Stephen F. Bansberg

Relationship of the Optic Nerve to the Paranasal Sinuses as Shown by Computed Tomography

Restricted exposure and inconsistencies in sinus pneumatization place the optic nerve at risk during operations on the sphenoid sinus and posterior ethmoid cells. In this study, computed tomography was used to examine these relationships. We reviewed 80 patients who underwent high-resolution computed tomographic scanning for ophthalmologic complaints in which the scan was negative. Forty-eight percent of posterior ethmoid cells are separated from the optic nerve by the thin bony lamina of the optic canal. Nearly 90% of sphenoid sinuses contact the ipsilateral optic nerve and 10% contact both nerves. Eight percent of posterior ethmoid cells override the ipsilateral sphenoid sinus and contact the optic nerve on that side. Paraxial reformatted displays allowed estimation of the degree of projection of the optic nerve into adjacent sinus cavities. Three percent of optic nerves have significant projection into the posterior ethmoid cell, and 23% project significantly into the sphenoid sinus. The width of the bony plate that separates the optic nerve from the sinus cavity was the same for sphenoid and ethmoid sinuses. Although sinus pneumatization varies among individuals, right and left sides are generally similar within one person.

Safety and efficacy of botulinum toxin type B (Myobloc) in adductor spasmodic dysphonia

This single‐site, open‐label, dose‐finding study evaluated the safety and efficacy of botulinum toxin type B (BoNT‐B; Myobloc) for the treatment of adductor spasmodic dysphonia (AdSD) in 13 patients. Three patients received a total of 50 U (25 U per vocal fold); the same three subsequently received 100 U, and then 10 more received 200 U. The primary measure of efficacy was the patients rating of the change in the severity of spasms on a scale from −3 to +3. There were seven secondary measures of efficacy, including blinded ratings of the sound of voice recorded on audiotape. At Week 8 after injection, spasms improved in 0 of 3 patients who received 50 U, 1 of 3 patients who received 100 U, and 8 of 10 patients who received 200 U. The mean (± standard deviation [SD]) score for the change in spasm severity at Week 8 in the 200 U group was 1.4 (±1.2) points (P = 0.004). All seven secondary measures also showed improvement. Breathiness was the most common side effect but was mild in intensity and of short duration. We conclude that BoNT‐B is safe and effective for the treatment of adductor spasmodic dysphonia.

Operative time and cost of resident surgical experience: Effect of instituting an otolaryngology residency program

Objective Describe the procedure length difference between surgeries performed by an attending surgeon alone compared with the resident surgeon supervised by the same attending surgeon. Study Design Case series with chart review. Setting Tertiary care center and residency program. Subjects and Methods Six common otolaryngologic procedures performed between August 1994 and May 2012 were divided into 2 cohorts: attending surgeon alone or resident surgeon. This division coincided with our July 2006 initiation of an otolaryngology–head and neck surgery residency program. Operative duration was compared between cohorts with confounding factors controlled. In addition, the direct result of increased surgical length on operating room cost was calculated and applied to departmental and published resident case log report data. Results Five of the 6 procedures evaluated showed a statistically significant increase in surgery length with resident involvement. Operative time increased 6.8 minutes for a cricopharyngeal myotomy (P = .0097), 11.3 minutes for a tonsillectomy (P < .0001), 27.4 minutes for a parotidectomy (P = .028), 38.3 minutes for a septoplasty (P < .0001), and 51 minutes for tympanomastoidectomy (P < .0021). Thyroidectomy showed no operative time difference. Cost of increased surgical time was calculated per surgery and ranged from

The Mayo Clinic Arizona Spasmodic Dysphonia Experience: A Demographic Analysis of 718 Patients.

286 (cricopharyngeal myotomy) to

The effect of systemic triamcinolone acetonide on nerve repair.

2142 (mastoidectomy). When applied to reported national case log averages for graduating residents, this resulted in a significant increase of direct training-related costs. Conclusion Resident participation in the operating room results in increased surgical length and additional system cost. Although residency is a necessary part of surgical training, associated costs need to be acknowledged.

Consensus-Based Attributes for Identifying Patients With Spasmodic Dysphonia and Other Voice Disorders

Objective: Analyze demographic data collected over a 25-year experience of 718 patients with spasmodic dysphonia (SD) who have been treated with botulinum toxin-A (BoNT-A) and compare our data with previously published studies. Methods: Seven hundred eighteen patients with SD were treated with 6621 BoNT-A injections at Mayo Clinic Arizona between 1989 and 2014. All patients were treated by the same physician team. Background demographic data for each patient were recorded. Results: Of 718 patients, 557 patients were female (77.6%). Six hundred sixty of 718 (91.8%) patients had adductor SD (AdSD), and 58 of 718 (8.1%) patients had abductor SD (AbSD). Average age of onset was 51 years. Of 718 patients, 378 (52.6%) had vocal tremor (VT); VT was present in 54.4% of AdSD patients and 32.1% of AbSD patients. Thirty-seven of 718 (5.2%) patients had other dystonias, including cervical dystonia (2.3%), blepharospasm (1.4%), limb dystonia (1.1%), and oromandibular dystonia (0.3%). A positive family history of SD was present in only 6 of 718 patients (0.8%) and of other dystonias in 11 of 718 patients (1.5%). Conclusions: Spasmodic dysphonia is a chronic and potentially disabling focal laryngeal dystonia. The Mayo Clinic Arizona SD experience compares to prior reports and reveals a female preponderance, onset in middle age, infrequent hereditary pattern, high co-occurrence of VT, and low co-occurrence of other dystonias.

Spasmodic Dysphonia: A Review. Part 2: Characterization of Pathophysiology

The effects of timed-release pellets of triamcinolone acetonide on sciatic nerve regeneration were studied. Bilateral nerve defects were created in 18 rats. One defect was sutured primarily, while the contralateral side was grafted with a 1 cm autogenous graft. Nerve regeneration was assessed at 20 weeks by muscle-twitch strength and compound action potential parameters measured proximal and distal to the repair site. Conduction velocity and regenerative index (ratio of distal to proximal compound action potential area) were calculated. Significant improvement of the regenerative index and twitch strength occurred in animals treated with a 0.5 mg 21-day-release pellet. Improvement occurred in animals treated with 0.5 mg 60-day pellets, but the difference was not significant. The findings suggest that regeneration was enhanced as a result of increased numbers of axons that made distal connections in the animals that received 21-day-release triamcinolone systemically. Corticosteroid therapy may benefit motor nerve repair.

Spasmodic Dysphonia: A Review. Part 1: Pathogenic Factors

Importance A roadblock for research on adductor spasmodic dysphonia (ADSD), abductor SD (ABSD), voice tremor (VT), and muscular tension dysphonia (MTD) is the lack of criteria for selecting patients with these disorders. Objective To determine the agreement among experts not using standard guidelines to classify patients with ABSD, ADSD, VT, and MTD, and develop expert consensus attributes for classifying patients for research. Design, Setting and Participants From 2011 to 2016, a multicenter observational study examined agreement among blinded experts when classifying patients with ADSD, ABSD, VT or MTD (first study). Subsequently, a 4-stage Delphi method study used reiterative stages of review by an expert panel and 46 community experts to develop consensus on attributes to be used for classifying patients with the 4 disorders (second study). The study used a convenience sample of 178 patients clinically diagnosed with ADSD, ABSD, VT MTD, vocal fold paresis/paralysis, psychogenic voice disorders, or hypophonia secondary to Parkinson disease. Participants were aged 18 years or older, without laryngeal structural disease or surgery for ADSD and underwent speech and nasolaryngoscopy video recordings following a standard protocol. Exposures Speech and nasolaryngoscopy video recordings following a standard protocol. Main Outcomes and Measures Specialists at 4 sites classified 178 patients into 11 categories. Four international experts independently classified 75 patients using the same categories without guidelines after viewing speech and nasolaryngoscopy video recordings. Each member from the 4 sites also classified 50 patients from other sites after viewing video clips of voice/laryngeal tasks. Interrater &kgr; less than 0.40 indicated poor classification agreement among rater pairs and across recruiting sites. Consequently, a Delphi panel of 13 experts identified and ranked speech and laryngeal movement attributes for classifying ADSD, ABSD, VT, and MTD, which were reviewed by 46 community specialists. Based on the median attribute rankings, a final attribute list was created for each disorder. Results When classifying patients without guidelines, raters differed in their classification distributions (likelihood ratio, &khgr;2 = 107.66), had poor interrater agreement, and poor agreement with site categories. For 11 categories, the highest agreement was 34%, with no &kgr; values greater than 0.26. In external rater pairs, the highest &kgr; was 0.23 and the highest agreement was 38.5%. Using 6 categories, the highest percent agreement was 73.3% and the highest &kgr; was 0.40. The Delphi method yielded 18 attributes for classifying disorders from speech and nasolaryngoscopic examinations. Conclusions and Relevance Specialists without guidelines had poor agreement when classifying patients for research, leading to a Delphi-based development of the Spasmodic Dysphonia Attributes Inventory for classifying patients with ADSD, ABSD, VT, and MTD for research.

The Mayo Clinic Spasmodic Dysphonia Experience: A Demographic Analysis of 686 Patients

Objective The purpose of this review is to describe the recent advances in characterizing spasmodic dysphonia. Spasmodic dysphonia is a task-specific focal laryngeal dystonia characterized by irregular and uncontrolled voice breaks. The pathophysiology is poorly understood, and there are diagnostic difficulties. Data Sources PubMed, Google Scholar, and Cochrane Library. Review Methods The data sources were searched using the following search terms: (spasmodic dysphonia or laryngeal dystonia) and (etiology, aetiology, diagnosis, pathogenesis, or pathophysiology). Conclusion The diagnosis of spasmodic dysphonia can be difficult due to the lack of a scientific consensus on diagnostic criteria and the fact that other voice disorders may present similarly. Confusion can arise between spasmodic dysphonia and muscle tension dysphonia. Spasmodic dysphonia symptoms are tied to particular speech sounds, whereas muscle tension dysphonia is not. With the advent of more widespread use of high-speed laryngoscopy and videokymography, measures of the disruptions in phonation and delays in the onset of vocal fold vibration after vocal fold closure can be quantified. Recent technological developments have expanded our understanding of the pathophysiology of spasmodic dysphonia. Implications for Practice A 3-tiered approach, involving a questionnaire, followed by speech assessment and nasolaryngoscopy is the most widely accepted method for making the diagnosis in most cases. More experimental and invasive techniques such as electromyography and neuroimaging have been explored to further characterize spasmodic dysphonia and aid in diagnosing difficult cases.

Botulinum Toxin Type A for Treating Voice Tremor

Objective The purpose of this review is to describe the recent advances in identifying possible factors involved in the pathogenesis of spasmodic dysphonia. Spasmodic dysphonia is a task-specific focal laryngeal dystonia characterized by irregular and uncontrolled voice breaks. Pathogenesis of the disorder is poorly understood. Data Sources PubMed, Google Scholar, and Cochrane Library. Review Methods The data sources were searched using the following search terms: (spasmodic dysphonia or laryngeal dystonia) and (etiology, aetiology, diagnosis, pathogenesis, or pathophysiology). Conclusions Several potential etiological factors have been proposed by epidemiological, genetic, and neuropathological studies. Spasmodic dysphonia is a rare disorder primarily affecting females beginning in their 40s. Vocal tremor co-occurs in 30% to 60%. Large cohort studies identified risk factors such as a family history of neurological disorders including dystonia and tremor, recent viral illness, and heavy voice use. As none are rare events, a complex interactive process may contribute to pathogenesis in a small proportion of those at risk. Consequences to pathogenesis are neurological processes found in spasmodic dysphonia: loss of cortical inhibition, sensory processing disturbances, and neuroanatomical and physiological differences in the laryngeal motor control system. Implications for Practice Diagnosis of spasmodic dysphonia usually includes speech and laryngoscopic assessment. However, as diagnosis is sometimes problematic, measurement of neurophysiological abnormalities may contribute useful adjuncts for the diagnosis of spasmodic dysphonia in the future.