Findings of multiple muscle involvement in a study of 214 patients with laryngeal dystonia using fine-wire electromyography.

Although perceptual and stroboscopic data help in diagnosing and classifying laryngeal dystonia, these measures do not aid the voice clinician in targeting which specific muscles to treat with botulinum toxin. Most patients achieve smoother, less effortful voicing with standard injection regimens. However, there is a notable failure rate. We performed fine-wire electromyography on 214 consecutive patients with laryngeal dystonia. We correlated voice ratings, stroboscopy data, and fine-wire electromyography data. Videostroboscopy was successful in visually demonstrating most of the audible findings in isolated vocal tremor, but it was much less successful in identifying breaks alone or a combination of breaks and tremor. Fine-wire electromyography revealed that the thyroarytenoid muscle was significantly more likely than the lateral cricoarytenoid muscle to be the predominant muscle associated with adductor spasmodic dysphonia, and that the thyroarytenoid and lateral cricoarytenoid muscles were equally likely to be predominantly involved in tremor spasmodic dysphonia. In addition, several patients in both the adductor spasmodic dysphonia and the tremor spasmodic dysphonia groups presented with interarytenoid muscle predominance. All of the intrinsic laryngeal muscles are capable of being the predominant muscle in laryngeal dystonia, and there are patterns of muscle abnormalities that differ between adductor spasmodic dysphonia and tremor spasmodic dysphonia. Some of the failures in treating adductor spasmodic dysphonia with botulinum toxin, and the greater difficulty with success in treating patients with tremor spasmodic dysphonia, are due to failure to deliver toxin to the appropriate muscles.

Treatment of the interarytenoid muscle with botulinum toxin for laryngeal dystonia.

The treatment of laryngeal dystonia with botulinum toxin has provided various degrees of relief to the majority of patients with adductor dysphonia; however, a significant number of patients have limited or no improvement with this type of therapy. It remains unclear why some patients respond to the routine administration of toxin to the thyroarytenoid muscles whereas others do not. Injections into the lateral cricoarytenoid muscles have provided an improved voice in some patients who were unresponsive to injections into the thyroarytenoid muscles. Fine-wire electromyography can demonstrate the particular dystonic activity of these muscles to help determine which muscle is predominantly involved. It can also demonstrate dramatic dystonic activity in the interarytenoid (IA) muscle in many patients. We present the results of 23 patients treated with injections to the IA muscle after demonstration of dystonic IA activity. Ten have benefited from IA therapy. Five of these 10 patients did not have a good result from botulinum toxin until IA injections were added to the treatment plan. In 8 patients, IA therapy provided no improvement, and 5 patients were lost to adequate follow-up. According to fine-wire electromyography and clinical response, the IA muscle is an active dystonic muscle in some patients with laryngeal dystonia and should be treated with botulinum toxin in selected patients.

Surgical management of posterior epistaxis: a changing paradigm.

OBJECTIVE: To demonstrate that surgery, as the initial treatment option for posterior epistaxis, can provide comparable success and complication rates to nonsurgical management with fewer associated costs. STUDY DESIGN: A retrospective chart review and cost analysis. METHODS: Two hundred three consecutive charts were reviewed for patient outcome, complications, and hospitalization time. Average costs were calculated from hospital department and physician fee schedules. RESULTS: Average success rate of all surgical procedures performed for posterior epistaxis was 90%, anterior-posterior packing success was 62%, and embolization success was 75%. The packing-only group had a significantly greater mean hospitalization time (5.29 d) than patients who were treated either surgically (2.1 d) or with embolization (2.6 d). The average per-patient admission charges were, for successful posterior packing, $5136 per patient; for surgical treatment, $3851 per patient; and for embolization, $5697 per patient. Surgery offered a cost savings of $1846 per patient over traditional packing. There was no significant difference in complication rates between the groups. CONCLUSION: The review suggests that a better success rate, a comparable complication rate, and a cost savings can be achieved with surgical intervention as the first-line treatment for intractable epistaxis when compared with traditional anterior-posterior packing and embolization.