the otolaryngologic uses of botox malcolm baxter fracs
TRANSCRIPT
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The Otolaryngologic Uses of Botox
Malcolm Baxter FRACS
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BotoxClostridium botulinum toxin
7 Serotypes -ABCDEFG
Type A used Botox (Allergan)
Dysport
Neurotoxin-paralyses neuromuscular transmission by binding ACh
Mouse units
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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
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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 post-
laryngectomy• CA Joint Dislocation/Relocation• Vocal Cord Dysfunction (PVFM)
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Botox cont.
Side Effects
Effects of overweakening-depends on location
Abs produced-Anaphylaxis theoretically possible but not in
practice
? No Deaths
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Laryngeal Botox for SD in Melbourne
• RVEEH 1992-2008 Baxter,Hughes & Oates
Continues as private clinics
• MMC Monash Neurolaryngology Clinic 2010- Baxter & Raghav
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SPASMODIC DYSPHONIA
Action induced laryngeal motion disorder resulting in a dysphonia
characterised by spasms in phonation
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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
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Aetiology of SD
Unknown
Genetic Probable in some cases
??Stress
??Infective
PM Studies-unhelpful with varying findings, eg basal ganglia
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SD-2 TypesADDuctor SD >90% -strained and
strangled voice due to spasmodic interruptions to fluency
(Thyroarytenoid-vocalis)
ABDuctor SD <10% -breathy interruptions to fluency (PCA)
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Spasmodic DysphoniaF>M about 2:1
Onset any age (Satalhoff ave 62)
Many patients relate to some traumatic or stressful event
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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
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Differential Diagnosis
Laryngeal Tremor
Severe Hyperfunctional or Muscle Tension Dysphonia
Psychogenic Dysphonia
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Treatment of SD• Psychiatric
• Drugs
• Speech Therapy
• Surgery
• BOTOX
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Botox in SD
Transoral Concious pt / GA
Transcutaneous with EMG Control
Monopolar Teflon coated EMG neeedle connected to EMG machine
GA -occasionally
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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??
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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
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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
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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
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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
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Results
• Consecutive series of 81 patients, complete information available in 79
• 511 injections of Botox
• 59 female, 20 male
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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)
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Adductor Group
• 95% of injections (459) improvement in symptoms
• Median improvement 4 points (range 1-8)
• Mean duration of response 15.3 weeks (range 0.5-72)
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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)
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Abductor group
• 7 patients, 30 injections
• 2 bilateral injection, 28 unilateral
• median dose 4.5 (range 2.5 to 6.25)
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Abductor group
• 60% injections (18) symptom improvement
• Median improvement 3 points ( range 1-5)
• Mean duration response 11.4 weeks (range 4-20)
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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
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Can we extrapolate to VCD?
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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
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Diagnosis of VCD
• History– Stridor Not responding to asthma meds– Exercise induced– Psych ??
• Flexible Scope
• 360 Slice CT
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Treatment of VCD
• Breathing Exercises (SP) Effective ~80%
• Medication – Asthma meds,Diazepam etc
• PPIs often effective for the Laryngospasm
• Botox –Anecdotal evidence , Awaiting RCT