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Biomedical subjects

A Blitzer

Publications and source records attributed to A Blitzer.

At least 37 records · Page 2Linked to original sources
PubMed1997

Adductor spasmodic dysphonia: standard evaluation of symptoms and severity.

Description and quantification of the symptoms of adductor spasmodic dysphonia often reflect the clinician's knowledge of the disorder, ideas about the cause of the disorder, and personal experience. No reliable instrument that identifies and quantifies the spectrum of perceptual symptoms has been available. Therefore, we developed a standardized measure called the Unified Spasmodic Dysphonia Rating Scale (USDRS) in cooperation with a team of 118 experienced voice judges. Consensual validations of content validity guided the incremental development of the scale. Using the USDRS allows more consistent and complete data collection, both clinically and in research clinical trials.

Humans↗
PubMed1996

Supraglottic and pharyngeal sensory abnormalities in stroke patients with dysphagia.

Dysphagia and aspiration are two devastating sequelae of stroke, accounting for nearly 40,000 deaths from aspiration pneumonia each year in the United States. While motor deficits in the larynx and pharynx are thought responsible for dysphagia and aspiration in stroke patients, no prior study has evaluated whether these patients also have sensory deficits. The aim of this study was to evaluate the sensory capacity of the laryngopharynx (LP) in supratentorial or brain stem stroke patients who presented with dysphagia. Fifteen stroke patients (mean age, 66.7 +/- 13.8 [SD] years) were prospectively evaluated by means of our previously described method whereby air pulse stimuli were delivered via a flexible fiberoptic telescope to the mucosa innervated by the superior laryngeal nerve. There were 15 age-matched controls. No LP sensory deficits were found in any of the age-matched controls. In all stroke patients studied, either unilateral (n = 9) or bilateral (n = 6) sensory deficits were identified. Deficits were defined as either a moderate impairment in sensory discrimination thresholds (3.5 to 6.0 mm Hg) or a severe sensory impairment (> 6.0 mm Hg). These sensory discrimination thresholds were significantly greater than in age-matched controls (7.05 +/- 0.17 mm Hg for the supratentorial group and 6.05 +/- 1.22 mm Hg for the infratentorial group versus 2.61 +/- 0.69 mm Hg for the controls). Among patients with unilateral deficits, sensory thresholds were moderately to severely elevated in all 9 cases on the affected side compared with the unaffected side (p < .01, Fisher's exact test). Moreover, the sensory thresholds of the unaffected side were not significantly different from those of age-matched controls (2.51 +/- 0.25 mm Hg versus 2.61 +/- 0.69 mm Hg, respectively). All 6 patients with bilateral deficits had severe impairments. The results of an outcome assessment in 13 of 15 patients revealed that 2 out of 5 patients with moderate LP sensory impairment and 5 out of 8 with severe impairment developed aspiration. Our results show for the first time that stroke patients with dysphagia have significant sensory deficits in the LP and that these impairments are likely to contribute to the development of aspiration.

Aged↗
PubMed1996

Semon's law revisited: an electromyographic analysis of laryngeal synkinesis.

Felix Semon's fascination with vocal fold paralysis led to his theory attributing medialization to isolated abductor paralysis. Later, the Wagner-Grossman hypothesis explained the vocal fold position on the basis of cricothyroid muscle activity. Other authors since that time have dispelled the notion of a role for the cricothyroid muscle in vocal fold position with paralysis. Utilizing laryngeal electromyography, several authors have found electrical activity suggestive of variable reinnervation and synkinesis. This current study included patients with persistent vocal fold immobility. Fourteen patients were studied: half with good voice and half with poor voice. The patients with good voice had a relatively normal arytenoid position and evidence of synkinesis. The group with poor voice had an arytenoid that tipped into the laryngeal inlet and had denervation or poor reinnervation. This suggests that the medialization and upright position of the arytenoid is due to synkinesis.

Electromyography↗
PubMed1995

Speech dysfunction in early Parkinson's disease.

The purpose of this study is to determine if subjects in the early stages of untreated Parkinson's disease (PD) or PD treated with deprenyl alone suffer from motor speech abnormalities. Speech defects are common in advanced PD, including disturbances of respiration, phonation, and articulation. We studied 12 subjects with early PD (Hoehn and Yahr stage < or = 2, mean duration disease 3.2 years) who were not taking symptomatic therapy and tested them under two conditions: on and off deprenyl. None of the subjects was depressed or demented (Mini Mental Status mean 29.9/30; Hamilton Depression Rating mean 2.7/52). All functioned independently (Schwab and England Activities of Daily Living mean 93.1/100). Acoustic and speech productions were assessed using the DSP Sona-Graph 5500 and an evaluation of dysarthria. All 12 had at least two characteristics of dysarthria on examination, although 8 were not aware of it. Vocal tremor was identified on narrow band spectrogram for four subjects. Deprenyl did not have a consistent effect on speech. Ten subjects had no detectable change in speech on deprenyl, one was worse, and one was improved.

Adult↗
PubMed1995

Voice failure after tracheoesophageal puncture: management with botulinum toxin.

Primary or secondary tracheoesophageal puncture with a speaking prosthesis has provided rehabilitation of speech in most patients after total laryngectomy. Persistent constrictor spasm is thought to be responsible for a small percentage of these patients' inability to speak with the prosthesis. Management of these patients has included bougienage and pharyngeal myotomy and/or pharyngeal neurectomy. Botulinum toxin injections of the cricopharyngeus muscle complex in six patients have been successfully used diagnostically and therapeutically for tracheoesophageal puncture failures. The assessment, technique, and results are discussed.

Aged↗
PubMed1995

Dyspnea in dystonia. A functional evaluation.

BACKGROUND: Dystonia consists of action-triggered sustained focal muscle contractions, worsened by effort, and resulting in voice changes, abnormal posturing, and dyspnea. The cause of dyspnea, previously unexplained, is the basis of this report. METHODS: Since the maximal efforts required to perform pulmonary function testing (PFT) could worsen the muscular contractions in dystonic patients, we used several tests to identify possible causes of dyspnea. These included spirometry with flow volume loops (FVL), tidal volume breathing, maximum voluntary ventilation (MVV), and inspiratory and expiratory muscle pressures (PImax, PEmax), sitting and supine. We used cycle ergometry with arterial blood gas (ABG) values to detect cardiac/pulmonary limitations and respiratory inductive plethysmography (RIP) to assess chest wall/abdominal movements for synchrony. Dynamic videofluoroscopy (VF) assessed and recorded the action-triggered muscle activity of the upper airways and the diaphragm during quiet breathing, speech, swallowing, and maximal respiratory maneuvers similar to the efforts required during PFT. RESULTS: Twenty-six dystonic patients, 12 women and 14 men, ages 14 to 70 years (mean age, 52.3 years) were evaluated. Their neurologic classification included 22 primary (idiopathic) and 4 secondary (2 postneuroleptic use, 2 posstraumatic). Four patients originally classified as having focal dystonia had dyspnea and were found to have diaphragmatic and/or upper airway dysfunction too. The PFTs showed abnormal FVL and/or tidal volume breathing patterns, with intermittent interruptions of air flow during inspiration or expiration in 20 of 24 patients. The VF was abnormal in 24 of 26 patients: 19 patients had combined upper airway (UA) and diaphragmatic dysfunction (DD); 1 patient had UA dysfunction alone, and 4 patients had DD alone. Except for poor effort and/or dystonic movements, cycle ergometry was normal in 18 of 21 patients. The ABG values and/or pulse oximetry were normal in 19 of 22 patients. CONCLUSION: Dyspnea in dystonia appears to be due to excessive and/or dysynchronized contractions of the upper airways and/or diaphragm, with usually normal gas exchange. These spasmodic and irregular muscular contractions during speech and daily activities are associated with the sensation of excessive effort to overcome the spasms. Excessive spasms can be triggered during PFT and are best detected on FVL patterns coupled with dynamic VF.

Adolescent↗
PubMed1994

Enterogenous cyst of the orbital apex and superior orbital fissure.

BACKGROUND: Enterogenous cysts of the central nervous system are rare congenital tumors with a single layer of mucin-secreting epithelial cells resembling gastrointestinal epithelium. The tumor is located most commonly at lower cervical and cervicothoracic spinal levels; only 22 intracranial cases have been reported. To the authors knowledge, this entity has not been described in the orbit. METHODS: A 23-year-old woman with painful loss of vision and ophthalmoplegia in the left eye was treated with oral and intravenous corticosteroids for presumed orbital inflammation. After a cystic lesion in the left orbital apex was demonstrated on computed tomographic scan and magnetic resonance imaging, various diagnoses, including optic nerve tumor, granulomatous inflammation, lymphoma, vascular anomaly, and pseudotumor, were considered until transcranial biopsy established the correct diagnosis. The tumor subsequently recurred twice. RESULTS: More than 3 years after the last recurrence, the patient has no pain but had unilateral optic atrophy, significant visual field loss, limited motility, and an anesthetic cornea in the left eye. CONCLUSION: The diagnosis of enterogenous cyst is difficult without adequate biopsy because the radiologic and clinical presentation of this rare tumor may be confused with other lesions. Previous attempts to explain intracranially placed enterogenous cysts offer no explanation for an orbital occurrence nor do they adequately describe a mechanism for an intracranial location in general. An embryologically based explanation that takes into account the occurrence of this entity from the caudal to rostral extent of the neuraxis is described. This theory suggests that the orbit is the most rostral possible location for an enterogenous cyst.

Adult↗
PubMed1994

Botulinum toxin A for hyperkinetic facial lines: results of a double-blind, placebo-controlled study.

Previous work on patients with muscular dystonia has shown that small intramuscular doses of botulinum toxin A eliminated hyperkinetic facial lines for approximately 6 months. The purpose of this study was to determine the efficacy of botulinum toxin A injections in eliminating facial wrinkles in aesthetic surgery patients who do not have muscular dystonia. Eleven healthy subjects were studied in a double-blind fashion. On both sides of the face, 0.2 cc of either normal saline or botulinum toxin A was injected into the forehead or into the periorbital wrinkles (crow's feet). Documentation of results was made by photographs taken of the patients during repose and during facial animation before and after injection. Assessment of facial wrinkles was done from a grading system in which the patient and the facial plastic surgeon were asked to judge the severity of the wrinkles on a scale from 0 to 3, with 0 reflecting no facial wrinkles and 3 reflecting severe facial wrinkling. Nine of 11 subjects injected with botulinum toxin A noted a significant improvement in the severity of their facial wrinkles in comparison with the side of the face injected with saline, with a rating improvement of 2 points. Two of 11 subjects noted a moderate improvement, with a rating improvement of 1 point. No patient injected with saline reported an improvement in the severity of the facial wrinkles on the control side. There were no serious complications. Botulinum toxin A is an efficacious method of nonsurgically eliminating facial wrinkles and may play a role in the cosmetic enhancement of the aging face.

Adult↗
PubMed1994

Age-related changes in pharyngeal and supraglottic sensation.

As one ages, sensory discrimination in the oral cavity progressively diminishes, and dysphagia and aspiration are more likely to occur. Whether similar age-related laryngeal and pharyngeal sensory abnormalities exist and contribute to dysphagia and aspiration is unknown. The purpose of this study was to determine if sensory discrimination in the area innervated by the superior laryngeal nerve diminishes with increasing age. By applying a previously described new device and technique that utilizes brief air pulse stimulation of the anterior wall of the pyriform sinus, sensory discrimination can be reliably determined. We carried out 672 trials in 56 healthy adults divided into three age groups: 20 to 40, 41 to 60, and 61 to 90 years of age. Overall, the average sensory discrimination was 2.30 +/- 0.50 mm Hg. In subjects 20 to 40 years of age, sensory discrimination was 2.07 +/- 0.20 mm Hg, while in subjects 61 to 90 years of age, sensory discrimination was 2.68 +/- 0.63 mm Hg (p < .05). There also was a statistically significant difference between the 41- to 60-year and 61- to 90-year age groups (p < .05). Progressive diminution in pharyngeal and supraglottic sensitivity with increasing age might be a contributing factor in the development of dysphagia and aspiration in the elderly.

Adult↗
PubMed1994

Epistaxis, medical history, and the nasopulmonary reflex: what is clinically relevant?

Posterior epistaxis and its management are associated with increased morbidity and sudden death. A "nasopulmonary reflex," changes in pulmonary function induced by packing, has been postulated to cause hypoxia and lead to the reported morbidities. However, no study has followed patients prospectively to associate complications with oxygen status. Continuous pulse oximetry monitoring of 19 patients hospitalized with posterior packing was undertaken to document the incidence and extent of oxygen desaturation, and to correlate complications with O2 status and historical factors. A further aim was to clarify the clinical relevance of the nasopulmonary reflex. In 1200 hours of monitoring, desaturations to less than 90% were observed on only two occasions: one self-limited episode in an actively bleeding patient and one major hypoxic event with respiratory arrest in an alcoholic patient under sedation for delirium tremens. Complications, while uncommon, were more appropriately ascribed to rebleeding or underlying medical problems than to primary O2 status. The nasopulmonary reflex, as previously described in terms of a primary drop in O2, therefore seems clinically irrelevant. Early surgery for posterior epistaxis is not warranted on the basis of maintenance of adequate oxygenation alone.

Adult↗
PubMed1994

Laryngeal botulinum toxin injections for disabling stuttering in adults.

Stuttering is an action-induced speech disorder with involuntary, audible, or silent repetitions or prolongations in the utterance of short speech elements (sounds, syllables) and words. Symptomatic treatment programs frequently have initial success; persistent benefit is variable and many patients remain disabled. Stuttering has many characteristics similar to spasmodic dysphonia (laryngeal dystonia), often including the presence of adductor laryngeal spasms that obstruct airflow (glottal block). We hypothesized that relief of the spasmodic dysphonic glottal blocks in stutterers would modify the stuttering phenomenon and increase fluency. We therefore studied the effects of bilateral vocal fold injections of botulinum toxin type A (BTX) on dysfluency and speech characteristics in stuttering. We treated 14 adult patients (12 men, 2 women) with persistent stuttering and glottal block who previously failed standard speech therapy with 1.25 U BTX into each thyroarytenoid (vocalis) muscle. Fluency evaluations included the Stuttering Severity Instrument, the Perceptions of Stuttering Inventory, and a global rating scale (percent of normal function). Patients were evaluated at baseline and at 2-, 6-, and 12-week follow-up visits. Improvement in fluency documented by each rating instrument occurred at 2 and 6 weeks, with functional relapse by 12 weeks in most patients. We conclude that therapeutic laryngeal injections of botulinum toxin are useful in the management of stuttering with glottal block and result in a moderate improvement in fluency. When an adult patient with developmental stuttering with glottal blocks has failed speech interventional therapy and presents for treatment, a trial of BTX can be considered early.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Treatment of adductor laryngeal breathing dystonia with botulinum toxin type A.

Adductor laryngeal breathing dystonia (ALBD) is a rare disorder in which patients have persistent inspiratory stridor, usually normal voice, and cough. Physical exam is characterized by paradoxical movement of the vocal cords on inspiration. These patients have involuntary action-induced spasms of the adductor laryngeal muscles on inspiration. There has been no uniformly satisfactory treatment for the disease. Speech therapy, psychotherapy, and pharmacotherapy have all had limited success. We report the successful use of botulinum toxin type A in seven patients with adductor laryngeal breathing dystonia. All patients received bilateral thyroarytenoid injections. All patients had toxin effect within 72 hours, reaching maximal effect within 2 weeks with sustained improvement for an average of 13.8 weeks. Adverse effects included breathy voice and mild choking on liquids. Both resolved, on average, within 2 weeks. This retrospective study supports the safe and effective use of botulinum toxin type A in the treatment of adductor laryngeal breathing dystonia.

Botulinum Toxins↗
PubMed1993

Botulinum toxin for the treatment of hyperfunctional lines of the face.

OBJECTIVE: To determine the effectiveness of botulinum toxin injections for the management of hyperfunctional facial lines in patients with dystonia. DESIGN: Twenty-six patients were included in the study: 24 patients had dystonic movement of the face as either a primary or secondary component, and two patients were treated for purely hyperfunctional lines. Botulinum toxin type A was injected via a monopolar hollow-bore Teflon-coated electromyography needle into the facial muscles associated with the hyperfunctional lines. Doses were divided into 1.25- to 10-U aliquots. Qualitative assessments by the patient and physician were made before injection and 2 to 3 weeks after injection. PATIENTS: Twenty-six patients (two male and 24 female) with hyperfunctional lines were included. The ages were from 32 to 84 years with an average age of 59 years. Twenty had dystonia, four had hemifacial spasm, and two had pure hyperfunction without neuromuscular disease. RESULTS: All of the patients had an effect of toxin within the first 24 to 72 hours. All of the patients experienced benefit from the toxin injections with partial or total resolution of painful contractions or unsightly hyperfunctional lines and spasms. The effects of the injection lasted 3 to 6 months. No systemic side effects were noted. Adverse effects included mild, temporary eyelid or lip weakness. CONCLUSION: Based on this initial pilot study, botulinum toxin may be an important new option for the treatment of patients with hyperfunctional facial lines.

Adult↗
PubMed1993

Air pulse quantification of supraglottic and pharyngeal sensation: a new technique.

There are no published studies evaluating the sensory capacity of the region innervated by the superior laryngeal nerve. A normal sensory capacity is important in this area, since hypesthesia or anesthesia of the pharynx and supraglottic larynx may result in dysphagia and aspiration. This often occurs after stroke or after ablative surgery of the pharynx and larynx. Evaluating the efficacy of restorative procedures for supraglottic and pharyngeal sensation is dependent on defining and quantifying the sensory deficit. We have developed a new, noninvasive method to measure sensation in the pharynx and supraglottic larynx. A puff of air--of precisely controlled duration and pressure--was delivered via a flexible telescope to the anterior wall of the pyriform sinus. Surface sensibility was determined according to the psychophysical method of limits by varying air pressure while holding puff duration constant. We conducted 204 trials in 20 healthy adults. The average sensory discrimination threshold was 2.09 +/- 0.15 mm Hg. An intraclass correlation revealed excellent consistency (R = .80). There was no statistically significant difference between the right and left sides. Brief air pulse stimulation is an easy, relatively safe, and reliable method of determining supraglottic and pharyngeal sensory discrimination thresholds.

Adult↗