Life Threatening Delayed Complication of Botulinum Toxin Injection for Treatment of Spasmodic Dysphonia.

Spasmodic dysphonia is a primary task specific focal dystonia affecting the laryngeal muscles during speech. Most medical and surgical approaches to treatment of spasmodic dysphonia are aimed at the denervation of the laryngeal muscles to block symptom expression in the voice. The standard of care for the adductor form of spasmodic dysphonia is botulinum toxin chemodenervation. The common side effects of treatment with Botox are excessive breathiness and aspiration of fluids. We present the report of a delayed presentation of upper airway obstruction due to a complete vocal cords adduction requiring intubation ten days post Botox injection for the adductor form of spasmodic dysphonia. This presentation may be preceded by a change in voice, productive cough, shortness of breath, or odynophagia. We would recommend supportive treatment in an Intensive Care Unit and close liaison with the otolaryngology team for the management of this complication. Acute upper airway obstruction requiring tracheal intubation is a delayed complication of botulinum toxin administration in the adductor form of spasmodic dysphonia.

A case of a duplicated superficial branch of radial nerve and a two-bellied brachioradialis muscle presenting a potential entrapment syndrome.

We have found an interesting coincidental variation of the superficial branch of the radial nerve and the brachioradialis muscle in a male cadaver. The superficial branch of the radial nerve was duplicated with one branch taking an aberrant course between two bellies of the brachioradialis muscle. The variant brachioradialis muscle featured two muscle bellies, a superficial one and a deep one, with one common origin and one common insertional tendon. The accessory nerve branch was impinged by two blood vessels and pierced through muscle bundles connecting two bellies of the brachioradialis muscle. The knowledge of this neuromuscular variant is of clinical relevance for the differential diagnosis of pain and paresthesia on the dorsoradial aspect of the hand and for the surgical management of the Wartenberg's syndrome.

Unusual Variation of the Biceps Brachii with Possible Median Nerve Entrapment.

The biceps brachii is one of three muscles of the anterior compartment of arm. Variations of the biceps brachii are not rare. The most frequent is the existence of a third head called the humeral head by Le Double (1897) (Rodríguez-Vázquez et al., 1999). Our article is based on the unexpected result of a routine dissection class held for medical students. Dissection was performed according to the guidelines accepted by the anatomy department (Seichert, 1999). We describe a third (accessory) head of the biceps brachii. In addition of two regular heads, the third head originated together with the short head from the coracoid process and had three insertions on the humerus after enfolding the median nerve and the brachial artery. This particular variation is important from a clinical perspective as the third head may cause entrapment syndrome of the median nerve and hypoperfusion of the upper limb due to compression of the brachial artery.

Delayed enterocutaneous fistula formation secondary to an inverted non-absorbable suture post midline laparotomy closure.

INTRODUCTION: Enterocutaneous fistula is a well recognised complication of intra-abdominal surgery. Postoperatively, it may occur due to a small bowel injury or an anastomotic leak and usually presents within days or weeks after surgery. METHODS: We present a case report. Information was obtained through a retrospective review of the notes, clinic letters, images and the histology report. RESULTS: We present a case of a patient who developed an enterocutaneous fistula 34 years after panproctocolectomy for ulcerative colitis. Imaging was consistent with an enterocutaneous fistula arising from mid-small bowel. A laparotomy and small bowel resection was performed. The enterocutaneous fistula occurred due to an inverted non-absorbable suture post midline laparotomy closure. CONCLUSION: Suture-related enterocutaneous fistula can be a rare delayed complication of a midline laparotomy closure when a knot is inverted intra-peritoneally. Consideration should be given to either leaving a knot in the subcutaneous fat tissue or feeding it between the rectus sheath and the suture bites.