Anatomic direction of entry for botulinum toxin injection to treat the adductor spasmodic dysphonia in Thais.

Background: Botulinum toxin injections into the thyroarytenoid (TA) muscle of the larynx is the most popular treatment for adductor spasmodic dysphonia. Injection is usually done by percutaneous transcricothyroid membrane with either electromyography (EMG) or fiberoptic laryngoscopy (FOL) to verify placement of the needle within the TA muscle. This procedure requires a working knowledge of three-dimensional anatomy of the larynx to establish the direction for the accurate placement of the needle. Objective: Find out the appropriate angles and depth of the needle for placement of percutaneous transcricothyroid membrane method of botulinum toxin injection by means of studying the larynges of Thai cadavers. Methods: The descriptive study was performed in 45 Thai freshly thawed cadavers. The angle of the needle from midline sagittal plane, the angle in superior relation to tracheal plane, and the depth from midline cricothyroid (CT) membrane to midlength of TA muscle were measured from the two views of photographs, anteroposterior and lateral. Results: The mean angle of 24.2±6.76ο (mean±SD) from the midline sagittal plane in male and 24.9±7.6ο in female were worked out. A mean angle in superior relation to the tracheal plane was 47.7±7.8ο and 51.4±9.6ο in male and female, respectively. The mean depth was 1.7±0.2 and 1.4±0.1 cm in male and female, respectively. Conclusion: The mean angles and depth of the needle insertion from the midline of CT membrane to the center of TA muscle in Thai laryngeal specimens were evaluated. These values were different from the studies in Caucasians, but it could provide a direct relationship to the build of the races. This knowledge may help laryngologists do this procedure more accurately with better outcome, especially in hospitals that have no EMG or FOL guide.

Botulinum toxin injection for treatment of spasmodic dysphonia: experience at Srinagarind Hospital.

BACKGROUND: Spasmodic dysphonia (SD) is a focal dystonia and adductor SD is the most common form. The standard treatment for adductor SD is EMG-guided, transcutaneous injections of botulinum toxin into the thyroarytenoid muscle. OBJECTIVE: Report the clinical presentation of SD, treatment with botulinum toxin injection, injection technique, results, and adverse effects. MATERIAL AND METHOD: A reviewed of clinical records of patients diagnosed with SD at the Voice Clinic between April 1999 and December 2004 at Srinagarind Hospital, Khon Kaen University, Thailand. Thirty-seven patients were identified but only twenty-five were treated with EMG-guided botulinum toxin injection to the thyroarytenoid muscle. RESULTS: In the presented 37 patients, SD was more common in women (89%) than men (11%). The median duration of symptoms prior to diagnosis was 12 months: all were the adductor type. The average age at onset was 46 years. The presenting symptoms included influence to the voice (84%), hoarseness (70%), strained or strangled voice (65%), decreased loudness (27%), and breathy voice (22%). A vocal tremor coexisted with dystonia in 60% of the presented patients. Treatment with botulinum toxin injection was carried out on 25 patients for 78 injections (mean, 3 per patient). The time for botulinum toxin to take effect averaged 2.3 days (peak effect, 7 days). The patients received substantial relief from their SD symptoms, an average functional improvement of 39.2% (37.6% initially vs. 76.8% finally). Patients' best voice was achieved within one week and persisted for an average of 13.6 weeks. Side effects from the injections included mild breathiness (68%) and mild choking on fluid (56%). After injection, decreased potential for volume was a common complaint, but since all of the patients experienced increased fluency, they were satisfied. Almost all of the patients returned for repeat injections when the benefit diminished. CONCLUSION: Botulinum toxin therapy has become the standard care for the treatment of SD. An acceptable and flexible treatment plan to produce a balance between decreased spasms and loss of function must be developed for each patient.

Retropharyngeal space infection.

Retropharyngeal space infections are relatively rare since the widespread use of modern antibiotics. In children, retropharyngeal space infections usually occur following an upper respiratory tract infection, while in adults they are usually caused by trauma, foreign bodies or extension from adjacent spaces. The authors reviewed 12 patients with retropharyngeal space infection between July 1996 and June 2002. Age, sex, duration of symptoms and hospitalization time, clinical presentation, etiology, underlying disease, bacteriology, treatment and complications were analyzed. Widening of the prevertebral soft tissue as seen on a plain film of the lateral neck was the most important diagnostic tool. Fever was the most common symptom (91.6%) and showed a high prevalence in adult populations (66.6%). Half of the cases were caused by ingestion of a foreign body. Nine cases underwent surgical drainage which was positive in eight cases (88.8%). Staph. aureus, K. pneumoniae and Enterobacter species were the predominant pathogens. Early diagnosis and appropriate use of antibiotics lessened morbidity. Only two cases had postoperative complications and both recovered.

Small vocal cord polyps: completely resolved with conservative treatment.

Vocal fold polyps usually occur on the anterior or middle part of the membranous vocal fold and are the commonest laryngeal pathology requiring surgical removal. We report on six cases of small vocal polyps (4 cases angiomatous polyps and 2 gelatinous) that completely resolved using conservative treatment. Not every case of polyps requires surgical removal.

Surgical emphysema following intraoral drainage of buccal space abscess.

The authors present a case of surgical emphysema following intraoral drainage of a buccal space abscess, a complication not previously reported. Surgical emphysema was remedied after removing a penrose drain and conservative treatment, suggesting retention of the drain caused the emphysema.

The masticator space infection.

The masticator space is an important suprahyoid tissue compartment. Infection of the masticator space can break through the fascia and involve the adjacent space. Severe complications including mediastinitis, pericarditis and death have been reported. The correct diagnosis and proper management are, therefore, crucial in order to reduce this complication. The authors reviewed 22 patients with masticator space infection between July 1996 and June 2001. All of the patients presented with trismus and 18 patients (81.8%) had a suspected dental cause of infection. Five patients had underlying disease; three were diabetic and two had human immunodeficiency virus (HIV) infection. High dosage intravenous antibiotics directed towards the causative microorganism were given to all of the patients. Fourteen patients underwent surgical drainage and surgical drain was positive in eleven patients (78.5%). Routine aerobic cultures were done on samples of the drained material. Bacteriology showed Streptococcus spp. the dominant microorganism in three patients, Pseudomonas spp. in one patient and no growth in ten patients. Blood culture grew Burholderia pseudomallei in one patient who responded to medical treatment. Three patients had post-operative complications but all recovered.

Otolaryngological complications of osteopetrosis.

Osteopetrosis is a rare inherited bone disease that affects both humans and various mammals. The authors report on two cases of osteopetrosis with otolaryngological complications. One patient had the childhood form and presented with chronic otitis media and brain abscess. The second patient had the adult form and presented with sinusitis from tooth extraction which developed into chronic osteomyelitis of the maxillary bone.

Botulinum toxin injection for objective tinnitus from palatal myoclonus: a case report.

Objective tinnitus may be caused by many etiologies-palatal myoclonus being one of them. We report one patient of voluntary palatal myoclonus presenting with objective tinnitus treated with botulinum toxin injection. Five units of botulinum toxin A were injected into each side of the soft palate at the palatal muscles (levator veli palatini and tensor veli palatini muscle). The tinnitus disappeared within two days of injection and no side effect was observed.

Clinical aspects of tonsillar tuberculosis.

A clinical analysis of 6 patients with pathologically confirmed tonsillar tuberculosis was carried out retrospectively. The subjects comprised three men and three women, ranging in age from 20 to 74 years. All of the patients presented with a sore throat and 5 had lymphadenopathy. Ulcerations, masses and white patches characterized the tonsillar lesions; the pathological findings included caseous granuloma with positive acid-fast bacilli (AFB) in 5 patients and chronic granulomatous inflammation with negative AFB in one patient. Four of the six patients had pulmonary tuberculosis. The three patients who received complete treatment responded well. The presenting symptoms and abnormal tonsillar findings associated with tonsillar tuberculosis are similar to those of malignant tumors and therefore it is difficult to differentiate the two pathologies; moreover, tonsillar tuberculosis often occurs with pulmonary tuberculosis and AIDS and therefore, a chest X-ray and HIV-screening are recommended for all patients with tonsillar tuberculosis.