Does botulinum toxin alter laryngeal secretionsand mucociliary transport?

Localized botulinum toxin injection disrupts cholinergic transmissionand has potential to cause focal dysautonomia. Mucociliary transport and laryngeal secretions are thought to be mediated in part by autonomic, cholinergic transmission. We questioned whether patients who receive Botox® injection for adductor spasmodic dysphonia (ADSD) report postinjection symptoms possibly related to altered mucociliary clearance or laryngeal secretions. Medical histories, audiotaped interviews, and symptom ratings were retrospectively examined for 29 patients with ADSD who were followed after one or more Botox injections. Patients had received bilateral, percutaneous Botox injections of 2.5 units using an EMG-guided approach. One or more weeks after injection, four patients reported either burning, tickling, or irritation of the larynx/throat, excessive thick secretions, or dryness. Symptoms recurred with subsequent injections in two patients and were not associated with swallowing difficulty. These symptoms are consistent with, but not diagnostic of, the known effects of botulinum toxin on cholinergic, autonomic transmission.     

Botox for hyperadduction of the false vocal folds: A case report

We present a patient with severe hyperadduction of the false vocal folds (FVF) treated with Botulinum Toxin injections to each FVF. This patient presented with severe dysphonia and was found to demonstrate severe hyperadduction of the FVF's with all phonatory tasks. The patient was treated with extensive speech therapy without improvement in voice quality nor FVF motion pattern. He was then injected with Botox A bilaterally using a peroral approach to the FVFs. Shortly after treatment the patient experienced dramatic improvement in voice quality. Videolaryngoscopy revealed no adduction of the FVFs with phonation and essentially normal true vocal fold motion. He remained with normal voice quality one year after treatment without any further treatment. Possible mechanism of action of this type of treatment are discussed.     

Treatment of spasmodic dysphonia (laryngeal dystonia) with local injections of Botulinum toxin

In 1984 the authors performed the first laryngeal injection of Botulinum toxin for laryngeal dystonia via percutaneous, electromyographically guided technique. Since that time we have treated 450 patients with adductor spasmodic dysphonia, abductor spasmodic dysphonia, and adductor breathing dystonia. In general, the adductor patients received bilateral injections of 1.25 U to 3.75 U, obtaining greater than 90% of normal voice. The abductor patients received unilateral or staged bilateral injections of the posterior cricoarytenoid muscles with 0.6 to 3.75 U, obtaining 70% of normal function. We have found laryngeal injections of Botulinum toxin to be safe and effective therapy for the symptoms of laryngeal dystonia (spasmodic dysphonia).     

Tics are caused by alterations in prefrontal areas, thalamus and putamen, while changes in the cingulate gyrus reflect secondary compensatory mechanisms

Background

Despite strong evidence that the pathophysiology of Tourette syndrome (TS) involves structural and functional disturbances of the basal ganglia and cortical frontal areas, findings from in vivo imaging studies have provided conflicting results. In this study we used whole brain diffusion tensor imaging (DTI) to investigate the microstructural integrity of white matter pathways and brain tissue in 19 unmedicated, adult, male patients with TS “only” (without comorbid psychiatric disorders) and 20 age- and sex-matched control subjects.

Results

Compared to normal controls, TS patients showed a decrease in the fractional anisotropy index (FA) bilaterally in the medial frontal gyrus, the pars opercularis of the left inferior frontal gyrus, the middle occipital gyrus, the right cingulate gyrus, and the medial premotor cortex. Increased apparent diffusion coefficient (ADC) maps were detected in the left cingulate gyrus, prefrontal areas, left precentral gyrus, and left putamen. There was a negative correlation between tic severity and FA values in the left superior frontal gyrus, medial frontal gyrus bilaterally, cingulate gyrus bilaterally, and ventral posterior lateral nucleus of the right thalamus, and a positive correlation in the body of the corpus callosum, left thalamus, right superior temporal gyrus, and left parahippocampal gyrus. There was also a positive correlation between regional ADC values and tic severity in the left cingulate gyrus, putamen bilaterally, medial frontal gyrus bilaterally, left precentral gyrus, and ventral anterior nucleus of the left thalamus.

Conclusions

Our results confirm prior studies suggesting that tics are caused by alterations in prefrontal areas, thalamus and putamen, while changes in the cingulate gyrus seem to reflect secondary compensatory mechanisms. Due to the study design, influences from comorbidities, gender, medication and age can be excluded.     

Short-Term Effects of Endotracheal Intubation on Voice

The objective of this study was to examine the vocal symptoms and acoustic changes perceived in the short period after endotracheal intubation, and to find the association between these changes and the endotracheal tube parameters. A total of 35 subjects were included. They were examined preoperatively, and 2 and 24 hours postoperatively. The vocal symptoms of hoarseness, vocal fatigue, loss of voice, throat clearing, globus pharyngeus, throat pain, and the acoustic variables mainly average fundamental frequency, relative average perturbation, shimmer, noise to harmony ratio, voice turbulence index, habitual pitch, and maximum phonation time (MPT) were assessed as such and in relation to the following endotracheal tube parameters: duration of anesthesia, number of intubation attempts, size of the tube, cuff volume, cuff mean pressure, and the emergence. The association between anesthesia parameters with incidence of vocal complaints and changes in acoustic parameters were examined using logistic and linear regression. Vocal fatigue was associated significantly with the increase in cuff volume and the number of intubation attempts. Throat clearing was associated significantly with the increase in cuff mean pressure. Only the increase in habitual pitch was associated significantly with the increase in cuff volume. The acute short-term effect of endotracheal intubation on voice is significant. The most important endotracheal tube parameters that affect the vocal changes are the cuff mean pressure and volume. The laryngeal contribution to these vocal changes seems to be minimal. All vocal symptoms increased significantly except for globus pharyngeus at 2 hours postoperatively. The acoustic parameters did not change significantly except for a decrease in MPT. At 24 hours postoperatively, all vocal symptoms subsided with no significant difference to baseline value. The habitual pitch increased significantly, and the rest of the parameters remained comparable to baseline value.     

Voice problems as side effects of inhaled corticosteroids in asthma patients—a prevalence study

Voice disturbances in asthma patients may be caused by inhaled corticosteroids. In order to study the prevalence of such voice disturbances, a questionnaire was delivered to asthma patients at three asthma and allergy departments in Stockholm. The questionnaire consisted of 25 questions concerning the asthma disease symptoms, medication, voice function, and voice disturbances. A total of 350 questionnaires were delivered. Response frequency was 80%. There was a significant positive correlation between inhalation of cortison and voice disturbances. Most of the patients complained about hoarseness, followed by throat clearing, a lump in the throat, loss of voice, and less frequently, throat pain. There were no significantly differences between men and women. Elderly had more voice problems than young persons. Patients with voice-demanding professions had more problems than patients who used their voice to a lesser extent during the working day. There was a significant positive correlation between high cortison doses and voice problems as well as between voice problems and acid regurgitation.     

The effect of patient factors on response outcomes toBotox treatment of spasmodic dysphonia

Injection of botulinum toxin (Botox) into the laryngeal muscleshas become the treatment of choice for controlling the symptoms of spasmodic dysphonia (SD). Currently, no specific battery of objective tests to assess the outcome is universally accepted. The purpose of this study was to investigate demographic, clinical, and treatment factors with voice outcome following Botox injection. Sixty-eight patients with adductor SD who underwent at least one Botox injection during a 5-year period were studied. Voice outcome measures were made from patient self-reporting scales and included overall vocal quality, length of response, and duration of breathiness. Vocal quality was significantly correlated with the underlying severity of vocal symptoms prior to treatment, incidence of breathiness and unilateral versus bilateral injection. The length of response was greater in males and following bilateral injections. An increased period of breathiness significantly correlated with bilateral injections.     

Vocal and Laryngeal Effects of Voiced Tongue Vibration Technique According to Performance Time

Our objective is to study the vocal and laryngeal effect as well as the negative signs and sensations related to the voiced tongue vibration technique (VTVT), regarding the time of performance (from 0 to 7 minutes). Thirty adults (15 men and 15 women) with no vocal complaints nor laryngeal disorders were involved. All subjects underwent laryngostroboscopic and auditory perceptual analysis and answered about the existence of uncomfortable sensations that occurred during the exercise (1, 3, 5, and 7 minutes) and postexercise. For the auditory perceptual analysis, the female group presented better outcomes in the third minute of exercise, whereas in general the male group showed no modification because of performance time. Some men presented a significant change in the parameters involved from the fifth minute on. Men and women showed a gradual increase of undesirable sensations. It is extremely important that the performance time of the VTVT is properly prescribed to provide the expected results, without causing undue injuries to the vocal system. Therefore, we suggest this technique should be recommended for 3 and 5 minutes for women and men, respectively.     

Dissipation mechanisms near the superfluid 3He transition in aerogel

We have investigated the dissipation (Q-1) using the torsion pendulum technique for pure 3He and 3He-4He mixtures in silica aerogel near the 3He superfluid transition (T(c)) in aerogel. With pure 3He the Q-1 decreases at the onset of superfluidity. When phase separated 3He-4He mixtures are introduced into the aerogel, the Q-1 does not decrease as rapidly and eventually increases for the highest 4He content. We provide a model for the related attenuation of transverse sound alpha that takes into account elastic and inelastic scattering processes and exhibits a decrease in alpha at T(c).     

Acoustic Measures and Self-reports of Vocal Fatigue by Female Teachers

This study investigated the relation of symptoms of vocal fatigue to acoustic variables reflecting type of voice production and the effects of vocal loading. Seventy-nine female primary school teachers volunteered as subjects. Before and after a working day, (1) a 1-minute text reading sample was recorded at habitual loudness and loudly (as in large classroom), (2) a prolonged phonation on [a:] was recorded at habitual speaking pitch and loudness, and (3) a questionnaire about voice quality, ease, or difficulty of phonation and tiredness of throat was completed. The samples were analyzed for average fundamental frequency (F0), sound pressure level (SPL), and phonation type reflecting alpha ratio (SPL [1-5 kHz]-SPL [50 Hz-1 kHz]). The vowel samples were additionally analyzed for perturbation (jitter and shimmer). After a working day, F0, SPL, and alpha ratio were higher, jitter and shimmer values were lower, and more tiredness of throat was reported. The average levels of the acoustic parameters did not correlate with the symptoms. Increase in jitter and mean F0 in loud reading correlated with tiredness of throat. The results seem to suggest that, at least among experienced vocal professionals, voice production type had little relevance from the point of view of vocal fatigue reported. Differences in the acoustic parameters after a vocally loading working day mainly seem to reflect increased muscle activity as a consequence of vocal loading.     

Symptoms of Extraesophageal Reflux in a Community-Dwelling Sample

OBJECTIVES: Extraesophageal reflux disease (EERD) is linked with serious and varied health concerns. The authors' goal was to determine the prevalence of EERD and the effect on health-related quality of life in adults within a large community-based sample. STUDY DESIGN: Survey study conducted in a community setting. METHODS: In the Madison, Wisconsin area, 1845 adult subjects were surveyed. Main outcome measures were frequently of GERD and laryngeal symptoms, the Medical Outcomes Trust Short Form 12 (SF-12), Voice Handicap Index (VHI), and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires. RESULTS: More than 66% of subjects reported either GERD or laryngeal symptoms, and 26% reported both GERD and laryngeal symptoms (which reflect symptoms commonly reported for EERD). In addition, 39% of our sample took medicine for heartburn. Forty-four percent of subjects with both GERD and laryngeal symptoms reported occasional breathing difficulties, and 38% of these subjects reported a voice disorder. Significant reductions in perceived quality of general health, digestive health, and voice-related quality of life were found in subjects with both GERD and laryngeal symptoms, in comparison with subjects manifesting each symptom group alone, or in subjects with no symptoms. CONCLUSIONS: The presence of GERD and laryngeal symptoms, and their concurrence, was identified in a substantial number of subjects. The GERD and laryngeal symptoms surveyed represent those most commonly reported for EERD. Because EERD has been linked with tissue damage and reductions in health-related quality of life, it is important to identify these persons and provide treatment before progression of the condition.     

Effects of risedronate in a rat model of osteopenia due to orchidectomy and disuse: densitometric, histomorphometric and microtomographic studies

Dual energy X-ray absorptiometry (DXA), histomorphometry and X-ray microtomography (microCT) were used to assess effects of risedronate and testosterone in a combined rat model of orchidectomy (ORX) and local paralysis induced by botulinum neurotoxin (BTX). Four groups of mature rats were studied for 1 month: SHAM operated; ORX and right hindlimb immobilization (BTX); ORX+BTX+risedronate or testosterone. Changes in bone and body composition were measured by DXA (BMC, lean and fat mass), histomorphometry (BV/TV(2D), Tb.Th and microarchitectural parameters) and microCT (BV/TV(3D), SMI and cortical parameters). ORX and BTX had additive effects on bone loss since differences were maximized on the immobilized bone. The decrease in BMC on the tibial metaphysis reached -33.6% vs. -11.3% in the non-immobilized limb. BV/TV and Tb.N decreased and Tb.Sp increased in both hindlimbs whereas Tb.Th was significantly lower only in the immobilized limb. Decrease of tibial cortical area and thickness was greater in the immobilized limb. Risedronate prevented BMC, BV/TV and architecture loss but not reduction in Tb.Th. Cortical bone was preserved only in the non-immobilized limb. Testosterone was unable to prevent trabecular and cortical bone loss, but it prevents loss of whole body lean mass. In conclusion, ORX and BTX resulted in additive effects on bone loss. Risedronate had protective effects on trabecular bone loss but was less effective on cortical bone.     

Arytenoid Cartilage Dislocation: A 20-year Experience

SUMMARY: Arytenoid cartilage dislocation is an infrequently diagnosed cause of vocal fold immobility. Seventy-four cases have been reported in the literature to date. Intubation is the most common origin, followed by external laryngeal trauma. Decreased volume and breathiness are the most common presenting symptoms. We report on 63 patients with arytenoid cartilage dislocation treated by the senior author (RTS) since 1983. Significantly more posterior than anterior dislocations were represented. Although reestablishing joint mobility is difficult, endoscopic reduction should be considered to align the heights of the vocal processes. This process may result in significant voice improvement even long after the dislocation. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography (CT) imaging are helpful in the evaluation of patients with vocal fold immobility to help distinguish arytenoid cartilage dislocation from vocal fold paralysis. Familiarity with signs and symptoms of arytenoid cartilage dislocation and current treatment techniques improves the chances for optimal therapeutic results.     

Perceptual Clinical Features in Exercise-Induced Laryngeal Obstruction (EILO): Toward Improved Diagnostic Approaches

IntroductionAthletes with exercise-induced laryngeal obstruction (EILO) (previously commonly referred to as paradoxical vocal fold motion disorder, or paradoxical vocal fold motion, among other terms) are often misdiagnosed, resulting in prolonged, and at times inappropriate, clinical management. The high prevalence of misdiagnosis is largely due to a lack of universal consensus of key clinical features indicating EILO and a dearth of validated quantitative approaches to accurately detect episodic laryngeal breathing disorders (ELBD) from other pathologies. Additionally, mechanisms underlying EILO clinical presentation are poorly understood, further confounding identification and management of the condition. Therefore, the objectives of this study were twofold. The first was to identify patient-centered perception of symptoms that could distinguish adolescent athletes with EILO from athletes without the condition, at baseline (rest) and during an exercise challenge (provocation), and to quantify symptom severities for use as preliminary diagnostic benchmarks. The second objective was to investigate the merit of one commonly proposed mechanism in the EILO literature—stress reactivity (temperament)—by comparing personality traits in athletes with and without EILO.MethodsTwelve (12) athletes diagnosed with EILO and 14 healthy athletic volunteers without the condition were asked to rate the severity of their present symptoms using a 0–100 continuous visual analog scale. Participants then underwent an exercise challenge with simultaneous laryngoscopy and were asked to complete the same set of symptom severity ratings experienced during rigorous exercise. Finally, participants completed the Fear subscale on the early adolescent temperament questionnaire—revised (EATQ-R) to measure self-perceived levels of stress reactivity.ResultsThere were significant group differences for inspiratory and expiratory dyspnea with exercise (P = 0.01). Symptoms of stridor (EILO: P = .01; control: P = .001) and throat tightness (EILO: P = .01, control: P = .01) were statistically different between rest and exercise in both groups. However, no group differences were found on these two parameters (P > .05). Other symptoms from the list of previously purported symptoms indicative of ELBD (e.g. cough, dysphonia) were infrequently reported in the exercise variant. Additionally, measurements of stress reactivity on the EATQ-R Fear subscale were similar between the two athletic groups. Interestingly, EATQ-R Fear Subscale scores for both groups were significantly higher compared to typical adolescents in the U.S. population (P < .001, respectively).DiscussionResults suggest dyspnea severity, particularly when experienced during an exercise-induced ELBD (EILO) episode, is the most sensitive symptom parameter to distinguish individuals with EILO from those without the condition. These findings confirm previous literature describing episodic laryngeal breathing disorders in clinical cohorts. Results also showed symptoms of throat tightness and stridor is more prevalent during exercise, compared to rest. However, the level of their severity occurred variably across both groups of athletes and may point to a less robust indication of pathology. Finally, similarities to stress reactivity between the two athletic groups imply certain temperaments historically attributed to patients with EILO may instead better reflect temperaments in competitive young athletes, in general.ConclusionStudy findings highlight the importance of using normative comparisons in the study of episodic laryngeal breathing disorders to prevent overgeneralization of characteristics to clinical cohorts. Results also speak of the clinical utility of exercise challenge to improve specificity of EILO diagnosis.     

Sound transmission at ground level in a short-grass prairie habitat and its implications for long-range communication in the swift fox Vulpes velox

The acoustic environment of swift foxes Vulpes velox vocalizing close to the ground and the effect of propagation on individual identity information in vocalizations were quantified in a transmission experiment in prairie habitat. Sounds were propagated (0.45 m above the ground) at distances up to 400 m. Effects of transmission were measured on three sound types: synthesized sweeps with 1.3 kHz bandwidths spanning in the range of 0.3-8.0 kHz; single elements of swift fox barking sequences (frequency range of 0.3-4.0 kHz) and complete barking sequences. Synthesized sweeps spanning 0.3-1.6 and 1.2-2.5 kHz propagated the furthest and the latter sweeps exhibited the best transmission properties for long-range propagation. Swift fox barking sequence elements are centered toward the lower end of this frequency range. Nevertheless, measurable individual spectral characteristics of the barking sequence seem to persist to at least 400 m. Individual temporal features were very consistent to at least 400 m. The communication range of the barking sequences is likely to be farther than 400 m and it should be considered a long-ranging vocalization. However, relative to the large home ranges of swift foxes (up to 16 km(2) in the experimental area) the barking sequence probably functions at intermediate distances.     

Chronic Refractory Cough as a Sensory Neuropathy: Evidence From a Reinterpretation of Cough Triggers

Objectives/Hypothesis

The aims of this study were to examine cough triggers in individuals with chronic cough (CC), identify sensory symptoms consistent with central reflex sensitization (paresthesia and allotussia), and interpret this information in relation to sensory laryngeal neuropathy.

Study Design

Prospective observational study.

Methods

Patients (n = 53) with CC that was refractory to medical management based on the anatomic diagnostic protocol completed questionnaires regarding cough triggers, anxiety and depression, and factors contributing to laryngeal irritation such as vocal hygiene and laryngopharyngeal reflux.

Results

An abnormal sensation in the laryngeal area (laryngeal paresthesia) was present in 94% of people with refractory CC. Nontussive stimuli including phonation were frequent triggers for cough (allotussia), occurring in 71% of participants. Although tussive stimuli were significantly more potent than nontussive stimuli (P = 0.005), the relative clinical importance was not statistically different (P = 0.072). Most participants with refractory cough had poor vocal hygiene.

Conclusion

The sensory symptom changes that accompany CC suggest central reflex sensitization and include laryngeal paresthesia and allotussia. The results are consistent with cough as a sensory neuropathic disorder.     

Analysis of spasmodic dysphonia by aerodynamic and laryngostroboscopic measurements

Sequential assessment of laryngeal function using laryngostroboscopy and phonatory air flow assessment was carried out in 18 patients with spasmodic dysphonia (SD). Comparison was made between findings in patients before treatment (n = 18), after unilateral recurrent nerve block by lidocaine (n = 6), after bilateral injections of botulinum toxin (Botox) (n = 13), and prior to Botox reinjection (n = 3). Unilateral nerve block resulted in higher mean phonatory airflows than after bilateral Botox injections. Both unilateral nerve block and Botox injections increased fluctuant or alternating flow source (AC); however, unilateral nerve block resulted in more unmodulated airflow leakage. Phonation time on a single breath was longer than with Botox injection. Bilateral Botox injections resulted in better glottal closure, fewer instances of vocal fold level differences, and, better vocal fold vibrations with phase symmetry, as determined by laryngostroboscopy. Partial bilateral denervation using Botox resulted in laryngeal function, which appeared to be intermediate between that of tightly squeezed pretreatment status and a breathy voice with incomplete adduction after unilateral nerve block. Of all treatments assessed, bilateral partial denervation by Botox appeared to be the most physiologic in restoring normal vocal fold vibratory function and airflow.     

Heterogeneous adsorption and catalytic oxidation of benzene, toluene and xylene over spent and chemically regenerated platinum catalyst supported on activated carbon

The heterogeneous adsorption and catalytic oxidation of benzene, toluene and o-xylene (BTX) over the spent platinum catalyst supported on activated carbon (Pt/AC) as well as the chemically treated spent catalysts were studied to understand their catalytic and adsorption activities. Sulfuric aqueous acid solution (0.1N, H₂SO₄) was used to regenerate the spent Pt/AC catalyst. The physico-chemical properties of the catalysts in the spent and chemically treated states were analyzed by using nitrogen adsorption-desorption isotherm and elemental analysis (EDX). The gravimetric adsorption and the light-off curve analysis were employed to study the BTX adsorption and oxidation on the spent catalyst and its modified Pt/AC catalysts. The experimental results indicate that the spent Pt/AC catalyst treated with the H₂SO₄ aqueous solution has a higher toluene adsorption and conversion ability than that of the spent Pt/AC catalyst. A further studies of H₂SO₄ treated Pt/AC catalyst on their catalytic and heterogeneous adsorption behaviours for BTX revealed that the activity of the H₂SO₄ treated Pt/AC catalyst follows the sequence of benzene > toluene > o-xylene. The adsorption equilibrium isotherms of BTX on the H₂SO₄ treated Pt/AC were measured at different temperatures ranging from 120 to 180 °C. To correlate the equilibrium data and evaluate their adsorption affinity for BTX, the two sites localized Langmuir (L2m) isotherm model was employed. The heterogeneous surface feature of the H₂SO₄ treated Pt/AC was described in detail with the information obtained from the results of isosteric enthalpy of adsorption and adsorption energy distributions. Furthermore, the activity of H₂SO₄ treated Pt/AC about BTX was found to be directly related to the Henry's constant, isosteric enthalpy of adsorption and adsorption energy distribution functions.     

Acoustic Interpretation of Resonant Voice

Resonant voice, often described in terms of vibratory sensations in the face, is investigated acoustically by calculating vocal tract inertance. It appears that the ease of production and vibrancy of resonant voice depends more on lowering phonation threshold pressure than on tissue or air resonance in or around the face. Phonation threshold pressure is lowered by increasing air column inertance in the laryngeal vestibule. The fact that the sensations are felt in the face is an indication of effective conversion of aerodynamic energy to acoustic energy, rather than sound resonation in the sinuses or the nasal airways.     

Unilateral Versus Bilateral Injections of Botulinum Toxin in Patients with Adductor Spasmodic Dysphonia

Both unilateral and bilateral thyroarytenoid muscle injections of Botox provide effective management of voice symptoms in patients with adductor spasmodic dysphonia; however, the preferred injection technique has not been established. In this study, 16 patients were treated with unilateral injections (72 injections total) and 33 patients were managed with bilateral injections (133 injections total). Individual assignments to injection type were based on treatment previously received and dose was adjusted according to the patient's previous treatment response. An optimal treatment included a benefit lasting 3 months or more with side effects lasting 2 weeks or less. Compared to patients receiving bilateral injections, those receiving unilateral injections more frequently noted a benefit of 3 months or more (p = 0.03), side effects of 2 weeks or less duration (p = 0.03), as well as both a 3-month benefit and a 2-week or less side effect (p = 0.0004). Injection type had no effect on optimal Botox dosing with repeat injections. Successive unilateral injections at the same dose were more likely (p = 0.012) than successive bilateral injections to produce the same or longer duration of benefit. We conclude that a unilateral injection routine has a more optimal and consistent treatment effect/side effect profile.