Consensus statement: Using laryngeal electromyography for the diagnosis and treatment of vocal cord paralysis.

INTRODUCTION: The purpose of this study was to develop an evidence-based consensus statement regarding use of laryngeal electromyography (LEMG) for diagnosis and treatment of vocal fold paralysis after recurrent laryngeal neuropathy (RLN). METHODS: Two questions regarding LEMG were analyzed: (1) Does LEMG predict recovery in patients with acute unilateral or bilateral vocal fold paralysis? (2) Do LEMG findings change clinical management in these individuals? A systematic review was performed using American Academy of Neurology criteria for rating of diagnostic accuracy. RESULTS: Active voluntary motor unit potential recruitment and presence of polyphasic motor unit potentials within the first 6 months after lesion onset predicted recovery. Positive sharp waves and/or fibrillation potentials did not predict outcome. The presence of electrical synkinesis may decrease the likelihood of recovery, based on 1 published study. LEMG altered clinical management by changing the initial diagnosis from RLN in 48% of cases. Cricoarytenoid fixation and superior laryngeal neuropathy were the most common other diagnoses observed. CONCLUSIONS: If prognostic information is required in a patient with vocal fold paralysis that is more than 4 weeks and less than 6 months in duration, then LEMG should be performed. LEMG may be performed to clarify treatment decisions for vocal fold immobility that is presumed to be caused by RLN. Muscle Nerve 53: 850-855, 2016.

Common peroneal nerve palsy following total knee arthroplasty: prognostic factors and course of recovery.

Common peroneal nerve palsy (CPNP) is a serious complication following total knee arthroplasty (TKA). There is little information regarding the clinical course and prognostic factors for recovery. Between January 2000 and December 2008, 44 patients (0.53%) developed CPNP following TKA and were matched to 100 control patients based on year of surgery, type of surgery and surgeon. Regression analysis was performed to identify prognostic factors for recovery. A significant difference was seen in CPNP patients who were on average younger (62.1 years) and had higher BMI (34.5 kg/m(2)) than those who did not have nerve palsy (67.5 years and 31.8 kg/m(2), respectively). Only 37 patients with palsies could be followed, 32 (62.2%) had incomplete nerve palsy, twenty four (75%) of them fully recovered, while only 1 of patients with complete nerve palsy fully recovered. More severe initial injury was a negative prognostic factor for recovery of palsy (P<0.03).

Complete Resolution of Skull Base Solitary Plasmacytoma Using Proton-Beam Radiotherapy: A Case Report.

Cranial solitary plasmacytomas are uncommon lesions, and localization to the skull base is rare. Here we present a case in a 36-year-old woman who complained of dizziness and mild headaches. Radiographic imaging indicated the presence of a solitary skull base lesion in the posterior cranial fossa. Laboratory tests and imaging excluded systemic disease. A biopsy of the lesion confirmed the diagnosis of plasmacytoma. The patient was treated with proton-beam radiation and had a complete clinical and radiographic resolution, demonstrating the previously unreported utility of monotherapy with proton-beam radiation in such cases.

Desflurane versus sevoflurane for maintenance of outpatient anesthesia: the effect on early versus late recovery and perioperative coughing.

BACKGROUND: There is controversy regarding the relative perioperative benefits of desflurane versus sevoflurane when used for maintenance of anesthesia in the ambulatory setting. Although studies have consistently demonstrated a faster emergence with desflurane (versus sevoflurane), the impact of this difference on the later recovery end points has not been definitively established. Furthermore, the effect of desflurane (versus sevoflurane) on the incidence of coughing is also controversial. METHODS: We randomized 130 outpatients undergoing superficial surgical procedures requiring general anesthesia to one of two maintenance anesthetic treatment groups. All patients were induced with propofol, 2 mg/kg IV, and after placement of a laryngeal mask airway, anesthesia was maintained with either sevoflurane 1%-3% or desflurane 3%-8% in an air/oxygen mixture. The inspired concentration of the volatile anesthetic was varied to maintain hemodynamic stability and a Bispectral Index value of 50-60. Analgesia was provided with local anesthetic infiltration and ketorolac (30 mg IV). Antiemetic prophylaxis consisted of a combination of ondansetron (4 mg), dexamethasone (4 mg), and metoclopramide (10 mg) at the end of surgery. Assessments included recovery times to eye opening, response to commands, orientation, fast-track score of 14, first oral intake, sitting, standing, ambulating unassisted, and actual discharge. Patient satisfaction with anesthesia, the ability to resume normal activities on the first postoperative day, adverse side effects (e.g., coughing, purposeful movement, oxygen desaturation <90%, sore throat, postoperative nausea, and vomiting), and the requirement for postoperative analgesic and antiemetic drugs were recorded in the early postoperative period and during the initial 24-h period after discharge. RESULTS: The two study groups had comparable demographic characteristics. Although the overall incidence of coughing during the perioperative period was higher in the desflurane group (60% versus 32% in the sevoflurane group, P < 0.05), the incidences of coughing during the actual administration of the volatile anesthetics (i.e., the maintenance period) did not differ between the two groups. Emergence from anesthesia was more rapid after desflurane; however, all patients achieved fast-track recovery criteria (fast-track score >or=12) before leaving the operating room. Finally, the time to discharge home (90 +/- 31 min in sevoflurane and 98 +/- 35 min in desflurane, respectively) and the percentage of patients able to resume normal activities on the first postoperative day (sevoflurane 48% and desflurane 60%) did not differ significantly between the two anesthetic groups. CONCLUSIONS: Use of desflurane for maintenance of anesthesia was associated with a faster emergence and a higher incidence of coughing. Despite the faster initial recovery with desflurane, no significant differences were found between the two volatile anesthetics in the later recovery period. Both volatile anesthetics should be available for ambulatory anesthesia.

Laryngeal electromyography.

Laryngeal electromyography (LEMG) evaluates the integrity of the neuromuscular system in the larynx by recording action potentials generated in the laryngeal muscles during voluntary and involuntary contraction. LEMG is particularly useful for helping to differentiate between disorders involving upper motor neurons, lower motor neurons, peripheral nerves, the neuromuscular junction, muscle fibers, and the laryngeal cartilages and joints. LEMG should be considered to be an extension of the physical examination, not an isolated laboratory procedure. A careful history and laryngeal evaluation determine the indication for LEMG and which muscles or muscle groups, in particular, are to be studied. Abnormalities detected by LEMG are always interpreted within the context of the clinical picture.

Evaluating malingering in contested injury or illness.

An interdisciplinary task force of physicians and neuropsychologists with advanced training in impairment and disability assessment provided a review of the literature on malingering in chronic pain, medical disorders, and mental/cognitive disorders. Our review suggests that treating health care providers often do not consider malingering, even in cases of delayed recovery involving work injuries or other personal injuries, where there may be a significant incentive to feign or embellish symptoms or delay recovery. This report discusses the implications of this issue and offers recommendations to evaluating physicians and other health care professionals.

Treatment Guidelines for Rheumatologic Manifestations of Sjögren's Syndrome: Use of Biologic Agents, Management of Fatigue, and Inflammatory Musculoskeletal Pain.

OBJECTIVE: The Sjögren's Syndrome Foundation clinical practice guidelines (CPGs) are designed to improve quality and consistency of care in Sjögren's syndrome by offering recommendations for management. METHODS: Management questions for the systemic manifestations of Sjögren's syndrome were posed by the CPG committee with input from patients and rheumatologists. Clinical questions were assigned to a topic review group that performed systematic reviews and data extraction and drafted guidelines. Quality of evidence and strength of recommendation were rated using the American Society of Clinical Oncology's modification of the Grading of Recommendations Assessment, Development, and Evaluation. Guideline recommendations were reviewed by a consensus expert panel (CEP) composed of 30-40 clinicians from academia and community practices, as well as registered nurses and patients, using a modified Delphi process. A CEP agreement level of 75% was set as a minimum for adoption of a guideline recommendation. RESULTS: Consensus was achieved for 19 recommendations; for 11 additional modules, available data were insufficient to allow a recommendation to be formulated. Of the 19 recommendations, 15 required 1 Delphi round, 2 required 2 rounds, and 2 required 3 rounds. CONCLUSION: Key recommendations include a decision tree for the use of oral disease-modifying antirheumatic drugs for inflammatory musculoskeletal pain, use of self-care measures and advice regarding exercise to reduce fatigue, and the use of rituximab in selected clinical settings for oral and ocular dryness and for certain extraglandular manifestations, including vasculitis, severe parotid swelling, inflammatory arthritis, pulmonary disease, and mononeuritis multiplex. The CPG committee strongly discouraged the use of tumor necrosis factor inhibitors for sicca symptoms and for the majority of clinical contexts in primary Sjögren's syndrome.

Objective voice measures in nonsinging patients with unilateral superior laryngeal nerve paresis.

The clinical value of objective voice measures in nonsinging patients with superior laryngeal nerve dysfunction is unknown. In this study, patients with symptomatic unilateral superior nerve paresis were evaluated for maximum phonation time, frequency range of phonation, and mean flow rate. Patients with coexisting pathology, bilateral superior nerve paresis, and those with recurrent laryngeal nerve paresis were excluded from this analysis. A total of 35 nonsinging patients, 14 men and 21 women, with unilateral superior laryngeal nerve paresis were examined between 1999 and 2002. The severity of superior laryngeal nerve paresis ranged from 25% to 85% of normal recruitment with a mean of 70% superior laryngeal nerve recruitment in men and 65% in women by electromyography. In both men and women with superior laryngeal nerve paresis, the maximum phonation time and frequency range of phonation were decreased and the mean air flow rate was increased when compared with normal population values. The jitter percent, shimmer percent, and noise-to-harmonic ratio were also increased in patients when compared with normative data. Selected objective voice measures are abnormal in voice patients with superior laryngeal nerve paresis, which suggests that the measures may be useful as outcomes measures after therapy. More research is encouraged.

Repetitive phonatory tasks for identifying vocal fold paresis.

Vocal fold paresis may be present in patients with voice complaints. Identification of paresis is important so that appropriate neurolaryngologic evaluation can be ordered and the appropriate treatment can be offered. Repetitive phonatory tasks (RPTs) fatigue patients vocally and may elicit signs of subtle paresis. In this study, four laryngologists independently reviewed the RPT portions of routine fiberoptic voice examinations of 100 patients in a blinded fashion. All patients had presented with voice complaints, were suspected of having a movement disorder of the larynx, and had been referred for laryngeal electromyography (LEMG). Predictions were compared with LEMG results and with predictions made at the time of each initial evaluation. Although RPTs are useful to laryngologists, predictions based on the entire examination are more accurate. LEMG can confirm clinical suspicions or identify paresis missed on fiberoptic laryngeal examination.

Abnormal computerized dynamic posturography findings in dizzy patients with normal ENG results.

The complexities of the balance system create difficulties for professionals interested in testing equilibrium function objectively. Traditionally, electronystagmography (ENG) has been used for this purpose, but it provides information on only a limited portion of the equilibrium system. Computerized dynamic posturography (CDP) is less specific than ENG, but it provides more global insight into a patient's ability to maintain equilibrium under more challenging environmental circumstances. CD Palso appears to be valuable in obtaining objective confirmation of an abnormality in some dizzy patients whose ENG findings are normal. Our review of 33 patients with normal ENG results and abnormal CDP findings suggests that posturography is useful for confirming or quantifying a balance abnormality in some patients whose complaints cannot be confirmed by other tests frequently used by otologists.

Practice parameter: laryngeal electromyography (an evidence-based review).

This paper reports on an evidence-based review of laryngeal electromyography (EMG) as a technique for use in the diagnosis, prognosis, and treatment of laryngeal movement disorders including the laryngeal dystonias, vocal fold paralysis, and other neurolaryngological disorders. The authors performed a systematic review of the medical literature from 1944 through 2001 on the clinical application of EMG to laryngeal disorders. The review yielded 584 articles of which 33 met the predefined inclusion criteria. The evidence demonstrated that in a double-blind treatment trial of botulinum toxin versus saline, laryngeal EMG used to guide injections into the thyroarytenoid muscle in persons with adductor spasmodic dysphonia was beneficial. A cross-over comparison between laryngeal EMG-guided injection and endoscopic injection of botulinum toxin into the posterior cricoarytenoid muscle in abductor spasmodic dysphonia found no significant difference between the 2 techniques and no significant treatment benefit. Based on the evidence, laryngeal EMG is possibly useful for the injection of botulinum toxin into the thyroarytenoid muscle in the treatment of adductor spasmodic dysphonia. There were no evidence-based data sufficient to support or refute the value of laryngeal EMG for the other uses investigated, although there is extensive anecdotal literature suggesting that it is useful for each of them. There is an urgent need for evidence-based research addressing other applications in the use of laryngeal EMG for other applications.

Practice parameter: laryngeal electromyography (an evidence-based review).

This paper reports on an evidence-based review of laryngeal electromyography (EMG) as a technique for use in the diagnosis, prognosis, and treatment of laryngeal movement disorders, including the laryngeal dystonias, vocal fold paralysis, and other neurolaryngological disorders. The authors performed a systematic review of the medical literature from 1944 through 2001 on the clinical application of EMG to laryngeal disorders. Thirty-three of the 584 articles met the predefined inclusion criteria. The evidence demonstrated that in a double-blind treatment trial of botulinum toxin versus saline, laryngeal EMG used to guide injections into the thyroarytenoid muscle in persons with adductor spasmodic dysphonia was beneficial. A cross-over comparison between laryngeal EMG-guided injection and endoscopic injection of botulinum toxin into the posterior cricoarytenoid muscle in abductor spasmodic dysphonia found no significant difference between the two techniques and no significant treatment benefit. Based on the evidence, laryngeal EMG is possibly useful for the injection of botulinum toxin into the thyroarytenoid muscle in the treatment of adductor spasmodic dysphonia. There were no evidence-based data sufficient to support or refute the value of laryngeal EMG for the other uses investigated, although there is extensive anecdotal literature suggesting that it is useful for each of them. There is an urgent need for evidence-based research addressing other applications in the use of laryngeal EMG for other applications.

Botulinum toxin type B for treatment of spasmodic dysphonia: a case report.

Although treatment with botulinum toxin type A (BTXA) has become the standard of care for most patients with laryngeal dystonia, its use is limited by the development of resistance to the toxin in some patients. Botulinum toxin type B (BTXB) has been found to be safe and effective in the treatment of cervical dystonia, but it has not been used previously to treat spasmodic dysphonia. Our experience with BTXB in a patient who developed resistance to BTXA suggests that BTXB may be safe and effective for the treatment of laryngeal dystonia, as well.

ACOEM practice guidelines: opioids for treatment of acute, subacute, chronic, and postoperative pain.

DESCRIPTION: The American College of Occupational and Environmental Medicine's guidelines have been updated to develop more detailed guidance for treatment of acute, subacute, chronic, and postoperative pain with opioids. METHODS: Literature searches were performed using PubMed, EBSCO, Cochrane Review, and Google Scholar without publication date limits. Of 264,617 articles' titles screened and abstracts reviewed, 263 articles met inclusion criteria. Of these, a total of 157 were of high and moderate quality addressing pain treatment. Comprehensive literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel to develop evidence-based guidance. RECOMMENDATIONS: No quality evidence directly supports histories, physical examinations, and opioid treatment agreements, although they are thought to be important. No quality trials were identified showing superiority of opioids, compared with nonsteroidal anti-inflammatory and other medications for treatment of chronic, noncancer pain. The use of opioid-sparing treatments associated with lower doses of postoperative opioids is also associated with better long-term functional outcomes. Selective use of opioids is recommended for patients with acute and postoperative pain. Consensus recommendations also include consideration of carefully conducted trials of chronic opioid treatment for highly select patients with subacute and chronic pain and to maintenance opioid prescriptions only if documented objective functional gain(s) results. A strong and reproducible dose-response relationship identifies a recommended morphine equivalent dose limit of no more than 50 mg/day. Higher doses should be prescribed only with documented commensurately greater functional benefit(s), comprehensive monitoring for adverse effects, informed consent, and careful consideration of risk versus benefit of such treatment. Chronic opioid use should be accompanied by informed consent, a treatment agreement, tracking of functional benefits, drug screening, and attempts at tapering.

ACOEM practice guidelines: opioids and safety-sensitive work.

OBJECTIVE: ACOEM has updated the treatment guidelines concerning opioids. This report highlights the safety-sensitive work recommendation that has been developed. METHODS: Comprehensive literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel to develop evidence-based guidance. A total of 12 moderate-quality studies were identified to address motor vehicle crash risk, and none regarding other work among opioid-using patients. RESULTS: Acute or chronic opioid use is not recommended for patients who perform safety-sensitive jobs. These jobs include operating motor vehicles, other modes of transportation, forklift driving, overhead crane operation, heavy equipment operation and tasks involving high levels of cognitive function and judgment. CONCLUSION: Quality evidence consistently demonstrates increased risk of vehicle crashes and is recommended as the surrogate for other safety-sensitive work tasks.

Common peroneal nerve palsy following total hip arthroplasty: prognostic factors for recovery.

BACKGROUND: Common peroneal nerve palsy, although rare, is a serious complication of total hip arthroplasty. Although several publications have dealt with the risk factors for peroneal nerve palsy, there is little literature regarding the time it takes for the nerve to recover and the factors that influence its recovery. The purpose of this study was to elucidate the clinical course of this injury and identify prognostic factors for recovery. METHODS: From January 2000 to December 2007, 7969 primary and 1601 revision total hip arthroplasties were performed at our institution. Common peroneal nerve palsy developed following thirty-one (0.32%) of these procedures. Thirty of these patients were evaluated by a neurologist at the time of diagnosis and at regular intervals thereafter. Univariate and multivariate regression analyses were performed to identify risk factors and prognostic factors for recovery. RESULTS: On average, patients who developed common peroneal nerve palsy were significantly younger (fifty-six years) than those who did not develop palsy (sixty-three years, p < 0.05). Higher body mass index (BMI) was a negative prognostic factor for recovery from palsy (p < 0.05). The palsy was incomplete in twenty-five of the thirty patients, and fourteen of these recovered fully at a mean of 10.3 months (range, 1.0 to 50.0 months). Three of the five patients with complete nerve palsy recovered fully at a mean of 14.5 months (range, 8.0 to 21.0 months). CONCLUSIONS: Only one-half of the patients in the study who developed common peroneal nerve palsy following total hip arthroplasty recovered fully. The mean time to recovery was approximately one year for partial peroneal palsy and one and one-half years for complete palsy. Obesity adversely influenced the nerve recovery.

Utility of the Rey-15 recognition trial to detect invalid performance in a forensic neuropsychological sample.

The current study sought to address the utility of the Rey Fifteen Item Test (Rey-15), with the use of a combined score [recall correct + (recognition correct - false positives)], to distinguish between valid and invalid performance among a sample of litigating persons referred for neuropsychological evaluation. Scores on the Rey-15 were analyzed across four comparison groups: (1) litigating persons with evidence of invalid performance (n = 29), (2) litigating persons with valid performance (n = 63), (3) learning-disabled patients (n = 36), and (4) a mixed clinical neuropsychological sample not involved in litigation (n = 54). A Rey-15 combined cutoff score of < 21 yielded the highest sensitivity (70%) and specificity (92.8%) rates. If the Rey-15 is to be used in clinical practice to detect invalid performance, the recognition trial with combined score < 21 should be used. Findings support the use of the combined Rey-15 score in place of the previously used recall Rey-15 score to improve sensitivity and specificity rates for detection of invalid performance in litigating neuropsychological referrals.

Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology.

OBJECTIVE: To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article. METHODS: We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations. RESULTS: Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

The predictors of postoperative laryngeal nerve paresis in patients undergoing thyroid surgery: a pilot study.

OBJECTIVES: The objective of this study was to evaluate the factors predictive of postoperative laryngeal nerve paresis (LNP) in patients undergoing thyroid surgery. We also assess the implications of preoperative LNP on postoperative vocal fold status. STUDY DESIGN: Case series with retrospective chart review. METHODS: Charts of 17 patients who underwent thyroid surgery and had pre- and postoperative laryngeal electromyography (LEMG) were reviewed. LEMGs were ordered routinely in all patients undergoing thyroid surgery, not just in those with clinical findings suggestive of paresis. We collected data relating to pre- and postoperative laryngeal and thyroid evaluations and the details of the surgical procedure. We analyzed the prevalence of preoperative LNP and relationship of thyroid diagnoses, size of thyroid mass, and type of surgery performed with respect to the outcome of the LNP. RESULTS: All the 17 patients had a mild to moderate degree of unilateral or bilateral LNP preoperatively. However, only seven (41.2%) had vocal symptoms. After surgery, only five of these seven patients had voice complaints, and there were no patients with voice complaints among the group that had been asymptomatic preoperatively. Thyroid diagnoses included 11 cases of benign disease (64.7%) in which LNP improved in two, worsened in four, and remained the same in five; and six cases of malignant disease (35.3%) in which LNP improved in none, worsened in two, and remained the same in four. Predictors of worsening postoperative LNP on LEMG included the diagnosis of goiter (P=0.0005) and size of mass greater than 5cm (0.032). CONCLUSIONS: This study supports the notion that there is an intrinsic relationship between benign thyroid diseases and LNP that is probably related to local effects of the disease on the laryngeal nerves. All patients with the postoperative diagnosis of goiter worsened, and all patients with the postoperative diagnosis of adenoma showed no change on postoperative electromyography (EMG). Similarly, all patients with the diagnosis of thyroiditis alone improved, and there were no cases of improvement outside this group. Of the six cases of malignancy, four exhibited no change on EMG and only two worsened. The only reliable predictors of worsening paresis postoperatively are mass size greater than 5cm and diagnosis of goiter.

Neurologic causes of hip pain in dancers.

Hip pain in dancers is typically attributed to musculoskeletal etiologies due to local "wear-and-tear"; however, one must be aware of neurologic etiologies that may present with additional clinical findings and require specialized treatment. This article explores the presentation, potential causes, suggested work-up, and treatment options for femoral neuropathy, lateral femoral cutaneous syndrome, and piriformis syndrome.