurological and motor speech evaluations. It seemed to be a concomitant feature with the constellation of other signs and symptoms that led to the clinical diagnosis. LITERATURE REVIEW The vocal flutter may be described as pitch and loudness fluctuations during phonation. Different from a vocal tremor, the flutter phenomenon has higher oscillation frequencies. The neuropathological underpinnings of vocal flutter may be related to generalized laryngeal dysfunction that is commonly described in MSA-P. CONCLUSION Vocal flutter may be a unique speech feature in some individuals who have MSA-P. Future studies using perceptual and acoustic measures of speech are warranted to quantify these observations and directly compare to other MSA variants, PD, and a control group.
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Affiliation(s)
- Michela J. Mir
- Department of Physical TherapyBREATHE Center, University of FloridaGainesvilleFloridaUSA
| | - Nicole E. Herndon
- Department of Speech, Language, and Hearing SciencesCollege of Public Health and Health Professions, University of FloridaGainesvilleFloridaUSA
- UF Health Norman Fixel Institute for Neurological DiseasesGainesvilleFloridaUSA
| | - Aparna Wagle Shukla
- UF Health Norman Fixel Institute for Neurological DiseasesGainesvilleFloridaUSA
- Department of NeurologyCollege of Medicine, University of FloridaGainesvilleFloridaUSA
| | - Karen Wheeler‐Hegland
- Department of Speech, Language, and Hearing SciencesCollege of Public Health and Health Professions, University of FloridaGainesvilleFloridaUSA
- UF Health Norman Fixel Institute for Neurological DiseasesGainesvilleFloridaUSA
| | - Nikolaus R. McFarland
- UF Health Norman Fixel Institute for Neurological DiseasesGainesvilleFloridaUSA
- Department of NeurologyCollege of Medicine, University of FloridaGainesvilleFloridaUSA
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Silva C, Iranzo A, Maya G, Serradell M, Muñoz-Lopetegi A, Marrero-González P, Gaig C, Santamaría J, Vilaseca I. Stridor during sleep: description of 81 consecutive cases diagnosed in a tertiary sleep disorders center. Sleep 2020; 44:5909297. [DOI: 10.1093/sleep/zsaa191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/02/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study Objectives
To describe the characteristics of stridor during sleep (SDS) in a series of adults identified by video-polysomnography (V-PSG).
Methods
Retrospective clinical, V-PSG, laryngoscopic, and therapeutic data of patients diagnosed with SDS in a tertiary referral sleep disorders center between 1997 and 2017.
Results
A total of 81 patients were identified (56.8% males, age 61.8 ± 11.2 years). Related etiologies were multiple system atrophy (MSA), amyotrophic lateral sclerosis, spinocerebellar ataxia type 1, anti-IgLON5 disease, fatal familial insomnia, brainstem structural lesions, vagus nerve stimulation, recurrent laryngeal nerve injury, the effect of radiotherapy on the vocal cords, cervical osteophytes, and others. Stridor during wakefulness coexisted in 13 (16%) patients and in MSA was only seen in the parkinsonian form. Laryngoscopy during wakefulness in 72 (88.9%) subjects documented vocal cord abductor impairment in 65 (90.3%) and extrinsic lesions narrowing the glottis in 2 (2.4%). The mean apnea–hypopnea index (AHI) was 21.4 ± 18.6 and CT90 was 11.5 ± 19.1. Obstructive AHI > 10 occurred in 52 (64.2%) patients and central apnea index >10 in 2 (2.4%). CPAP abolished SDS, obstructive apneic events and oxyhemoglobin desaturations in 58 of 60 (96.7%) titrated patients with optimal pressure of 9.0 ± 2.3 cm H20. Tracheostomy in 19 (23.4%) and cordotomy in 3 (3.7%) subjects also eliminated SDS.
Conclusions
SDS in adults is linked to conditions that damage the brainstem, recurrent laryngeal nerve, and vocal cords. V-PSG frequently detects obstructive sleep apnea and laryngoscopy usually shows vocal cord abductor dysfunction. CPAP, tracheostomy, and laryngeal surgery abolish SDS.
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Affiliation(s)
- Cristiana Silva
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Alex Iranzo
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Gerard Maya
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Mónica Serradell
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Amaia Muñoz-Lopetegi
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Paula Marrero-González
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Carles Gaig
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Joan Santamaría
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Isabel Vilaseca
- Otorhinolaryngology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, CIBER Enfermedades Respiratorias, Bunyola, Spain
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Gandor F, Vogel A, Claus I, Ahring S, Gruber D, Heinze HJ, Dziewas R, Ebersbach G, Warnecke T. Laryngeal Movement Disorders in Multiple System Atrophy: A Diagnostic Biomarker? Mov Disord 2020; 35:2174-2183. [PMID: 32757231 PMCID: PMC7818263 DOI: 10.1002/mds.28220] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 12/14/2022] Open
Abstract
Background Multiple system atrophy (MSA) is a rare neurodegenerative disorder, and its parkinsonian variant can be difficult to delineate from Parkinson's disease (PD). Despite laryngeal dysfunction being associated with decreased life expectancy and quality of life, systematic assessments of laryngeal dysfunction in large cohorts are missing. Objectives The objective of this study was to systematically assess laryngeal dysfunction in MSA and PD and identify laryngeal symptoms that allow for differentiating MSA from PD. Methods Patients with probable or possible MSA underwent flexible endoscopic evaluation of swallowing performing a systematic task protocol. Findings were compared with an age‐matched PD cohort. Results A total of 57 patients with MSA (64 [59–71] years; 35 women) were included, and task assessments during endoscopic examination compared with 57 patients with PD (67 [60–73]; 28 women). Patients with MSA had a shorter disease duration (4 [3–5] years vs 7 [5–10]; P < 0.0001) and higher disease severity (Hoehn & Yahr stage 4 [3–4] vs 3 [2–4]; P < 0.0001). Of the patients with MSA, 43.9% showed clinically overt laryngeal dysfunction with inspiratory stridor. During endoscopic task assessment, however, 93% of patients with MSA demonstrated laryngeal dysfunction in contrast with only 1.8% of patients with PD (P < 0.0001). Irregular arytenoid cartilages movements were present in 91.2% of patients with MSA, but in no patients with PD (P < 0.0001). Further findings included vocal fold motion impairment (75.4%), paradoxical vocal fold motion (33.3%), and vocal fold fixation (19.3%). One patient with PD showed vocal fold motion impairment. Conclusion Laryngeal movement disorders are highly prevalent in patients with MSA when assessed by a specific task protocol despite the lack of overt clinical symptoms. Our data suggest that irregular arytenoid cartilage movements could be used as a clinical marker to delineate MSA from PD with a specificity of 1.0 and sensitivity 0.9. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society
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Affiliation(s)
- Florin Gandor
- Movement Disorders Hospital, Kliniken Beelitz GmbH, Beelitz-Heilstätten, Germany.,Department of Neurology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Annemarie Vogel
- Movement Disorders Hospital, Kliniken Beelitz GmbH, Beelitz-Heilstätten, Germany
| | - Inga Claus
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Sigrid Ahring
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Doreen Gruber
- Movement Disorders Hospital, Kliniken Beelitz GmbH, Beelitz-Heilstätten, Germany.,Department of Neurology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Hans-Jochen Heinze
- Department of Neurology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Rainer Dziewas
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Georg Ebersbach
- Movement Disorders Hospital, Kliniken Beelitz GmbH, Beelitz-Heilstätten, Germany
| | - Tobias Warnecke
- Department of Neurology, University Hospital Münster, Münster, Germany
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4
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Warnecke T, Vogel A, Ahring S, Gruber D, Heinze HJ, Dziewas R, Ebersbach G, Gandor F. The Shaking Palsy of the Larynx-Potential Biomarker for Multiple System Atrophy: A Pilot Study and Literature Review. Front Neurol 2019; 10:241. [PMID: 30972002 PMCID: PMC6443854 DOI: 10.3389/fneur.2019.00241] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/25/2019] [Indexed: 12/14/2022] Open
Abstract
In its early stages multiple system atrophy (MSA), a neurodegenerative movement disorder, can be difficult to differentiate from idiopathic Parkinson's disease (PD), and emphasis has been put on identifying premotor symptoms to allow for its early identification. The occurrence of vegetative symptoms in addition to motor impairment, such as orthostatic hypotension and neurogenic bladder dysfunction, enable the clinical diagnosis in the advanced stages of the disease. Usually with further disease progression, laryngeal abnormalities become clinically evident and can manifest in laryngeal stridor due to impaired vocal fold motion, such as vocal fold abduction restriction, mostly referred to as vocal fold paresis, or paradoxical vocal fold adduction during inspiration. While the pathogenesis of laryngeal stridor is discussed controversially, its occurrence is clearly associated with reduced life expectancy. Before the clinical manifestation of laryngeal dysfunction however, abnormal vocal fold motion can already be seen in patients that might not yet fulfill the diagnostic criteria of MSA. In this article we summarize the current literature on pharyngolaryngeal findings in MSA and report preliminary findings from a pilot study investigating eight consecutive MSA patients. Patients showed varying speech abnormalities. Only 2/8 patients exhibited laryngeal stridor. However, during FEES, all patients presented with irregular arytenoid cartilages movements and vocal fold abduction restriction. 3/8 showed vocal fold fixation and 1/8 paradoxical vocal fold motion. All patients presented with oropharyngeal dysphagia, 5/8 with penetration or aspiration events. We suggest that specific abnormal vocal fold motion can help identifying MSA patients and may allow for delimiting this disorder from idiopathic PD. These findings therefore may serve as a novel clinical biomarker for MSA. Based on the available data and our preliminary clinical experience we developed a standardized easy-to-implement task-protocol to be performed during flexible endoscopic evaluation of swallowing (FEES) for detection of MSA-related pharyngolaryngeal movement disorders. Furthermore, we initiated a prospective study to evaluate the diagnostic utility of this protocol.
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Affiliation(s)
- Tobias Warnecke
- Department of Neurology, University of Münster, Münster, Germany
| | - Annemarie Vogel
- Hospital for Movement Disorders/Parkinson's Disease, Beelitz-Heilstätten, Germany
| | - Sigrid Ahring
- Department of Neurology, University of Münster, Münster, Germany
| | - Doreen Gruber
- Hospital for Movement Disorders/Parkinson's Disease, Beelitz-Heilstätten, Germany.,Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - Hans-Jochen Heinze
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - Rainer Dziewas
- Department of Neurology, University of Münster, Münster, Germany
| | - Georg Ebersbach
- Hospital for Movement Disorders/Parkinson's Disease, Beelitz-Heilstätten, Germany
| | - Florin Gandor
- Hospital for Movement Disorders/Parkinson's Disease, Beelitz-Heilstätten, Germany.,Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
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5
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Berkowitz RG, Sun QJ, Pilowsky PM. Congenital Bilateral Vocal Cord Paralysis and the Role of Glycine. Ann Otol Rhinol Laryngol 2016; 114:494-8. [PMID: 16042108 DOI: 10.1177/000348940511400612] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: We sought to modify normal laryngeal constrictor (LC) motoneuron activity to induce a pattern of aberrant LC muscle function that may serve as a model of congenital bilateral vocal cord paralysis. Methods: Single unit extracellular recordings of functionally identified LC motoneurons were made in anesthetized Sprague-Dawley rats, and the response to both intravenous and iontophoretic application of the glycine antagonist strychnine was studied. Results: The postinspiratory firing pattern of LC motoneurons became inspiratory after intravenous injection of strychnine (4 of 5 rats), but no change was recorded in response to strychnine iontophoresis (7 of 8 rats). Conclusions: Blockade of glycinergic inhibitory neurotransmission by strychnine, acting above the level of the LC motoneuron, causes LC motoneurons to fire during inspiration rather than after inspiration. This observation suggests that impaired glycine neurotransmission may be an underlying mechanism that explains the clinical manifestations of congenital bilateral vocal cord paralysis.
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Affiliation(s)
- Robert G Berkowitz
- Hypertension and Stroke Research Laboratories, Department of Physiology, University of Sydney, Sydney, Australia
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6
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Maruyama Y, Tsukada Y, Hirai N, Nakanishi Y, Yoshizaki T. [Pursed Lips Inspiration for Vocal Cord Dysfunction]. NIHON JIBIINKOKA GAKKAI KAIHO 2015; 118:53-61. [PMID: 26333273 DOI: 10.3950/jibiinkoka.118.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Paradoxical vocal cord motion (PVCM) during vocal cord dysfunction (VCD) generally occurs spasmodically and transiently. After we had experienced 36 cases of VCD and successfully treated with conservative treatment including "pursed lips inspiration" method, we experienced a boy who had persistent PVCM. It was observed his PVCM vanished when he breathed in through pursed lips, while it appeared again when he stopped pursed lips inspiration. An airway reflex has been reported where the negative pressure in the subglottic space resulting from the inspiratory effort against a narrowed glottis activates the vocal cord adductor. VCD is considered to have both acceleration of laryngeal closure reflex against airway stimuli and active adductive movement of vocal cords against negative pressure in the subglottic space as underlying factors. The pursed lips inspiration method enables VCD patients not only to accomplish slow and light breathing but also to decrease the difference in the pressure between the supra--and subglottic space by occluding the nasal cavity and voluntary puckering up of the mouth which generate negative pressure in the supraglottic space. This is the first report of the pursed lips inspiration method as a treatment for VCD. Pursed lips inspiration is a simple method which is easy to perform anytime, anywhere without any special equipment, and is considered to be worth trying for VCD.
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7
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Singhal S, Chopra V, Kiran S, Verma M. Life-threatening upper airway obstruction associated with prior radiotherapy. South Asian J Cancer 2014; 2:219. [PMID: 24455637 PMCID: PMC3889040 DOI: 10.4103/2278-330x.119915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sanjay Singhal
- Chest Specialist and Trained in Critical Care, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - V Chopra
- Consultant Anesthesia, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - S Kiran
- Consultant anesthesia and Intensivist, Command Hospital, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Mranalini Verma
- Department of Radiation Oncology, SGPGIMS, Lucknow, Uttar Pradesh, India
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8
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Respiratory problems in neurologic movement disorders. Parkinsonism Relat Disord 2010; 16:628-38. [DOI: 10.1016/j.parkreldis.2010.07.004] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 07/03/2010] [Accepted: 07/07/2010] [Indexed: 01/31/2023]
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9
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Broniatowski M, Grundfest-Broniatowski S, Hadley AJ, Shah NS, Barbu AM, Phillipbar SA, Strohl KP, Tucker HM, Tyler DJ. Improvement of respiratory compromise through abductor reinnervation and pacing in a patient with bilateral vocal fold impairment. Laryngoscope 2010; 120:76-83. [PMID: 19877193 DOI: 10.1002/lary.20698] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine whether respiratory compromise from bilateral vocal fold impairment (paralysis) can be objectively alleviated by reinnervation and pacing. METHODS A patient with paramedian vocal folds and synkinesis had a tracheotomy for stridor after bilateral laryngeal nerve injury and Miller Fisher syndrome. One posterior cricoarytenoideus (PCA) received a nerve-muscle pedicle fitted with a perineural electrode for pacemaker stimulation. The airway was evaluated endoscopically and by spirometry for up to 1 year. RESULTS Bilateral vocal fold patency during quiet breathing was reversed to active vocal fold adduction during tracheal occlusion. Peak inspiratory flows (PIFs) were significantly higher (P < .001) after reinnervation. PIFs and glottic apertures increased further under stimulation (42 Hz, 1-4 mA, 42-400 microsec). although the differences were not significant. CONCLUSIONS Based on our preliminary data, PCA reinnervation and pacing offer promise for amelioration of respiratory compromise after paradoxical adduction in bilateral vocal fold impairment.
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Affiliation(s)
- Michael Broniatowski
- Department of Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
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10
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Shiba K, Isono S, Nakazawa K. Paradoxical vocal cord motion: A review focused on multiple system atrophy. Auris Nasus Larynx 2007; 34:443-52. [PMID: 17482397 DOI: 10.1016/j.anl.2007.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Revised: 02/10/2007] [Accepted: 03/14/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Paradoxical vocal cord motion (PVCM) is a well recognized respiratory condition in which active adduction of the vocal cords during inspiration causes functional airway obstruction. It is considered that laryngeal reflex acceleration underlies the generation of nonorganic PVCM. In various situations producing PVCM, multiple system atrophy (MSA) is a representative neurological disease causing nocturnal laryngeal stridor attributed to PVCM. The purpose of this review is to identify the underlying mechanisms associated with nonorganic and MSA-related PVCM. The following issues are addressed in this review: (1) the pathophysiology of nonorganic and MSA-related PVCM, (2) the relationships between PVCM and airway reflexes, and (3) the treatment for MSA-related PVCM. METHODS Review. RESULTS AND CONCLUSIONS An abnormality of the laryngeal output-feedback control underlies nonorganic PVCM, which is usually triggered by an excessive response to external and internal airway stimuli. Similarly, several clinical and experimental evidence suggest that MSA-related PVCM is attributed to the airway reflex as well as to paradoxical central outputs resulting from the MSA-induced damage to the pontomedullary respiratory center. Application of continuous positive airway pressure (CPAP), which suppresses the reflexive inspiratory activation of adductors, is recommended as the treatment for MSA-related PVCM.
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Affiliation(s)
- Keisuke Shiba
- Department of Otolaryngology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba City, Chiba 260-8670, Japan.
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Nonaka M, Imai T, Shintani T, Kawamata M, Chiba S, Matsumoto H. Non-invasive positive pressure ventilation for laryngeal contraction disorder during sleep in multiple system atrophy. J Neurol Sci 2006; 247:53-8. [PMID: 16647088 DOI: 10.1016/j.jns.2006.03.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Revised: 03/06/2006] [Accepted: 03/08/2006] [Indexed: 11/25/2022]
Abstract
We examined the usefulness of non-invasive positive pressure ventilation (NPPV) in the management of nocturnal laryngeal stridor associated with vocal cord dysfunction in five cases of multiple system atrophy (MSA). First, the patients were investigated during sleep induced by a minimal dose of propofol. Laryngoscopy showed paradoxical vocal cord movement resulting in inspiratory stridor. Electromyographic (EMG) study revealed synchronized bursts in the thyroarytenoid muscles and diaphragm in every inspiratory phase whenever the stridor emerged. NPPV was initiated after paradoxical movement was recognized with laryngoscopy. The NPPV mask was equipped with an additional channel for laryngoscopic monitoring. The optimal pressure for treatment was determined according to laryngoscopic and EMG findings. Next, NPPV was applied to natural sleep using the conditions determined in propofol-induced sleep. In all cases, NPPV eliminated nocturnal stridor and oxygen desaturation during natural sleep. Laryngoscopic observation during induced sleep is recommended as a useful procedure to titrate the optimal pressure for NPPV therapy. Since central hypoventilation progresses in the course of MSA, the choice of NPPV rather than continuous positive airway pressure should be encouraged to treat laryngeal contraction disorder associated with MSA.
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Affiliation(s)
- Michio Nonaka
- Department of Neurology, Sapporo Medical University School of Medicine, Minami 1-Jo Nishi 16-Chome, Sapporo, Japan.
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12
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Shiba K, Isono S. Tracheostomy abolishes paradoxical activation of the vocal cord adductor in multiple system atrophy. Auris Nasus Larynx 2006; 33:295-8. [PMID: 16406427 DOI: 10.1016/j.anl.2005.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Revised: 09/28/2005] [Accepted: 11/11/2005] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Inspiratory activation of the vocal cord adductor, which causes paradoxical vocal cord motion, develops in patients with multiple system atrophy (MSA). To confirm the hypothesis that airway reflexes trigger such paradoxical activation, we investigated the effects of tracheostomy on the adductor activation in a MSA patient. METHODS We compared the adductor electromyograms before and after breathing was diverted to a tracheostoma under propofol anesthesia. RESULTS The adductor inspiratory activation disappeared during tracheostoma breathing. CONCLUSION Airway reflexes as well as MSA-related damage to the respiratory center contribute to the generation of paradoxical adductor activation in MSA patients.
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Affiliation(s)
- Keisuke Shiba
- Department of Otolaryngology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba City, Chiba 260-8670, Japan.
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13
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Burkle CM, Walsh MT, Pryor SG, Kasperbauer JL. Severe Postextubation Laryngeal Obstruction: The Role of Prior Neck Dissection and Radiation. Anesth Analg 2006; 102:322-5. [PMID: 16368851 DOI: 10.1213/01.ane.0000181319.70639.3b] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aggressive treatment of advanced head and neck cancer may result in more patients undergoing surgery for unrelated illnesses. We present a case of a patient requiring emergency tracheostomy placement after a routine liver segment resection 10 yr after undergoing a bilateral modified radical neck dissection and radiation therapy. This type of patient may be at increased risk for both postoperative laryngeal edema and neuronal imbalance secondary to their preoperative condition.
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14
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Lo HI, Ho HC, Hwang JH. Paradoxical vocal cord motion—A case report. Auris Nasus Larynx 2005; 32:427-30. [PMID: 16039815 DOI: 10.1016/j.anl.2005.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2005] [Revised: 03/24/2005] [Accepted: 05/27/2005] [Indexed: 11/28/2022]
Abstract
Paradoxical vocal cord motion (PVCM) is an unusual cause of stridor, which is associated with some underlying causes, such as central nervous system lesion, gastroesophageal reflux or psychogenic problem. Once a diagnosis of PVCM is made, acute management with reassurance and sedation instead of aggressive airway intervention is required. Speech therapy, psychotherapy combination with anti-reflux medication is considered to be useful in long-term management. We present a 58 year-old male patient who had suffered from several episodes of acute onset of stridor, short of breath and tachypnea since one year ago. He was initially treated as an asthmatic patient with poor response. Aneurysm of ascending aorta by angiography, and mild gastroesophageal reflux with hiatal hernia by panendoscopy were noted. Then, the paradoxical vocal cord motion during inspiration phase was confirmed by flexible fiberoptic nasopharyngoscope after the consultation with an otolaryngologist. The emergency of his air-hunger was relieved quickly after psychological intervention. Now, he is free of stridor attack under anti-reflux therapy and psychotherapy.
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Affiliation(s)
- Hung-I Lo
- Department of Otolaryngology, National Cheng Kung University Hospital, Tainan, Taiwan
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15
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Sekita Y, Shiba K, Nakazawa K, Numasawa T, Isono S. Inspiratory activation of the vocal cord adductor, part II: Animal study in the cat. Laryngoscope 2004; 114:376-80. [PMID: 14755222 DOI: 10.1097/00005537-200402000-00037] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES/HYPOTHESIS The authors have shown previously that the vocal cord adductor is activated during inspiration in patients with vocal cord abduction impairment and that this adductor inspiratory activity is abolished by relief from inspiratory tracheal negative pressure by opening the tracheostoma. (Shiba K. Isono S, Sekita Y, Tanaka A. Inspiratory activation of the vocal cord adductor, Part I: human study in patients with restricted abduction of the vocal cords. Laryngoscope 2004;114:372-375). The authors hypothesized that insufficient opening of the glottis during inspiration generates strong negative pressure in the trachea and that this negative pressure triggers an airway reflex that activates the adductor. STUDY DESIGN Experimental study of the mechanism of laryngeal obstruction using an animal model of restricted abduction of the vocal cords. METHODS To identify such an airway reflex, the authors recorded the adductor electromyogram in anesthetized cats whose vocal cords were mechanically adducted by stitching both cords together. To determine whether this reflex modulation of adductor activity is induced through afferents from the larynx or from the lower airway, the authors applied negative pressure to the subglottic space and lower airway separately. RESULTS The adductor was activated during inspiration with powerful negative pressure in the trachea. Negative pressure in the subglottic space had a more marked effect on the adductor activity than did pressure in the lower airway. The adductor inspiratory activity was virtually abolished by laryngeal deafferentation. CONCLUSION Glottal narrowing during inspiration reflexly activates the vocal cord adductor. This paradoxical inspiratory-related adductor activation is induced by an airway reflex triggered mainly through afferents from the larynx and probably contributes to stridor and dyspnea in patients with laryngeal obstruction.
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Affiliation(s)
- Yasuko Sekita
- Department of Otolaryngology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba 260-8670, Japan.
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Inspiratory Activation of the Vocal Cord Adductor, Part II: Animal Study in the Cat. Laryngoscope 2004. [DOI: 10.1097/00005537-200402000-00042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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