Botulinum toxin injection in the treatment of vocal fold paralysis associated with multiple sclerosis: a case report.

Botulinum toxin has been demonstrated clinically to be an effective treatment for a variety of laryngeal problems, most notably spasmodic dysphonia. As in other movement disorders, the theory behind the injection of this substance in the larynx has been a weakening of the vocal fold musculature to relieve uncoordinated and spasmodic movement of the vocal folds, presumably rebalancing the forces within the intralaryngeal musculature. Recently, this concept was applied to help reposition the arytenoid cartilage in acute and longstanding anteromedial cricoarytenoid dislocations. This same concept may apply to the paralyzed vocal fold. In support of this idea, a number of investigators have shown that immobile, clinically paralyzed vocal folds may still have partial voluntary motor unit activity. This voluntary activation may not produce clinically evident movement but may be sufficient to produce tone within the fold. If the voluntary motor units in the abductor musculature of the paralyzed fold are weakened with botulinum toxin, the continued pull of the functioning adductor musculature may be sufficient to medialize the paralyzed fold. This idea has been supported by animal experiments, which have shown that botulinum toxin may affect the ability of the fold to rebalance itself. With this evidence in mind, a patient with fold immobility secondary to multiple sclerosis was treated in an attempt at laryngeal rebalancing, using botulinum toxin to medialize the fold. However, instead of simply having the fold return fixed to the midline, the patient regained normal laryngeal mobility and voice. While it is unclear whether the botulinum toxin alone was responsible, the coincidence of this occurrence certainly requires reporting. This paper is a report of the first successful treatment of vocal fold paralysis using botulinum toxin to treat vocal fold fixation in a patient with multiple sclerosis.

Bacteriologic findings from the nose, ethmoid, and bloodstream during endoscopic surgery for chronic rhinosinusitis: implications for antibiotic therapy.

This study addresses the bacterial flora of chronic rhinosinusitis at the time of endoscopic sinus surgery. We used the consensus definition of chronic rhinosinusitis as the presence of paranasal sinus inflammation present for greater than 12 weeks. In our patient study group, all cases of chronic rhinosinusitis had failed to respond to antibiotic therapy and had not been treated previously with surgery. By microscopic examination, chronic inflammatory changes were confirmed in the resected sinus lining of all study patients. Intraoperative cultures were obtained from the nasal vestibule, the middle meatus, ethmoid lining, and peripheral blood during and after the endoscopic procedure. We found approximately 30% of the patients with sterile sinuses, 50% with coagulase-negative staphylococci, and the remainder with a mixed group of "nonpathogenic" organisms. Anaerobes were conspicuously rare. The blood cultures were positive in 7% of cases and were consistent with an organism of the operative site. This is the first time bacteremia has been reported in association with endoscopic sinus surgery. The results suggest that chronic rhinosinusitis is not a bacterial disease, but rather the result of chronic inflammation produced by a previous acute inflammation. The incidence of positive blood cultures, while relatively low and cleared quickly, should alert the physician for the possible need for prophylactic antibiotics in patients with cardiac, prosthetic, or systemic conditions that could lead to metastatic infection.

Laryngeal rebalancing for the treatment of arytenoid dislocation.

In almost every type of functional laryngeal operation a successful result hinges on the surgeon's ability to control the muscular and ligamentous forces that act upon the vocal folds. Most of the time these forces are small in relation to the manipulations and resections performed. Occasionally, the forces are significant relative to the problem encountered, resulting in a failed surgery. Of all the many conditions that fit in to this latter description, perhaps the best example in arytenoid dislocation. Dislocation of the arytenoid is usually secondary to trauma with the majority of reported cases resulting from some type of anesthetic misadventure. Two types of dislocation have been described, anteromedial and posterolateral, each with a different mechanism of causation. This paper concerns itself with the more common anteromedial variety and its treatment using botulinum toxin.

An anatomic approach to local anesthesia for surgery of the nose and paranasal sinuses.

This is a review of the innervation of the midface and nose as a guide to anesthesia in this region. Through an understanding of the embryologic development, better predictions of nerve coverage are possible. The variables encountered during surgery can be appreciated, and in a practical sense this leads to anesthetic approaches that allow comfortable and controlled surgery in this area.

Use of laryngeal muscular tenotomy for bilateral midline vocal cord fixation.

As experience has increased in the treatment of bilateral vocal cord fixation, a significant and fundamental refinement in the concept of repair has evolved. By the use of selective tenotomy of the interarytenoid and thyroarytenoid muscles, the arytenoid and the vocal cord can be made to move away from the midline and thus open the glottis. This has allowed a drastic reduction in the amount of arytenoid that must be removed and prevents both aspiration and arthritis of the joint with subsequent stiffness. The procedure can be performed as an endoscopic or microscopic open procedure. All eight patients treated by this method have been decannulated by 6 weeks postoperation, have returned to full function, have not had aspiration, and have no worsening of their voices. The use of this concept and technique has led to a relatively safe and reliable method of rehabilitating patients with bilateral midline vocal cord paralysis.

Laryngeal liposarcoma.

Laryngeal liposarcomas are rare, with only 13 previously well-documented cases (to our knowledge). We report an additional case, which documents the use of computed tomography for treatment planning. Laryngeal liposarcomas appear to have a better prognosis than nonlaryngeal liposarcomas; therefore, a critical analysis of reported cases enabled us to identify clinical characteristics that contribute to the favorable prognosis. We also propose a rational therapeutic approach.

The clinical differentiation between vocal cord paralysis and vocal cord fixation using electromyography.

With newer techniques for laryngeal intervention, it becomes a practical necessity to understand whether an immobile cord is due to neurogenic dysfunction or cricoarytenoid fixation. An objective test for this differentiation is laryngeal electromyography, which can be done as an office procedure with a minimum of discomfort. Our experience in a clinical setting has shown laryngeal electromyography to be efficient in accurately assessing the neuromuscular status of the intrinsic laryngeal musculature.

Vocal cord injection techniques.

Injection techniques for the rehabilitation of paralytic dysphonia (e.g., Teflon) remain popular in the United States. This article presents a historical perspective of vocal cord paralysis, its work-up, and the indication, timing, techniques, and results of vocal cord injection.

A method for the treatment of abductor spasmodic dysphonia with botulinum toxin injections: a preliminary report.

A preliminary technical report of the effective treatment of abductor spasmodic dysphonia with botulinum toxin is presented. Our technique attempts to place the toxin close to the posterior cricoarytenoid muscle to allow diffusion of the material to the PCA. Our pilot study demonstrates that botulinum toxin is an effective approach for reducing or eliminating the abductor glottal spasms during phonation and, thereby, providing functional speech communication.

Studying whole-mounted sections of the paranasal sinuses to understand the complications of endoscopic sinus surgery.

Endoscopic techniques for paranasal sinus surgery have allowed detailed and complete removal of sinus disease while promising minimum distress to the patient. The telescopic view of the operative field shows detail of the sinus anatomy and its disease, not possible in earlier transnasal techniques. Several articles document the serious complications seen with the endoscopic surgery. To understand the paranasal sinuses and their relationships to the orbit and cribriform plate, blocks of cadaver heads that included the orbit and paranasal sinuses were whole sectioned. It has been possible to see areas of the cribriform and orbital wall that are at risk to produce cerebrospinal fluid rhinorrhea and orbital complications. At the same time, landmarks for avoiding these complications can be defined to guide the surgeon during this dissection as seen through the endoscope.

Endoscopic laryngeal surgery for bilateral midline vocal cord obstruction.

There are a number of treatment regimens for bilateral laryngeal paralysis, ranging from tracheostomy to external microscopic approaches. None has become the standard because of their unpredictable results and/or the need for an external approach. Recently, the use of micro-trapdoor flaps and suturing done via a laryngoscope has shown a possibility of correcting the airway problem, allowing a predictable result, with a completely endoscopic approach. This paper presents our experience with a group of 10 patients who had at least one treatment attempt that failed and were treated by endoscopic laryngoplasty. Eight have been decannulated.

The use of sialodochoplasty in the treatment of benign inflammatory obstructive submandibular gland disease.

One of the most common causes of submandibular gland enlargement is benign inflammatory disease. The usual cause is ductal outflow obstruction due to either a calculus or stenosis allowing stasis and retrograde movement of the saliva into the acinar structures leading to an inflammatory response and gland enlargement. Faced with a submandibular mass, a work-up that will rule out neoplastic causes of submandibular enlargement is instituted. This includes clinical assessment, probing of the gland, radiocontrast sialography, and CT scanning. The treatment should reflect the obstructive nature of the disease. Plastic reconstruction of the duct allows the removal of calculi, shortening of the duct, and enlargement of the outflow opening preventing recurrence and allowing healing of the gland. The procedure is performed intraorally as an outpatient, does not disrupt oral functioning, or subject the patient to the risks of gland removal or loss of that organ's function. Our experience with 27 patients over a 7-year period is presented with a detailed description of the technique and an analysis of the results. The procedure was successful in 22 of the 27 patients.

Anesthetic management for tracheobronchial laser surgery.

The use of the laser has become a well-recognized means of treating obstructing lesions of the tracheobronchial tree. Patients with lower airway compromise are in a precarious state of equilibrium. Everything done by the endoscopy-anesthesiology team tends to change this balance. Cooperation and coordination of this well-disciplined team is needed for efficient treatment of difficult cases. This paper outlines our surgical techniques, which have been tempered and modified to an anesthetic technique that provides the greatest safety with comfort. We detail the basic anesthetic methods for drug usage, pulmonary ventilation, and patient monitoring that we now use. A careful analysis of our results is presented to show that this technique does provide relatively safe anesthesia in this difficult setting.

Laser palliation for esophageal carcinoma.

The treatment of esophageal carcinoma presents itself or evolves into a palliative situation. The most likely symptom to distress the patient is obstruction. It is necessary to have available a means of alleviating this symptom in a way that will be effective, comfortable, and efficient in terms of time and expense. The Nd:YAG and the carbon dioxide lasers can give this type of palliation. This review of our experience in the cervical and lower two thirds of the esophagus has led us to believe that true palliation can be effected in both areas. Treatment is easier and more straight forward in the lower esophagus. The results in the upper one third require more care, but can be just as rewarding.

Jet insufflation anesthesia for endolaryngeal laser surgery: a review of 318 consecutive cases.

A series of 318 patients utilizing the jet insufflation technique for laser laryngeal anesthesia was studied. The technique utilizes a foil wrapped catheter placed below the vocal cords and attached to the Sanders ventilating adapter. Two pneumothoraces in children, one dental injury and one tube ignition were noted--all without permanent sequelae. Subsequent modification in technique prevented recurrence of these complications. The results indicate that this is a safe technique for laryngeal laser surgery, providing excellent visualization of the larynx while maintaining good oxygenation and airway control.

Flexible nontoxic fiberoptic delivery system for the carbon dioxide laser.

Presented is the first flexible, thin, nontoxic fiber to carry carbon dioxide laser energy. The physical characteristics of this fiber, examples of its use through a fiberoptic bronchoscope, and its features and applications are described.