Laryngeal Myasthenia Gravis: Report of 40 Cases

Myasthenia gravis, an autoimmune disorder of the neuromuscular junction, is usually recognized because of ocular complaints or generalized weakness. We report a series of 40 patients who presented with dysphonia as their initial and primary complaint. Diagnostic testing included strobovideolaryngoscopy, electromyography (EMG) with repetitive stimulation and Tensilon testing, and laboratory and radiographic evaluation. Strobovideolaryngoscopy most commonly revealed fluctuating impairment of vocal fold mobility, either unilateral or bilateral. EMG detected evidence of neuromuscular junction abnormalities in all patients. Only one patient had evidence of antiacetylcholine receptor (ACh-R) antibodies, but many other abnormalities suggestive of autoimmune dysfunction were present. Pyridostigmine therapy was initiated in 34 patients but was not tolerated in 4. Of the remaining 30 patients, 23 reported improvement of symptoms. We conclude that myasthenia gravis can present with symptoms confined primarily to the larynx and should be included in the differential diagnosis of dysphonia.     

The Relationship Between Chronic Cough and Paradoxical Vocal Fold Movement: A Review of the Literature

SUMMARY: Chronic cough (CC) and paradoxical vocal fold movement (PVFM) are debilitating conditions. PVFM has been given many labels, including vocal cord dysfunction, Munchausen's stridor, functional inspiratory stridor, nonorganic functional or psychogenic upper airway obstruction, factitious asthma, psychogenic stridor, emotional laryngeal wheezing, and episodic laryngeal dyskinesia. Although CC and PVFM have been considered separate entities in many reports, there is preliminary support for the notion that there may be an underlying link between these two conditions. Speech pathologists have become increasingly involved in the treatment of these patients and therefore need to understand the theoretical background of these disorders, the pathophysiological links between the two, and the impact of voice disorders on these populations. The aim of this article is to review the current literature on CC and PVFM from a speech pathology perspective to provide a model for defining and conceptualizing the disorders and to provide a framework for management and future research.     

Effectiveness of Physical Therapy in Patients with Tension-type Headache: Literature Review

Background: Tension-type headache (TTH) is a disease with a great incidence on quality of life and with a significant socioeconomic impact. Objectives: The aim of this review is to determine the effectiveness of physical therapy by using manual therapy (MT) for the relief of TTH. Data sources: A review was done identifying randomized controlled trials through searches in MEDLINE, PEDro, Cochrane and CINAHL (January 2002 – April 2012). Study selection: English-language studies, with adult patients and number of subjects not under 11, diagnosed with episodic tension-type headache (ETTH) and chronic tension-type headache (CTTH) were included. Data extraction: Initial search was undertaken with the words Effectiveness, Tension-type headache, and Manual therapy (39 studies). In addition, a search which included terms related to treatments such as physiotherapy, physical therapy, spinal manipulation was performed (25 studies). Results: From the two searches 9 studies met the inclusion criteria and were analysed finding statistically significant results: 1) myofascial release, cervical traction, neck muscles trigger points in cervical thoracic muscles and stretching; 2) Superficial heat and massage, connective tissue manipulation and vertebral Cyriax mobilization; 3) cervical or thoracic spinal manipulation and cervical chin-occipital manual traction; 4) massage, progressive relaxation and gentle stretching, program of active exercises of shoulder, neck and pericranial muscles; 5) massage, passive rhythmic mobilization techniques, cervical, thoracic and lumbopelvic postural correction and cranio-cervical exercises; 6) progressive muscular relaxation combined with joint mobilization, functional, muscle energy, and strain/counterstrain techniques, and cranial osteopathic treatment; 7) massage focused on relieving myofascial trigger point activity; 8) pressure release and muscle energy in suboccipital muscles; 9) combination of mobilizations of the cervical and thoracic spine, exercises and postural correction. All studies used a combination of different techniques and none analyzed treatments separately, also all the studies have assessed aspects related to TTH beyond frequency and intensity of pain. Conclusions: The findings from these studies showed evidence that physiotherapy with articulatory MT, combined with cervical muscle stretching and massage are effective for this disease in different aspects related with TTH. No evidence was found of the effectiveness of the techniques applied separately.     

Outcome of laryngeal and velopharyngeal biofeedback treatment in children and young adults: A pilot study

A relatively new management strategy for the treatment of voice disorders is the use of laryngeal (LB) and velopharyngeal biofeedback (VB). The main purpose of the present pilot study is to document the outcome of vocal and velopharyngeal performances after a well-defined LB and VB treatment. Four subjects were studied pretreatment (1 week before LB or VB treatment) and posttreatment (1 week after the LB or VB treatment). To measure and compare the effect of LB and VB, objective and subjective assessment techniques were used. Perceptual voice assessment included a perceptual rating of the voice using the GRBAS scale. Furthermore, the vocal quality in this population is modeled by means of the Dysphonia Severity Index. For the objective assessment of nasal resonance, the Nasometer and the Glatzel test were used. A perceptual evaluation of speech, the Gutzmann test, and the tests from Bzoch were used as subjective assessment techniques. Both patients selected for LB and VB treatment showed improvement of their performances. The resulting improvement, as measured by means of an objective approach, is in agreement with the perceived (auditory) improvement of voice and resonance. The use of LB and VB treatment in patients, especially in some subjects who are not responding to traditional voice or velopharyngeal therapy, must be encouraged.     

Outcome of laryngeal manual therapy in four Dutch adults with persistent moderate-to-severe vocal hyperfunction: a pilot study

A relatively new management strategy for the treatment of voice disorders is the use of laryngeal manual therapy. The main purpose of the present pilot study is to document the outcome of vocal quality after a well-defined laryngeal manual therapy (LMT) program. Four Dutch professional voice users with a persistent moderate or severe muscle tension dysphonia were studied pretreatment (1 week before LMT) and posttreatment (1 week) after completion of manual therapy (25 sessions). These subjects had received several months of traditional voice therapy, without any success. To measure and compare, the effect of LMT objective and subjective assessment techniques were used. Perceptual voice assessment included a perceptual rating of the voice using the GRBAS scale. Furthermore, the vocal quality in this population was modeled by means of the Dysphonia Severity Index (DSI). All of the subjects selected for LMT showed improvement in perceptual vocal quality and DSI values. As the DSI is a weighted variable including aerodynamic and acoustic measures, small improvements (closer to 5) are very indicative of vocal quality improvement.¹ The use of LMT in professional voice users with persistent moderate-to-severe muscle tension dysphonia, especially in some subjects who have not responded to traditional voice therapy, is supported by this pilot study.     

Electrotherapy and the Human Voice: A Literature Review of the Historical Origins and Contemporary Applications

SUMMARY: The present article surveys the literature on the electrotherapy treatment for voice disorders from the mid-18th century to World War I (1914--1918) and the post 1970s reappearance of such therapies. The reappearance of electrotherapy as treatment for voice disorders in the past 20 years has been heralded as a major breakthrough. In light of our reading of the scientific literature of the 19th century, it can be shown to repeat many of the presuppositions of electrotherapists of that time. The current resurgence of interest and research in electrical stimulation of the larynx is buoyed by technological innovations analogous to those in the 19th century. Although the current state of research has enhanced our understanding of vocal fold physiology, it does not necessarily provide a new therapeutic approach as a survey of the most recent literature shows.     

Cytotoxic Agents in the Treatment of Laryngeal Sarcoidosis: A Case Report and Review of the Literature

SUMMARY: Sarcoidosis is a multisystem disease with various clinical manifestations. It is characterized primarily on a histopathologic basis by the presence of noncaseating granulomata. Laryngeal involvement reportedly occurs in 3-5% of cases, and it is typically localized to the supraglottic region. Patients often present with hoarseness, dysphagia, stridor, or dyspnea. Laryngoscopy typically demonstrates a pale, edematous epiglottis studded with nodules. Tissue biopsy reveals the classic noncaseating granuloma; however, the finding is not diagnostic. Sarcoidosis remains a diagnosis of exclusion to be entertained once other verifiable etiologies for granulomatous disease of the larynx, such as TB, syphilis, fungal infection, berylliosis, or Wegener's granulomatosis, have been ruled out. Systemic corticosteroids remain the mainstay of treatment; however, new steroid-sparing therapies that target the inflammatory response of sarcoidosis are currently being investigated. The case history of a patient with laryngeal sarcoidosis who was managed with the immunosuppressant azathioprine (Imuran) is summarized along with a discussion of other treatment options.     

A Narrative Review of Alternate Gait Training Using Knee-ankle-foot Orthosis in Stroke Patients with Severe Hemiparesis

Impairments resulting from stroke lead to persistent difficulties with walking. Subsequently, an improved walking ability is one of the highest priorities for people living with stroke. The degree to which gait can be restored after a stroke is related to both the initial impairment in walking ability and the severity of paresis of the lower extremities. However, there are some patients with severe motor paralysis and a markedly disrupted corticospinal tract who regain their gait function. Recently, several case reports have described the recovery of gait function in stroke patients with severe hemiplegia by providing alternate gait training. Multiple studies have demonstrated that gait training can induce “locomotor-like” coordinated muscle activity of paralyzed lower limbs in people with spinal cord injury. In the present review, we discuss the neural mechanisms of gait, and then we review case reports on the restoration of gait function in stroke patients with severe hemiplegia.     

Acoustic Measures of Phonatory Improvement Secondary to Treatment by Oral Corticosteroids in a Professional Singer: A Case Report

Short-term administration of corticosteriods is sometimes indicated for professional voice users experiencing laryngeal edema and/or inflammation. Unfortunately, no data are available to document the effectiveness of these medications to improve phonatory parameters. We present a case report of a 32-year-old male professional singer with vocal fold edema experiencing imminent vocal demands who was prescribed a 6-day course (dose-pack) of oral methyl prednisolone. Endoscopic and stroboscopic evaluations were completed premedication and postmedication, and acoustic measures of phonatory function were obtained premedication, 3 days during the dose cycle, 5 days during the dose cycle, and 1 day postmedication. Postmedication results revealed an increase in fundamental frequency (F0) and large decreases in jitter, shimmer, long-term frequency, and amplitude variability. These corresponded with patient and evaluator perceptual measures of improved voice, and with endoscopic observations of reduced edema. The benefits and risks of corticosteroid therapy are discussed, specific to their use in the professional voice population.     

Evidence of Improvement in Various Impairments by Exercise Interventions in Patients with Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Purpose: To investigate improvement in various impairments by exercise interventions in patients with knee osteoarthritis (OA). Methods: We collected data on randomized controlled trials (RCTs) comparing the effects of exercise intervention with those of either nonintervention or psychoeducational intervention in patients with knee OA. Data on pain, stiffness, muscle strength, range of motion, flexibility, maximal oxygen uptake, and position sense were synthesized. The Grading of Recommendations Assessment, Development, and Evaluation system was used to determine the quality of the evidence. Results: Thirty-three RCTs involving 3,192 participants were identified. Meta-analysis provided highquality evidence that exercise intervention improves maximal oxygen uptake, and moderate-quality evidence that exercise intervention also improves pain, stiffness, knee extensor and flexor muscle strength, and position sense. The evidence that exercise intervention improves knee extension and flexion range of motion was deemed as undetermined-quality. Conclusion: In patients with knee OA, improvement in pain, stiffness, muscle strength, maximal oxygen uptake, and position sense with the use of exercise intervention can be expected. Although the quality of evidence of the effect of exercise intervention on range of motion was inconclusive, exercise intervention should be recommended for patients with knee OA to improve various impairments.     

Determination of Mycotoxins in Food: A Review of Bioanalytical to Analytical Methods

Abstract

This review highlights methods for the detection of the main mycotoxins: aflatoxins, fumonisins, ochratoxin, patulin, trichothecene, zearalenone, citrinin. Detection methods such as competitive or noncompetitive immunoassays, different biosensors, and the use of optoelectronics devices to miniaturize the equipment in a portable way, are described. The importance of spectroscopic techniques are underlined and the maxima permissible by various committees are indicated.     

Chemical Vapor Generation with Slurry Sampling: A Review of Applications to Atomic and Mass Spectrometry

Abstract

A critical review of published analytical methods and techniques for chemical vapor generation (CVG) with slurry sample introduction for detection by atomic and mass spectrometry is presented. The nstrumentation used for the reaction as well as separation and transport of the species, influence of chemical and physical factors, and efficiency of the process are considered. A brief comparison of detection limits obtained with atomic absorption, emission, and fluorescence as well as mass spectrometry along with practical applications to analytical samples are summarized. The current state-of-the-art, including advantages and limitations of this approach, is discussed.