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Botulinum toxin treatment for laryngeal dystonia - PowerPoint - PowerPoint

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Botulinum toxin treatment for laryngeal dystonia - PowerPoint - PowerPoint Powered By Docstoc
					Botulinum toxin treatment
 for laryngeal dystonia
     Dr. Jens-Øyvind Loven
  ØNH avd. Lovisenberg sykehus



                                 1
              Dystonia

¥ Dystonia is a condition characterized
  by involontary muscle contractions

¥ Dystonia can involve any volontary
  muscle



                                       2
              Dystonia
A)Focal
¥ blepharospasm
¥ laryngeal dystonia,torticollis
¥ 90% ideopatic,dysfunction in basal gangl?

B)Segmental
 Meige Syndrom

C) Generalized
                                          3
         Classification-
       Laryngeal dystonia
¥ Adductor laryngeal dystonia
¥ Traube 1871

¥ -The vocal folds hyperadducts during
  phonation resulting in a hoarse, jerky,
  groanning voice with pitch breaks

¥ 80-90%
                                            4
         Classification-
       Laryngeal dystonia
¥ Abductor laryngeal dystonia
¥ Aronson 1968

¥ -Intermittent abduction of the vocal folds
  resulting in a whispering voice with
  aphonic segments of speech



                                               5
         Classification-
       Laryngeal dystonia
¥ Compensatory adductor dystonia
¥ Compensatory abductor dystonia
¥ Blitzer/Brin


¥ Mixed dystonia
¥ Adductor breathing dystonia
¥ Supraglottic dystonia
                                   6
   Dystonia-Classification
¥ a) Primary / ideopatic dyatonia

¥ b) Secondary / symtomatic dystonia
  ( Parkinson, Huntington, Tumor
    cerebri, Toxic, Postinfectious



                                       7
          Epidemiology
¥ Rochester, Minnesota ( Nutt 1988)

¥ Total 400 pr. million

¥ Focal dystonia :    300 pr. million
¥ Laryngeal dystonia: 50 pr. million

                                        8
        Spasmodic dysphonia-
              History
¥ Traube       1871 Òspastic dysphoniaÓ
¥ Schnitzler   1895 Òspastic aphoniaÓ
¥ Gowers       1899 Òphonic paralysisÓ

¥ Aronson      1968 Òadductor dystonia
   ı                Òabductor dystonia




                                          9
          Laryngeal dystonia/
              Treatment
¥   Speech therapy
¥   Psychotherapy
¥   Acupuncture
¥   Hypnosis
¥   Pharmacotherapy




                                10
   Treatment/ laryngeal dystonia

¥ Surgery

¥ Unilateral recurrent laryngeal nerve
  section

¥ 60-70% of the patients had recurrency of
  spasmodic dysphonia within 3 years


                                             11
        Botulinum toxin-History

¥ Elezelles, Belgum
¥ 3 died after eating raw, salted ham
  (neuroparalytic syndrom)

¥ Prof. E. van Ermegen
¥ Bacillus botulinus-Clostrideum botulinum

¥ 1979 Alan Scott : ÒBotulinum toxin injectionof eye
  muscles to corret strabismusÓ

                                                       12
               Botulinum toxin/
                Pharmacology
¥ Botulinum toxin acts presynaptically at the
  nerve terminals by inhibiting release of acetyl-
  cholin

¥ Chemical denervation - paralysis after 24-72
  hours

¥ Scott 1979


                                                     13
            Botulinum toxin

¥ The bacteria Clostridium botulinum
  produces eight serologically distinct
  toxins: A, B, C1, C2, D, E, F, G

¥ Potent neuroparalytic agent

¥ One Unit: LD 50 Swiss Webster mice


                                          14
             Botulinum toxin-
               Indications

¥   Strabismus               TICS
¥   Hemifacial spasm         Voice tremor
¥   Cervical dystonia        Head tremor
¥   Laryngeal dystonia       Spasticity
¥   Writers cramp            Blepharospasm
¥   Stuttering               Cosmetic
¥   Oromandibular dystonia


                                             15
   Laryngeal dystonia 1991-2002

¥ 90 patients      55 women (61%)
                   35 men   (39%)

¥ Age yr           25-86 mean 49 yr

¥ Age symtom onset 17-80 mean 45 yr



                                      16
   Laryngeal dystonia 1991-2002

¥ Laryng. adductor dystonia   78 (86%)
¥ Ò       abductor    Ò       6
¥ Adductor breathing Ò         4
¥ Supraglottic        Ò       2

¥ Total                       90 patients




                                            17
               Diagnosis

¥ Videostroboscopy of the larynx

¥ Voice analysis and recording of speech
  therapists at the National Center of
  logopedics, Oslo

¥ Neurological examination- CT scan


                                           18
         Injection Technique-
          adductor laryngeal dystonia/
          adductor breathing dystonia

¥ - Hollow, teflon-coated injection needle
  - Cricothyroid membran
  - Monopolar EMG

  - 1,25-2,5 U Botox bilaterally m. vocalis




                                              19
          Injection Technique-
        Laryngeal abductor dystonia

¥ Blitzer/ Brin:

¥ Botulinum toxin inj. of the posterior
  cricoarytenoid muscle




                                          20
           Speech dysfunction-
            preceding events
¥   No history      39
¥   Stress          40
¥   Soare throat    8
¥   Surgery         2
¥   Head trauma     1

¥ Total             90 patients


                                  21
                   Results-
          Adductor laryngeal dystonia
¥ Excellent results                 49 (61%)
  (80-100% of normal voice)
¥ Improved voice                    24 (33%)
¥ No voice improvement              5 (6%)

¥ Total                             78 patients

¥ 0%= total disability 100%= normal voice



                                                  22
             Results-
    Abductor laryngeal dystonia
¥ Excellent result       1
¥ Voice improvement      2
¥ No voice improvement   3

¥ Total                  6 patients




                                      23
             Results-
    Adductor breathing dystonia
¥ Excellent results              3
¥ Improvement                    1

¥ Total                          4 patients

¥ 2,5 U Botox inj. m. vocalis bilat



                                              24
     Adductor laryngeal dystonia-
    duration of voice improvement:
¥ -6 weeks - 132 months ( mean 3,5 months)

¥ Spontaneous remission of symptoms:
  6 patients




                                         25
             Adverse effects


¥Breathy voice 1-6 weeks after Botox
injections ( mean 12 days)

¥Mild sensation of dysphagia first
    week after Botox treatment



                                       26
    Neurologic Aspects-Excellent voice
    quality after Botox treatment (n=49)
¥   Laryngeal tremor          2
¥   Limb tremor               1
¥   Abnormal cerebral CT      1
¥   Blepharospasm             1

¥ Total                      5 (9%)
¥ Mean age of symptom onset (yr) 41
                                 (17-66)
                                           27
  Neurologic Aspects-Improved
voice after Botox treatment (n=22)
¥ Laryngeal tremor               17
¥ Oromandibular dystonia         2
¥ Blepharospasm                  1

¥ Total                           20 (90%)
¥ Mean age of symptom onset (yr): 67
                                 (37-80)


                                           28
               Conclusions

¥ Focal laryngeal dystonia without
  neurological disturbances:

¥ Excellent response to botulinum toxin
  treatment (80-100% of normal voice)

¥ Middle age


                                          29
              Conclusion

¥ Laryngeal dystonia assosiated with other
  neurological disturbances:

 Improved but not normal voice after
 botulinum toxin treatment

 > 60 yr


                                             30
                Conclusions

¥ Adductor breathing dystonia
 (paradoxical movements of vocal folds):



 Excellent results




                                           31
               Conclusions

¥ Abductor laryngeal dystonia:

¥ -difficult to diagnose
¥ -difficult treatment

¥ -mixed add-abductor dystonia ?



                                   32
 Unilateral injection of botulinum toxin in
          spasmodic dysphonia

¥ Ludlow C, Donovan D, Ford CN




                                              33

				
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