Monte S. Keen

Supraglottic and Pharyngeal Sensory Abnormalities in Stroke Patients with Dysphagia

Dysphagia and aspiration are two devastating sequelae of stroke, accounting for nearly 40,000 deaths from aspiration pneumonia each year in the United States. While motor deficits in the larynx and pharynx are thought responsible for dysphagia and aspiration in stroke patients, no prior study has evaluated whether these patients also have sensory deficits. The aim of this study was to evaluate the sensory capacity of the laryngopharynx (LP) in supratentorial or brain stem stroke patients who presented with dysphagia. Fifteen stroke patients (mean age, 66.7 ± 13.8 [SD] years) were prospectively evaluated by means of our previously described method whereby air pulse stimuli were delivered via a flexible fiberoptic telescope to the mucosa innervated by the superior laryngeal nerve. There were 15 age-matched controls. No LP sensory deficits were found in any of the age-matched controls. In all stroke patients studied, either unilateral (n = 9) or bilateral (n=6) sensory deficits were identified. Deficits were defined as either a moderate impairment in sensory discrimination thresholds (3.5 to 6.0 mm Hg) or a severe sensory impairment (>6.0 mm Hg). These sensory discrimination thresholds were significantly greater than in age-matched controls (7.05 ± 0.17 mm Hg for the supratentorial group and 6.05 ± 1.22 mm Hg for the infratentorial group versus 2.61 ± 0.69 mm Hg for the controls). Among patients with unilateral deficits, sensory thresholds were moderately to severely elevated in all 9 cases on the affected side compared with the unaffected side (p < .01, Fishers exact test). Moreover, the sensory thresholds of the unaffected side were not significantly different from those of age-matched controls (2.51 ± 0.25 mm Hg versus 2.61 ± 0.69 mm Hg, respectively). All 6 patients with bilateral deficits had severe impairments. The results of an outcome assessment in 13 of 15 patients revealed that 2 out of 5 patients with moderate LP sensory impairment and 5 out of 8 with severe impairment developed aspiration. Our results show for the first time that stroke patients with dysphagia have significant sensory deficits in the LP and that these impairments are likely to contribute to the development of aspiration.

Botulinum toxin A for hyperkinetic facial lines : results of a double-blind, placebo-controlled study

Previous work on patients with muscular dystonia has shown that small intramuscular doses of botulinum toxin A eliminated hyperkinetic facial lines for approximately 6 months. The purpose of this study was to determine the efficacy of botulinum toxin A injections in eliminating facial wrinkles in aesthetic surgery patients who do not have muscular dystonia. Eleven healthy subjects were studied in a double-blind fashion. On both sides of the face, 0.2 cc of either normal saline or botulinum toxin A was injected into the forehead or into the periorbital wrinkles (crows feet). Documentation of results was made by photographs taken of the patients during repose and during facial animation before and after injection. Assessment of facial wrinkles was done from a grading system in which the patient and the facial plastic surgeon were asked to judge the severity of the wrinkles on a scale from 0 to 3, with 0 reflecting no facial wrinkles and 3 reflecting severe facial wrinkling. Nine of 11 subjects injected with botulinum toxin A noted a significant improvement in the severity of their facial wrinkles in comparison with the side of the face injected with saline, with a rating improvement of 2 points. Two of 11 subjects noted a moderate improvement, with a rating improvement of 1 point. No patient injected with saline reported an improvement in the severity of the facial wrinkles on the control side. There were no serious complications. Botulinum toxin A is an efficacious method of nonsurgically eliminating facial wrinkles and may play a role in the cosmetic enhancement of the aging face.

Age-Related Changes in Pharyngeal and Supraglottic Sensation

As one ages, sensory discrimination in the oral cavity progressively diminishes, and dysphagia and aspiration are more likely to occur. Whether similar age-related laryngeal and pharyngeal sensory abnormalities exist and contribute to dysphagia and aspiration is unknown. The purpose of this study was to determine if sensory discrimination in the area innervated by the superior laryngeal nerve diminishes with increasing age. By applying a previously described new device and technique that utilizes brief air pulse stimulation of the anterior wall of the pyriform sinus, sensory discrimination can be reliably determined. We carried out 672 trials in 56 healthy adults divided into three age groups: 20 to 40, 41 to 60, and 61 to 90 years of age. Overall, the average sensory discrimination was 2.30 ± 0.50 mm Hg. In subjects 20 to 40 years of age, sensory discrimination was 2.07 ± 0.20 mm Hg, while in subjects 61 to 90 years of age, sensory discrimination was 2.68 ± 0.63 mm Hg (p < .05). There also was a statistically significant difference between the 41- to 60-year and 61- to 90-year age groups (p < .05). Progressive diminution in pharyngeal and supraglottic sensitivity with increasing age might be a contributing factor in the development of dysphagia and aspiration in the elderly.

Air pulse quantification of supraglottic and pharyngeal sensation : a new technique

There are no published studies evaluating the sensory capacity of the region innervated by the superior laryngeal nerve. A normal sensory capacity is important in this area, since hypesthesia or anesthesia of the pharynx and supraglottic larynx may result in dysphagia and aspiration. This often occurs after stroke or after ablative surgery of the pharynx and larynx. Evaluating the efficacy of restorative procedures for supraglottic and pharyngeal sensation is dependent on defining and quantifying the sensory deficit. We have developed a new, noninvasive method to measure sensation in the pharynx and supraglottic larynx. A puff of air—of precisely controlled duration and pressure—was delivered via a flexible telescope to the anterior wall of the pyriform sinus. Surface sensibility was determined according to the psychophysical method of limits by varying air pressure while holding puff duration constant. We conducted 204 trials in 20 healthy adults. The average sensory discrimination threshold was 2.09 ± 0.15 mm Hg. An intraclass correlation revealed excellent consistency (R̂ = .80). There was no statistically significant difference between the right and left sides. Brief air pulse stimulation is an easy, relatively safe, and reliable method of determining supraglottic and pharyngeal sensory discrimination thresholds.

Pseudotumor of the larynx--an unusual cause of airway obstruction.

Upper airway obstruction from a subglottic mass is not common. I The differential diagnosis of subglottic masses in children includes subglottic hemangioma. respiratory papilloma. lymphangioma. chondroma. tracheal webs. subglottic stenosis. and tracheomalacia. I At least two authors have stated that malignant tumors in this region are quite rare. 1.2 This article describes the first reported case of an inflammatory pseudotumor of the subglottis that mimicked a laryngeal neoplasm by presenting with upper airway obstruction and that was amenable to surgical excision. The diagnostic workup. the surgical management, and a review of the pertinent recent literature are included.

Control of epistaxis in the multiple trauma patient

Severe epistaxis in the multiple trauma victim can be rapidly controlled with immediate insertion of the intranasal anteroposterior balloon. The patients other life threatening injuries can then be assessed in an orderly fashion. Once the patient has been stabilized, the balloon can be deflated and removed and the patients maxillofacial injuries assessed and treated in a controlled setting.