Laryngeal electromyography in dysphonic patients with incomplete glottic closure

The lack of specificity in laryngoscopical examination requires that the diagnosis of superior laryngeal and recurrent laryngeal nerve involvement be carried out with the aid of electromyography. OBJECTIVE: This study aims to assess the electrophysiological function of the superior and inferior laryngeal nerves by measuring the electrical activity of the muscles they innervate in dysphonic patients with incomplete closure of the vocal folds during phonation. METHOD: Thirty-nine patients with incomplete glottic closure were enrolled in a prospective study and had their cricothyroid, thyroarytenoid, and lateral cricoarytenoid muscles examined bilaterally through electromyography. Insertion activity, electrical activity at rest (fibrillation, positive wave and fasciculation) and during muscle voluntary contraction (recruitment, amplitude, potential length and latency between electrical activity and phonation) were measured. RESULTS: No altered test results were observed for parameters insertion activity and electrical activity at rest. None of the patients had recruitment dysfunction. The mean electrical potential amplitude values were within normal range for the tested muscles, as were potential durations and latency times between the onset of electrical activity and phonation. CONCLUSION: No signs of denervation were seen in the thyroarytenoid, cricothyroid, and lateral cricoarytenoid muscles of the studied patients.O diagnóstico de comprometimento do nervo laríngeo superior e de ramos do laríngeo recorrente demanda eletromiografia, pois as alterações à laringoscopia são inespecíficas. OBJETIVO: Avaliar eletrofisiologicamente a função dos nervos laríngeo superior e inferior por meio da atividade elétrica dos músculos por eles inervados, em pacientes com disfonia com coaptação incompleta das pregas vocais à fonação. MÉTODO: Estudo prospectivo; 39 indivíduos com disfonia e fechamento glótico incompleto foram submetidos à eletromiografia dos músculos tireoaritenóideo, cricotireóideo e cricoaritenóideo lateral bilateralmente. Foram avaliadas atividade de inserção, no repouso (fibrilação, onda positiva e fasciculação) e durante contração voluntária dos músculos (recrutamento, amplitude e duração do potencial e latência entre início da atividade elétrica e a sonorização). RESULTADOS: Não observamos alteração na atividade de inserção e no repouso. Nenhum paciente apresentou recrutamento alterado. A média da amplitude dos potenciais elétricos esteve compatível com a normalidade nos músculos testados, assim como a duração do potencial e o tempo de latência entre o início da atividade elétrica e a sonorização. CONCLUSÃO: Não observamos sinais de desnervação nos músculos tireoaritenóideo, cricotireóideo e cricoaritenóideo lateral bilateralmente nos pacientes estudados.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUniversidade Federal de São Paulo (UNIFESP) Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço Escola Paulista de MedicinaInternational Federation of ORL SocietiesUNIFESP, EPMUNIFESP, Depto. de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço Escola Paulista de MedicinaSciEL

Comparison of botulinum toxin and propranolol for essential and dystonic vocal tremors

OBJECTIVES: Vocal tremors, which cause social difficulties for patients, may be classified as resting or action tremors. Of the vocal action tremors, essential and dystonic tremors are the most common. Botulinum toxin and oral medications have been used to treat vocal tremors, but no comparative clinical trials have been performed. The aim of this study was to compare the effects of botulinum toxin injection and the oral administration of propranolol in the treatment of essential and dystonic vocal tremors. METHODS: This clinical trial recruited 15 patients, divided into essential and dystonic vocal tremor groups. Patients in both groups received successive treatment with botulinum toxin and propranolol. The treatments were administered at different times; the order of treatment was randomly selected. Patients were assessed with flexible nasofibrolaryngoscopy and with perceptual and acoustic voice evaluations. A statistical significance level of 0.05 (5%) was used. RESULTS: Botulinum toxin produced statistically significant improvements in perceptual measures of vocal instability in patients with dystonic vocal tremors compared with baseline values and treatment with propranolol. The acoustic measure of variability in the fundamental frequency was significantly lower in patients with dystonic vocal tremors after treatment with botulinum toxin. CONCLUSION: Essential and dystonic vocal tremors responded differently to treatment. Dystonic vocal tremors responded significantly to treatment with botulinum toxin but not oral propranolol. Essential vocal tremors did not respond significantly to either treatment, perhaps due to the small number of patients, which is a limitation of this research

Laryngeal breathing dystonia

Laryngeal Breathing Dystonia (LBD) is a rare disorder characterized by inappropriate adduction of the true vocal cords during inspiration, resulting in stridor and dispnea. However, sometimes it is difficult to recognize the underlying etiology of the stridor, specially in emergencial situations, and LBD may be occasionally misdiagnosed, which makes this disease perhaps more frequent than it has been taught. The diagnosis is further supported by the finding of dystonic features and by exclusion of other causes of paradoxical vocal cord motion. There has been no satisfactory treatment for the disease. Botulinum toxin type A (Botox®) injection into the thyreoarytenoid muscle has been shown to be very effective, but only few cases have been reported. The authors describe the clinical presentation of Laryngeal Breathing Dystonia in two patients with complaints of stridor. Evaluation by laryngoscopy revealed paradoxical vocal cord motion and malacia of the epiglottis. Treatment was attempted by injection of Botox® in the adductor muscles. In this article the diagnostic approach of this disease is evaluated in accordance to the earliest concepts on laryngeal dystonias. Based on the classification system for laryngeal dystonias presented by Koufman and Blabock, the authors propose the recognition of a new subtype of DLR.A distonia laríngea respiratória (DLR) é uma desordem rara caracterizada por espasmos da musculatura adutora das pregas vocais durante a fase inalatória da respiração, com manifestação clínica de dispnéia e estridor. O diagnóstico etiológico do estridor laríngeo, entretanto, nem sempre é fácil de ser realizado, principalmente em situações emergenciais, de forma que a DLR pode não ser diagnosticada, o que nos leva a supor ser mais freqüente do que usualmente é descrita. O diagnóstico da DRL requer primeiramente a realização de uma história médica e exames laringológico e neurológico apropriados, com ênfase na verificação da presença de características distônicas e na exclusão de outras etiologias causadoras de movimentos paradoxais de pregas vocais. Muitos tratamentos foram propostos para a DLR, mas nenhum deles apresentou resultados satisfatórios. O uso da Toxina Botulínica do tipo A (Botox®) no músculo tireoaritenoídeo tem oferecido melhoras admiráveis, apesar dos poucos casos descritos. Apresentamos dois casos clínicos de pacientes com DLR tratados com Botox® que apresentavam o fechamento glótico inspiratório causado tanto pelos espasmos anômalos dos músculos tireoaritenoídeos, como pela movimentação paradoxal da epiglote. Dentro da classificação proposta por Koufman e Blabock para as distonias laríngeas, inserimos um novo subtipo de DLR caracterizado pela presença de paroxismos de adução de estruturas glóticas e supraglóticas durante a respiração.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Instituto da LaringeUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina OtorrinolaringologiaUNIFESP, EPM, Instituto da LaringeUNIFESP, EPM, OtorrinolaringologiaSciEL

Sulfated glycosaminoglycans in human vocal fold lamina propria

Introduction: The distribution, concentration and function of glycosaminoglycans in the various vocal fold tissues are still unclear. Objective: To evaluate the distribution and concentration of sulfated glycosaminoglycans in different layers of the human vocal fold according to gender and age. Methods: We used 11 vocal folds obtained from cadavers (7 men and 4 women) with no laryngeal lesion, less than 12 h after death, and aged between 35 and 98 years. The folds underwent glycosaminoglycans extraction from the cover and ligament, and post-electrophoresis analysis. Data were compared according to the layer, age and gender. Results: The concentration of dermatan sulfate was significantly higher in all layers. No differences were observed in the total concentrations of glycosaminoglycans in layers studied according to gender. It is significantly lower in the cover of individuals aged below 60 years. Conclusion: Dermatan sulfate, chondroitin sulfate, and heparan sulfate were observed in the human vocal folds cover and ligament of both genders, with the concentration of dermatan sulfate being significantly higher in all layers. Glycosaminoglycans concentration on the cover is significantly lower in individuals below 60 years compared with elderly. (C) 2016 Associacao Brasileira de Otorrinolaringologia e Cirurgia Cervico-Facial. Published by Elsevier Editora Ltda.Univ Fed Sao Paulo UNIFESP, EPM, Dept Otorrinolaringol & Cirurgia Cabeca & Pescoco, Setor Laringe & Voz, Sao Paulo, SP, BrazilUniv Fed Sao Paulo UNIFESP, EPM, Dept Bioquim, Div Biol Mol, Sao Paulo, SP, BrazilUniv Fed Sao Paulo UNIFESP, EPM, Dept Med, Div Endocrinol & Metab, Sao Paulo, SP, BrazilPUC SP, Sao Paulo, SP, BrazilUniv Fed Sao Paulo UNIFESP, EPM, Dept Otorrinolaringol & Cirurgia Cabeca & Pescoco, Setor Laringe & Voz, Sao Paulo, SP, BrazilUniv Fed Sao Paulo UNIFESP, EPM, Dept Bioquim, Div Biol Mol, Sao Paulo, SP, BrazilUniv Fed Sao Paulo UNIFESP, EPM, Dept Med, Div Endocrinol & Metab, Sao Paulo, SP, BrazilWeb of Scienc

The difficult management of patients with respiratory segmental dystonia

Respiratory dystonia is a rare and difficult to diagnose disorder, that causes breathing restriction of various degrees. The objective of the study is to report the case of a patient with respiratory dystonia involving the larynx and the pharynx and its evolution concerning spasms intensity and control. CASE REPORT: A 24 year-old-man has been followed for 5 years. The diagnosis was made by means of nasofibroscopy and electromyography. Treatment was carried out with laryngeal and pharyngeal Botulin toxin injections, as it became necessary for symptoms control. CONCLUSION: The difficult management can be secondary to the lack of knowledge on the etiology and physiopathology of the impairment, and because of the limitations in the treatment of associated respiratory symptoms.A forma respiratória da distonia laríngea é rara, de difícil diagnóstico e provoca restrição respiratória de graus variados. O objetivo deste trabalho é apresentar um caso de distonia respiratória envolvendo laringe e faringe e sua evolução em relação à intensidade dos espasmos e seu controle. ESTUDO DE CASO: Paciente de 24 anos, sexo masculino, acompanhado por 5 anos: diagnóstico por nasofibroscopia e eletromiografia e tratamento com toxina botulínica conforme necessidade de controle dos sintomas. CONCLUSÃO: O difícil manejo se deve ao fato do desconhecimento da etiologia e a pouca opção de tratamento, bem como do envolvimento da função respiratória.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaPontifícia Universidade Católica de São Paulo Escola Paulista de MedicinaEscola Paulista de Medicina Departamento de Oftalmo/OtorrinolaringologiaEscola Paulista de Medicina Departamento de Otorrinolaringologia e Distúrbios da Comunicação HumanaFundação para o Estudo e Tratamento das Deformidades Crânio-FaciaisUNIFESP CEVUniversidade Federal de São Paulo (UNIFESP) EPM Departamento de Otorrinolaringologia e Cirurgia de Cabeça e PescoçoUNIFESP-EPM Departamento de Otorrinolaringologia e Cirurgia de Cabeça e PescoçoUNIFESP, EPMPontifícia Universidade Católica de São Paulo Escola Paulista de MedicinaEscola Paulista de Medicina Depto. de Oftalmo/OtorrinolaringologiaEscola Paulista de Medicina Depto. de Otorrinolaringologia e Distúrbios da Comunicação HumanaUNIFESP, CEVUNIFESP, EPM, Depto. de Otorrinolaringologia e Cirurgia de Cabeça e PescoçoUNIFESP, EPM Depto. de Otorrinolaringologia e Cirurgia de Cabeça e PescoçoSciEL

Adduction laryngeal dystonia: proposal and evaluation of nasofibroscopy

Dystonias are organic central motor processing disorders characterized by involuntary muscular contractions or incontrollable spasms induced by task-specific movements. Adduction laryngeal dystonias present with important speech impairments, with inappropriate spasms and abrupt voice breaks. The diagnosis is based on clinical features, evaluation by a speech therapist and transnasal fiber optic laryngoscopy. AIM: Our objective is to propose and evaluate a task-oriented transnasal fiber optic laryngoscopy protocol, which shows the spasms, and propose maneuvers that reduce or make them disappear, in order to facilitate the diagnosis. METHODS: transversal study. Analysis of the transnasal fiber optic laryngoscopy records of 15 patients with adductor laryngeal dystonia using the proposed protocol. RESULTS: most of the speech and non-vocal tasks allowed us to identify the spasms and reduce or make them disappear. We propose the exclusion of two of the maneuvers that don t bring new data to the evaluation. CONCLUSION: the protocol was useful for the evaluation of the patients, showing changes in muscle behavior in the structure under investigation.Distonias são desordens orgânicas do processamento motor central caracterizadas por contrações musculares involuntárias e espasmos à fonação nas formas laríngeas adutoras, com quebras de sonoridade. O diagnóstico é clínico e baseado na avaliação perceptivo-auditiva da voz e nasofibroscopia. OBJETIVO: O nosso objetivo é propor e avaliar um protocolo de exame de nasofibrolaringoscopia que contemple tarefas que evidenciem os espasmos e tarefas que diminuam ou façam desaparecer os espasmos, visando facilitar a análise e o diagnóstico. MATERIAL E MÉTODO: Estudo transversal. Análise de imagens de 15 videonasolaringoscopias de pacientes com distonia laríngea de adução por meio do protocolo proposto. RESULTADOS: A maior parte das tarefas de fala e não-fonatórias permitiram a identificação de espasmos e a diminuição ou desaparecimento destes. Propomos a exclusão de duas delas que não acrescentaram dados à avaliação. CONCLUSÃO: O protocolo foi útil na avaliação dos pacientes, mostrando mudança de comportamento da musculatura nas estruturas estudadas conforme as tarefas executadas.Pontifícia Universidade Católica de São Paulo Faculdade de FonoaudiologiaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Otorrinolaringologia e Cirurgia de Cabeça e PescoçoUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaCentro de Estudos da Voz Setor de Laringe e VozUNIFESP, EPM, Depto. de Otorrinolaringologia e Cirurgia de Cabeça e PescoçoUNIFESP, EPMSciEL

Detection of hyaluronic acid receptor in human vocal folds by immunohistochemistry

Hyaluronic acid receptor is a glycoprotein of the plasmatic membrane, and the CD44 is its representative, expressed in many cell types where it has the task of cell adhesion. AIM: the goal of the present experimental study is to investigate the possibility of using immunohistochemistry to identify the distribution of hyaluronic acid along the vocal fold. MATERIALS AND METHODS: We resected the normal vocal folds from a normal 23 year-old male black individual. The slides were analyzed by means of a histomorphometric study, comparing the color intensity in the superficial, middle and deep layers of the lamina propria. In the silanized slides we used immunohistochemistry, and evaluated the slides under light microscopy with 40x magnification, and the color changed to brown when there was a reaction with the receptor for hyaluronic acid. RESULTS: Immunohistochemical findings showed the presence of hyaluronic acid receptors in the epithelium covering the vocal fold, being more concentrated in the central region of the vocal fold. CONCLUSION: immunohistochemistry, used to assess the distribution of hyaluronic acid receptors in the central portion of the vocal fold, proved it to be present in the vocal fold epithelium and it prevailed in its middle third.O receptor do ácido Hialurônico é uma glicoproteína da membrana plasmática, sendo o principal o CD44, e está expresso em vários tipos de células onde possui a função de adesão celular. OBJETIVO: Estudar a possibilidade de empregar o método imunohistoquímico para identificar a distribuição dos receptores de ácido hialurônico ao longo da prega vocal humana. MATERIAL E MÉTODOS: Foram ressecadas as pregas vocais normais de um indivíduo de 23 anos, sexo masculino, cor negra. As lâminas foram analisadas por meio de estudo histomorfométrico, comparando-se a intensidade das cores nas camadas superficial, média e profunda da lâmina própria. Nas lâminas silanizadas foi utilizado método imunohistoquímico, sendo avaliadas através de microscopia óptica com aumento 40 vezes, obtendo coloração marrom onde houve a reação com receptor para ácido hialurônico. RESULTADOS: Os achados imunohistoquímicos mostraram presença de receptores para ácido hialurônico no epitélio de cobertura da prega vocal tendo maior concentração na região central da prega vocal. CONCLUSÃO: A técnica de imunohistoquímica, utilizada para avaliar a distribuição dos receptores para ácido hialurônico na pregas vocais humanas, mostrou sua disposição em epitélio da prega vocal e predomínio no terço médio, em relação às demais regiões na prega vocal estudada.UNIFESP-EPM Departamento de ORLUFBAUNIFESP-EPM Departamento de PatologiaUNIFESP Departamento de ORLUNIFESP, EPM, Depto. de ORLUNIFESP, EPM Depto. de PatologiaUNIFESP, Depto. de ORLSciEL

Videofluoroscopic evaluation of mastication and swallowing in individuals with TMD

To study mastication and swallowing disorders in patients with temporomanclibular disorders (TMD). Objective: To investigate mastication and swallowing disorders in patients with severe TMD referred to surgery. Materials and Methods: Clinical and experimental study involving ten individuals with TMD submitted to deglutition videofluoroscopy. These patients did not have posterior teeth, mastication pain and food replacement in favor of pasty consistence food. The assessment of the oral and pharyngeal phases approached the following aspects: side of onset and preferential side for chewing, premature escape, remains of food residues in the oral cavity or in the pharyngeal recesses, number of necessary swallowing efforts, laryngeal penetration and/or tracheal aspiration. Results: During mastication and the oral phase we observed tongue compensatory movements upon chewing (n = 7; 70%), premature escape (n = 4; 40%), food remains in the cavity after swallowing (n = 5; 50%) and an excessive number of deglutition efforts (n = 5; 50%). On the pharyngeal phase we observed food remains in the valleculae (n = 6; 60%), in the pyriform sinuses (n = 4; 40%); laryngeal penetration (n = 1; 10%) and tracheal aspiration (n = 4; 40%). Conclusion: TMD patients may have alterations in their chewing and swallowing patterns, with laryngeal penetration and/or tracheal aspiration. The study indicates the need for a multidisciplinary assessment because of dysphagia in TMD patients

Laryngoscopy evaluation protocol for the differentiation of essential and dystonic voice tremor

ABSTRACT INTRODUCTION: Although syndromes that cause voice tremor have singular characteristics, the differential diagnosis of these diseases is a challenge because of the overlap of the existing signs and symptoms. OBJECTIVE: To develop a task-specific protocol to assess voice tremor by means of nasofibrolaryngoscopy and to identify those tasks that can distinguish between essential and dystonic tremor syndromes. METHODS: Cross-sectional study. The transnasal fiberoptic laryngoscopy protocol, which consisted of the assessment of palate, pharynx and larynx tremor during the performance of several vocal and non-vocal tasks with distinct phenomenological characteristics, was applied to 19 patients with voice tremor. Patients were diagnosed with essential or dystonic tremor according to the phenomenological characterization of each group. Once they were classified, the tasks associated with the presence of tremor in each syndrome were identified. RESULTS: The tasks that significantly contributed to the differential diagnosis between essential and dystonic tremor were /s/ production, continuous whistling and reduction of tremor in falsetto. These tasks were phenomenologically different with respect to the presence of tremor in the two syndromes. CONCLUSION: The protocol of specific tasks by means of transnasal fiberoptic laryngoscopy is a viable method to differentiate between essential and dystonic voice tremor syndromes through the following tasks: /s/ production, continuous whistling and reduction of tremor in falsetto

Paralysis of the lateral cricoarytenoid muscle: a case report as a contribution to the understanding of the functional anatomy of the larynx

In the last few years electromyography of the larynx (EMG) has become helpful in the evaluation of vocal fold immobility, especially to differentiate paralysis from fixation, and providing data for diagnosis, site of lesion and prognosis. Based on a case of selective paralysis of lateral cricoarytenoid muscle in a woman who had paralyzed vocal fold at lateral position, confirmed by electromyography study, we conducted an analysis in order to understand the role of intrinsic laryngeal muscles.A eletromiografia da laringe (EMG) vem sendo útil nas avaliações das alterações de mobilidade das pregas vocais, sobretudo diferenciando as paralisias das fixações, e também fornecendo dados para o prognóstico e localização de lesões neuromusculares. Com base na EMG e na telelaringoscopia buscamos entender o papel dos músculos intrínsecos da laringe a partir de um caso de paralisia de músculo cricoaritenóideo lateral, confirmado por estudo eletromiográfico, em uma paciente com história de afonia e perda de mobilidade da prega vocal esquerda, fixa na posição lateral.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaPontifícia Universidade Católica de São Paulo Faculdade de FonoaudiologiaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Otorrinolaringologia e Distúrbios da Comunicação HumanaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Neurologia e NeurocirurgiaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Serviço de EletroneurofisiologiaPontifícia Universidade Católica de São Paulo MedicinaUNIFESP, EPM, Depto. de Otorrinolaringologia e Distúrbios da Comunicação HumanaUNIFESP, EPM, Depto. de Neurologia e NeurocirurgiaUNIFESP, EPM, Serviço de EletroneurofisiologiaSciEL