Arytenoid dislocation杓状软骨脱位

Arytenoid dislocation杓状软骨脱位 Laryngology seminar 91.2.27 Botulinum Toxin for cricopharyngeal dysphagia R3 Tsai A. Introduction a. Discovery in 1897, and in1990 National Institutes of Health Consensus treatment in strabismus, blepharospasm, development conference – hemi-facial spasm, adductor spasmodic dysphonia, jaw-closing oromandibular dystonia, cervical dystonia b. Botulinum toxin ( BTX) : eight serotypees, A, B, C1, C2, D, E, F, G. only BTX-A is available used in USA c. Mechanism: binding – internalization -- membrane traslocation – protease activity: binds to presynaptic cholinergic nerve terminals – impairs the release of acetylcholine at neuromuscular junction d. It toxin is temporary, grade according to dose, works 3 days later and lasting up to 6 months (ave 3-4 months) e. In larynx, one small muscle 2.5U/0.1ml is useful but not always f. Using in ENT field: 1. facial dyskinesias 2. adductor spasmodic dysphonia 3. spasmodic torticollis 4. oromandibular dystonia 5. cricopharyngeal dysfunction 6. decrease the salivary gland secretion 7. Frey syndrome 8. cosmetic applications 9. tracheoesophageal puncture speaking 10. migraine 11. laryngeal joint dislocation 12. posterior glottic synechiae B. cricopharyngeal dysfunction a. cricopharyngeus muscles spasm or hypertonicity b. esophageal dilation? CP myotomy? Pharyngeal plexus neurectomy c. BTX injection – both treatment and diagnosis ( chemical myotomy) d. Incidence: 5.7% neurological disorder, 4.9% head neck cancer, 8.9% other medical problems (3.5%-25%) C. Pre-injection evaluation a. history taking 1. history of CVA or head and neck tumor? 2. response to medication or training? 3. exclude – globus syndrome, esophageal scars, cancer? 4. duration and frequency? 5. Questionnaire b. study 1. transnasal fibroscope with methylene blue swallowing ( FEES) 2. esophageal manometry 3. videofluoroscopic modified barium swallowing study ( MBSS) 4. cineradiography 5. EMG 6. stroboscope D. Injection a. usually general anesthesia b. short term muscle relaxants c. injection ways 1. percutaneous injection way: EMG, CT, videofluoroscopy guided 2. direct injection way: Groningen esophagoscope, larygoscope 3. flexible scope d. Injection in dorsomedial part and both side of ventrolateral CM (100 units) E. Results a. Evaluation below + study again 1. Type of diet? 2. Weight gain? 3. Aspiration symptom? 4. feeding tube? b. 65-90% successful rate c. works ave 4 months, lasting to 17 months d. some cases change to normal 1+ years post injection? e. Good result to isolate CP Reference 1. Haapaniemi JJ. Laurikainen EA. Pulkkinen J. Marttila RJ. Botulinum toxin in the treatment of cricopharyngeal dysphagia.Dysphagia. 16(3):171-5, 2001 Summer. 2. Shaw GY. Searl JP. Botulinum toxin treatment for cricopharyngeal dysfunction. Dysphagia. 16(3):161-7, 2001 Summer. 3. Ahsan SF. Meleca RJ. Dworkin JP. Botulinum toxin injection of the cricopharyngeus muscle for the treatment of dysphagia. Otolaryngology - Head & Neck Surgery. 122(5):691-5, 2000 May 4. Atkinson SI. Rees J. Botulinum toxin for cricopharyngeal dysphagia: case reports of CT-guided injection. Journal of Otolaryngology. 26(4):273-6, 1997 Aug. 5. Blitzer A. Brin MF. Use of botulinum toxin for diagnosis and management of cricopharyngeal achalasia. Otolaryngology - Head & Neck Surgery. 116(3):328-30, 1997 Mar