Transcript 120723-m_baxter-botox-and

The Otolaryngologic Uses of
Botox
Malcolm Baxter FRACS
Botox
Clostridium botulinum toxin
7 Serotypes -ABCDEFG
Type A used Botox (Allergan)
Dysport
Neurotoxin-paralyses neuromuscular
transmission by binding ACh
Mouse units
Botox cont.
Now widely used for muscle spasms and spasticity:
Laryngeal Conditions
Blepharospasm
Hemifacial Spasm
Spasmodic Torticollis
Palatal Myoclonus
Frey’s Syndrome
Failed TOP Speech Post Laryngectomy
Drooling (intraparotid )
Achalasia
Cerebral Palsy Patient Limbs
Cosmetic
Laryngologic Uses of Botox
• Spasmodic Dysphonia-Adductor &Abductor
Types
• Laryngeal Tremor
• Muscle Tension Dysphonia –unresponsive to SP
and local physio techniques
• Refractory Laryngeal Granulomata
• Cricopharyngeal Spasm –intact larynx and postlaryngectomy
• CA Joint Dislocation/Relocation
• Vocal Cord Dysfunction (PVFM)
Botox cont.
Side Effects
Effects of overweakening-depends on
location
Abs produced-Anaphylaxis
theoretically possible but not in
practice
? No Deaths
Laryngeal Botox for SD in
Melbourne
• RVEEH 1992-2008 Baxter,Hughes & Oates
Continues as private clinics
• MMC Monash Neurolaryngology Clinic
2010- Baxter & Raghav
SPASMODIC DYSPHONIA
Action induced laryngeal motion
disorder resulting in a dysphonia
characterised by spasms in phonation
Spasmodic Dysphonia
Classified as Focal Dystonia (class of
movement disorder)
These are task specific movement
disorders involving a few muscles
(laryngeal in this case)
Other examples are: Spasmodic
Torticollis, Writers Cramp,
Hemifacial Spasm, Blepharospasm,
Meige’s syndrome-orofacial dystonia
Aetiology of SD
Unknown
Genetic Probable in some cases
??Stress
??Infective
PM Studies-unhelpful with varying
findings, eg basal ganglia
SD-2 Types
ADDuctor SD >90% -strained and
strangled voice due to spasmodic
interruptions to fluency
(Thyroarytenoid-vocalis)
ABDuctor SD <10% -breathy
interruptions to fluency (PCA)
Spasmodic Dysphonia
F>M about 2:1
Onset any age (Satalhoff ave 62)
Many patients relate to some
traumatic or stressful event
Diagnosis of SD
Typical Phonation
Demonstrated Spasms on Video
during connected speech
Lack of response to other treatment
(espec. ST)
EMG ??
Must exclude other neurological
disease
Differential Diagnosis
Laryngeal Tremor
Severe Hyperfunctional or Muscle
Tension Dysphonia
Psychogenic Dysphonia
Treatment of SD
• Psychiatric
• Drugs
• Speech Therapy
• Surgery
• BOTOX
Botox in SD
Transoral
Concious pt / GA
Transcutaneous with EMG Control
Monopolar Teflon coated EMG neeedle
connected to EMG machine
GA -occasionally
Botox in SD cont
Adductor
- via CT membrane
intoThyroarytenoid/ vocalis
-2.5 Mu per vocal cord starting
dose (titrate response)
Abductor
- Into PCA
-More difficult
-Lateral or translaryngeal approach
- 3.75 Mu starting (titrated)
-Unilateral Injection
-May assess weakness by scope
Rating??
Method
• Prospective study
• Botox injections for adductor and abductor
spasmodic dysphonia between 1992 and
2003
• Assessment and diagnosis by
otolaryngologist, neurologist and speech
pathologist in voice clinic
Method
• Pre and post-injection self evaluation of voice
function on equal appearing interval scale 1 to 10
1= severe disabling voice problem, 10= no perceived
voice problem
• Complications (mild/ moderate/ severe)
–
–
–
–
Breathiness
Dysphagia
Pain
bruising
Method
• Pre and post-injection self evaluation of voice
function on equal appearing interval scale 1 to 10
1= severe disabling voice problem, 10= no perceived
voice problem
• Complications (mild/ moderate/ severe)
–
–
–
–
Breathiness
Dysphagia
Pain
bruising
Injection Method
• Transcutaneous submucosal injection through cricothyroid
membrane with EMG control
– few injections required transoral and translaryngeal technique
• Adductor patients- injection into thyroarytenoid muscle
• Abductor patients- injection into posterior cricoarytenoid
muscle
Results
• Consecutive series of 81 patients, complete
information available in 79
• 511 injections of Botox
• 59 female, 20 male
Adductor Group
• 72 patients, 481 injections
• Bilateral injections in 96% (464 injections),
unilateral 4% (17 injections)
• Median dose 2.5 mouse units (range 0.5-5)
Adductor Group
• 95% of injections (459) improvement in
symptoms
• Median improvement 4 points (range 1-8)
• Mean duration of response 15.3 weeks (range 0.572)
Adductor group
• 72% complications (346 injections)
– Breathiness (317), 68% mild, median duration
2 wks
– Dysphagia- (110) 86% mild, median duration 2
wks
– Pain (12)
– Bruising (4)
Abductor group
• 7 patients, 30 injections
• 2 bilateral injection, 28 unilateral
• median dose 4.5 (range 2.5 to 6.25)
Abductor group
• 60% injections (18) symptom improvement
• Median improvement 3 points ( range 1-5)
• Mean duration response 11.4 weeks (range 4-20)
Conclusions
• Laryngeal botox injections results in significant,
sustained voice improvements in adductor
spasmodic dysphonia
• Side effects are frequent but majority are mild in
severity
• Results in abductor spasmodic dysphonia less
favourable
Can we extrapolate to VCD?
Vocal Cord Dysfunction (VCD)
• Various names-Paradoxical Vocal Cord
Movement (PVFM ) probably best
• Adduction of VCs during inspiration
• Various types
– Dystonia
– Asthma associated (? >10% ED ‘asthma”
presentations (?? All have asthma)
– Exercise induced
– Psychological
– LPR—Acute laryngeal spasms-? different
Diagnosis of VCD
• History
– Stridor Not responding to asthma meds
– Exercise induced
– Psych ??
• Flexible Scope
• 360 Slice CT
Treatment of VCD
• Breathing Exercises (SP) Effective ~80%
• Medication – Asthma meds,Diazepam etc
• PPIs often effective for the Laryngospasm
• Botox –Anecdotal evidence , Awaiting RCT