No morphometric abnormality recurrent laryngeal nerve in spastic dysphonia.

Spastic dysphonia is a disorder of phonation that is usually markedly improved by surgical resection of one recurrent laryngeal nerve (RLN). In this study, biopsies of the RLN were obtained at surgery from nine patients with spastic dysphonia (disease group) and eight patients with laryngeal cancer (control group). The RLN was found to be composed of several nerve regions having characteristic fiber compositions. For the various nerve regions and for the whole nerve, we evaluated morphology, median fiber diameter, density, and size distribution of fibers. The morphologies of teased fibers were also evaluated. We found no significant differences between the nerves of the disease and control groups. Therefore, we were unable to verify previous reports of neuropathic abnormality of the RLN in spastic dysphonia.

Telemedicine and the diagnosis of speech and language disorders.

OBJECTIVE: To summarize results of telemedicine evaluations of speech and language disorders in patients in a small, rural hospital and in large multidisciplinary medical practices. MATERIALS AND METHODS: Eight patients underwent assessment as part of experiments with the National Aeronautics and Space Administration-launched Advanced Communications Technology Satellite. A second clinician was on-site with patients to assess the reliability of satellite observations. Twenty-four previously videotaped samples of speech disorders were also transmitted to assess agreement with original face-to-face clinical diagnoses. In addition, results of 150 telemedicine evaluations among Mayo Clinic practices in Minnesota, Arizona, and Florida were examined retrospectively. RESULTS: Evaluations were reliable, and patient satisfaction was good. Diagnoses were consistent with lesion localization and medical diagnosis when they were known, and they frequently had implications for lesion localization and medical diagnosis and management when they were previously unknown. The frequency of uncertain diagnosis (13%) for evaluation among the Mayo practices was only slightly higher than that encountered in face-to-face practice. Face-to-face evaluations were considered necessary for only 6 of the 150 patients (4%). CONCLUSION: Telemedicine evaluations can be reliable, beneficial, and acceptable to patients with a variety of acquired speech and language disorders, both in rural settings and within large multidisciplinary medical settings.

Dysarthria and apraxia of speech associated with FK-506 (tacrolimus).

The immunosuppressive agent FK-506 (tacrolimus) is one of the agents most commonly used to prevent rejection after liver transplantation. Neurologic toxicity related to FK-506 has been reported, including speech disorders; however, a detailed analysis of the speech disorder associated with use of FK-506 has not been presented. Herein we describe a patient who exhibited mutism, then severe apraxia of speech with a concomitant hypokinetic, spastic, and ataxic dysarthria after administration of FK-506. His residual mixed dysarthria, without radiographic evidence of a structural lesion, suggests dysfunction of one or more neurochemical systems. The pathophysiologic mechanisms underlying this intriguing entity remain obscure.

Clinician reliability in rating voice improvement after laryngeal nerve section for spastic dysphonia.

A recent study by Aronson and DeSanto (1983) showed that, although section of the recurrent laryngeal nerve to relieve adductor spastic dysphonia effected considerable improvement in nearly 100% of the voices immediately after surgery, within the next 3 years 64% had returned to their preoperative status or worse. These findings were based on ratings by one speech pathologist, and the study was not designed to measure the reliability of the rater's judgments.

Adductor spastic dysphonia: three years after recurrent laryngeal nerve resection.

The voices of 33 patients, ages 44 to 79 years, were assessed after recurrent laryngeal nerve resection for adductor spastic dysphonia. Voice improvement was noted in all patients 24 hours after surgery: in 97% at 1 month, 97% at 6 months, 82% at 1 year, 70% at 1 1/2 years, 58% at 2 years, 52% at 2 1/2 years, and 36% at 3 years. Of the 64% with failed voices by 3 years, 48% were worse than before surgery. Of the 36% whose voices remained improved, 58% were worse than at any previous period and 42% were better. Failures among women (77%) were considerably higher than among men (36%). Except for one patient, none of the patients with improvement achieved a normal voice. Patients with improvement had varied types and degrees of dysphonia: breathiness, hoarseness, diplophonia, and falsetto pitch breaks. The voices of some patients approached normalcy. A high percent of patients had voice tremor and regular voice arrests on vowel prolongation, signaling that the spastic dysphonia may have been related to essential (voice) tremor and that the spastic dysphonia returned because of increased severity of the neurologic tremor. We conclude that recurrent laryngeal nerve surgery for adductor spastic dysphonia has long-term limitations and that the differential diagnosis between neurologic and psychogenic types is imperative prior to therapeutic decision making.

Respiratory distress after recurrent laryngeal nerve sectioning for adductor spastic dysphonia.

Adductor spastic dysphonia is a voice sign associated with various neurologic and psychologic disorders. Treatment of spastic dysphonia in selected patients is unilateral recurrent laryngeal nerve sectioning. Except for voice change or, in some patients, return of phonatory spasticity, there have been no long-term sequelae or complications of this treatment. We describe three patients with adductor spastic dysphonia who underwent recurrent laryngeal nerve sectioning and who, 3 to 38 months later, suffered respiratory distress that required tracheostomy. The respiratory distress in all three patients was due to episodic jerky vocal cord hyperadductions that caused stridor during inspiration and expiration. These repetitive laryngospasms during respiration and phonation were progressive. Two patients needed an arytenoidectomy to achieve a useful voice, and all three required a permanent tracheostomy to alleviate inspiratory laryngeal obstruction.

Double-blind controlled study of botulinum toxin in adductor spasmodic dysphonia.

The treatment of adductor spasmodic dysphonia using botulinum toxin A was conducted in 13 patients as a double-blind, placebo-controlled study. Patients were diagnosed independently by an interdisciplinary team consisting of speech pathologists, an otolaryngologist, and a neurologist. The toxin or saline was injected into each thyroarytenoid muscle under electromyographic and laryngoscopic guidance. Botulinum toxin A markedly reduced perturbation, decreased fundamental frequency range, and improved the spectrographic characteristics of the voice. Fundamental frequency and phonation time remained unchanged. Patients injected with botulinum toxin A noticed significant improvement in their voices in comparison with the placebo-treated group. Excessive breathiness of the voice occurred in two patients, and mild bleeding in one patient in the botulinum toxin A-treated group. Injection with saline resulted in edema of the vocal cord in one patient. Botulinum toxin A proved to be an effective and safe treatment of adductor spasmodic dysphonia.

Botulinum toxin injection for adductor spastic dysphonia: patient self-ratings of voice and phonatory effort after three successive injections.

Ten patients (aged 35 to 70 years) with neurologic adductor spastic dysphonia rated themselves on a 7-point scale of severity for degree of voice improvement and physical effort after a series of three injections of botulinum toxin. Symptoms were noticeably reduced 24 and 48 hours after injection; this improvement was followed by considerable fluctuations in voice quality and phonatory effort. With successive injections, patients differed in their post-injection experiences, the time required to reach optimal voice, and the total duration of benefit. The study shows that the course of voice change after botulinum toxin injection is not predictable, uniform, or equal among patients with spastic dysphonia.

Adductor spastic dysphonia: 1 1/2 years after recurrent laryngeal nerve resection.

After recurrent laryngeal nerve resection for adductor spastic dysphonia, the voices of 37 patients (ages 39 to 79 years) were assessed 24 hours, 1 month, 6 months, and 1 year after surgery, and those of 33 patients up to 1 1/2 years after surgery. By 24 hours after surgery, 97% of patients had improved and 3% had failed; by 1 month, 97% were still improved while 3% had failed; by 6 months, 92% had maintained improvement while 8% had failed; by 1 year, 68% were still improved but 32% had failed; and by a 1 1/2 years, 61% were still improved while 39% had failed. The patients whose voices improved varied from one another in both type and degree of residual dysphonia. The typical postsurgical voice was free of spasm, with some breathiness, hoarseness, and reduced volume being present. The voices of some patients approached normalcy. To most patients, relief from the physical effort to phonate was as important as the improved voice. Continued long-term follow-up studies and careful, collaborative selection of surgical candidates are needed.

Judgment of voice improvement after recurrent laryngeal nerve section for spastic dysphonia: clinicians versus patients.

Four or more years after recurrent laryngeal nerve section for adductor spastic dysphonia, 25 patients assessed their voice quality and phonatory effort in relation to presurgical status, using categorical ratings (gradations of better or worse, and of easier and harder) and also numerical ratings. Quality was judged better by 88%, and effort easier by 84%; but many thought the improvement was only moderate or slight. Three speech pathologists, assessing presurgical and current recordings of the patient's voices numerically, rated the majority of the better and easier voices much closer to their presurgical status than to normal. Clinicians were highly consistent and reliable in their assessments. Patients were often in disagreement with clinician ratings and generally rated their dysphonia as less severe than the clinicians did. These discrepancies are discussed within the context of contradictory opinions regarding the efficacy of recurrent laryngeal nerve section for the treatment of adductor spastic dysphonia.