James Paul Dworkin

Botulinum Toxin Injection of the Cricopharyngeus Muscle for the Treatment of Dysphagia

OBJECTIVE: This study was conducted to evaluate, subjectively and objectively, the diagnostic and therapeutic effects of botulinum toxin (Botox) in patients with dysphagia caused by cricopharyngeus (CP) muscle spasm and/or hypertonicity. METHODS: A retrospective chart review was done of 5 patients with normally functioning larynges treated with CP Botox injection for dysphagia caused by perceived spasm. Subjective measures of swallowing function after injection were obtained with a patient questionnaire. Objective data were obtained both before and after surgery by one or more of the following tests: modified barium swallow study, manometry, videostroboscopy, and fiberoptic endoscopic evaluation of swallowing. Quality-of-life measures were obtained with a swallowing rating scale. RESULTS: Overall, all patients had initial improvement in swallowing after Botox injection. The duration of benefit was from 2 to 14 months. There were no complications. Four of 5 patients had long-term benefits, as evidenced by decreased or eliminated aspiration symptoms, removal of tracheotomy, ability to eat solid foods, and weight gain. One patient continues to have poor swallowing function. CONCLUSION: Botox injection of the CP muscle to treat dysphagia is effective in patients with underlying muscle spasm or hypertonicity. A positive response to Botox can also help confirm the diagnosis of CP muscle spasm.

Cymetra injection for unilateral vocal fold paralysis.

Cymetra has shown excellent tissue biocompatibility, a low rate of resorption, and no tissue reactivity when injected for treatment of facial wrinkling. On the basis of these findings, we hypothesize that injection of Cymetra into the thyroarytenoid muscle for treatment of glottal incompetence may demonstrate similar findings and lead to long-term improvement in voice quality and glottal gap closure. Ten patients with breathy dysphonia caused by unilateral vocal fold paralysis underwent transoral injection of Cymetra into the thyroarytenoid muscle. Each subject underwent preoperative and postoperative acoustic analysis, aerodynamic measures, taped voice sampling, and videostroboscopy. Significant improvements were identified in maximum phonation time, relative glottal area, and subjective judgment of glottal competency. These results were not maintained at the 3-month study interval. No significant change in quantitative or subjective voice quality was noted for the study group during the investigation. Resorption of Cymetra may play a significant role in contributing to these findings.

Functional Outcomes After Supracricoid Laryngectomy

Objectives Local control and 5‐year survival rates are similar for patients undergoing total laryngectomy and supracricoid laryngectomy for the treatment of advanced‐stage laryngeal carcinoma. However, comprehensive studies of functional outcomes after supracricoid laryngectomy are lacking.

Objective evaluation of the quality of voice following radiation therapy for T1 glottic cancer

BACKGROUND Radiation therapy is commonly considered the treatment of choice for T1 glottic cancer. While it is generally believed that the quality of voice following irradiation is quite satisfactory, few studies have reported the results of objective assessment of voice after radiation therapy. PURPOSE To objectively evaluate the quality of voice following radiation therapy for T1 glottic cancer. MATERIALS AND METHODS The voices of 12 patients treated for T1 glottic cancer with radiation therapy were evaluated by acoustic analysis and speech aerodynamic studies. Eleven patients received between 6300 and 6665 cGy at a daily fraction size of 180-225 cGy. One patient received 7000 cGy at a daily fraction size of 200 cGy. Evaluation of the quality of voice was done 3 months to 7 years following completion of radiation therapy. RESULTS The number of patients who scored abnormal values for the measurements of fundamental frequency, jitter, shimmer and harmonic to noise ratio was 2, 10, 4 and 3, respectively. The number of patients who scored abnormal values for transglottic airflow rate, subglottal pressure and glottal resistance was 12, 8 and 9, respectively. None of the studied patients scored normal values in all given tests. CONCLUSION Although radiation therapy cures a high proportion of patients with T1 glottic cancer, the quality of voice does not return to normal following treatment.

Botulinum toxin injection to improve tracheoesophageal speech after total laryngectomy

Total laryngectomy patients, after undergoing a tracheoesophageal puncture (TEP), may have poor TEP speech because of hypertonicity or spasm of the pharyngoesophageal segment (PES). Conventional treatment options include speech therapy, PES dilation, pharyngeal neurectomy, and myotomy. Botulinum toxin injection into the PES has recently been reported to be effective for this disorder. However, data accumulated were based primarily on subjective analyses. This prospective investigation used both qualitative and quantitative measures to assess the effects of videofluoroscopy-guided botulinum toxin injection on TEP voice quality in laryngectomees with PES dysfunction. Patients underwent voice analyses, tracheal air pressure measures, and barium swallows before and after botulinum toxin injection. Seven of 8 patients had significant voice quality improvement, and tracheal air pressures normalized in 6 of 8 patients after injection. Videofluoroscopic botulinum toxin injection into the PES is efficacious, safe, and cost-effective and should be considered as a first-line therapy for the treatment of laryngectomees with poor quality TEP speech caused by PES dysfunction.

Laryngitis: types, causes, and treatments.

Inflammatory processes that affect the unified airway can concurrently exert significant influence on the larynx and surrounding mucosal surfaces. Laryngeal inflammation can be present secondary to direct effects of irritants, toxins, and antigens, but can also involve mechanical and infectious effects as well as secondary inflammation from behavioral mechanisms. This review examines laryngeal inflammation in the context of the unified airway and discusses pathophysiologic mechanisms that are central to the development of acute and chronic laryngitis.

Swallowing Function Outcomes Following Nonsurgical Therapy for Advanced-Stage Laryngeal Carcinoma

The purposes of this study were to (1) evaluate swallowing function using both subjective and objective measures in patients treated nonsurgically for stages III and IV laryngeal squamous cell carcinoma, (2) assess the effect of time from treatment completion on swallowing function, and (3) assess sequelae associated with modality of treatment. To achieve these objectives, a retrospective study of 14 patients was conducted. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed and evaluated by three independent judges for seven functional criteria: standing secretions, valleculae spillage, valleculae residue, postcricoid residue, laryngeal penetration, aspiration, and cough. Patient interviews were performed to establish patient perception of swallowing and his/her current posttreatment diet. Results revealed that each patient exhibited swallowing abnormalities in at least one of the seven objective functional categories studied. Ten patients suffered from variable degrees of dysphagia, ranging from mild to severe, on all measures. No significant differences were noted between those patients with less than or greater than 12 months posttreatment. Common treatment sequelae included PEG tube placement for nutritional supplementation, tracheostomy placement for airway security and/or pulmonary toilet, repeated episodes of aspiration pneumonia requiring hospital admission, and radiation-induced oropharyngeal stricture. Further studies using subjective and objective swallowing function measures for patients treated with alternative chemoradiation regimens versus surgery (with or without adjuvant therapies) for advanced stage laryngeal cancer are needed.

Functional Outcomes Following Nonsurgical Treatment for Advanced-Stage Laryngeal Carcinoma†

Objectives Objectives were 1) to provide comprehensive evaluations of functional outcomes using perceptual and objective measures of patients treated nonsurgically for stages III and IV laryngeal squamous cell carcinoma and 2) to propose a standard battery of tests that can be used for appraising functional outcomes in this patient population.

Muscle tension dysphonia

The scarcity of published papers on muscle tension dysphonia has required that this literature review span a period of many years to yield useful information. Two primary sections are included, focusing on differential diagnosis of and therapy for this disorder. The authors complete the discussion with reference to the recently reported treatment approach that they have developed.

Voice and Deglutition Functions after the Supracricoid and Total Laryngectomy Procedures for Advanced Stage Laryngeal Carcinoma

OBJECTIVES This investigation compared speech and deglutition functions after alternative surgical treatments for advanced stage laryngeal carcinoma: the supracricoid laryngectomy (SCL) versus the total laryngectomy (TL). Study design and setting Cohort investigation at Wayne State University School of Medicine. METHODS Quantitative studies of laryngeal biomechanics, acoustic and speech aerodynamic features, and deglutition skills of these individuals were coupled to listener and patient self-impressions of speech and voice characteristics for group comparative analyses. RESULTS Results revealed that patients from each subgroup performed comparably relative to speech intelligibility and voice quality disturbances. Videostroboscopy of the neoglottal mechanisms in these two populations helped to explain these outcomes. Acoustic and speech aerodynamic testing demonstrated variably abnormal features in both surgical subgroups. Whereas the SCL patients eventually achieved full oral diets, they required many sessions of swallowing therapy to obtain this objective and eliminate tube feeding supplementation. The TL patients did not evidence protracted swallowing difficulties or the need for specific exercises in order to remove their feeding tubes postoperatively. References to organ preservation strategies in lieu of surgical management are included for completeness purposes. CONCLUSIONS The SCL and TL surgical procedures for advanced stage laryngeal carcinoma resulted in equivalent speech and swallowing functional outcomes.