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PubMed2005

Sleep paralysis and recovered memories of sexual abuse: comment on McNally and Clancy (2005).

McNally and Clancy [McNally, R. J., & Clancy, S. A. (2005). Sleep paralysis in adults reporting repressed, recovered, or continuous memories of childhood sexual abuse. Journal of Anxiety Disorders, 19, 595-602.] conducted a study on sleep paralysis among adults reporting either repressed, recovered, or continuous memories of sexual abuse. I suggest that the study be replicated with a larger number of recovered memory subjects (those who believe that they have recovered memories of childhood sexual abuse) who experienced sleep paralysis, using more neutral wording in order to identify the phenomenon of sleep paralysis.

Adult↗
PubMed2006

Thyrotoxic periodic paralysis and anesthesia report of a case and literature review.

Thyrotoxic periodic paralysis (TPP) is a disease characterized by recurrent episodes of paralysis and hypokalemia during a thyrotoxic state. The disease primarily affects people of Asian descent, but can affect other ethnic groups. In Asians, the symptoms of thyrotoxicosis are distinct and usually precede the first paralytic episode, whereas in non-Asian populations, paralysis is the presenting symptom. If TPP has not been diagnosed and the patient has a surgical procedure during general or regional anesthesia, symptoms of the disease may be confused with other adverse perioperative events such as delayed recovery from neuromuscular paralysis. No specific anesthetic regimen is superior. Current TTP treatment recommendations involve treating the underlying hyperthyroid state. Other modalities such as beta-blockade and potassium replacement are also important in the acute paralytic state. Future diagnostic and treatment innovations may lie in the genetic and molecular understanding of this disease. We present a case of an Asian male with known TPP undergoing general anesthesia, a brief case series involving 5 patients, and a review of the literature.

Adult↗
PubMed2005

Perturbation and nonlinear dynamic analyses of voices from patients with unilateral laryngeal paralysis.

This study used perturbation methods (eg, jitter and shimmer) and nonlinear dynamic methods (eg, phase space reconstruction and correlation dimension) to analyze sustained voices generated by normal subjects and patients with unilateral laryngeal paralysis. We found that normal and pathological voices had low-dimensional dynamic characteristics. For nearly periodic voices, jitter and shimmer values of pathological voices from patients with unilateral laryngeal paralysis were significantly different from normal voices. For nearly periodic and aperiodic voices, the correlation dimensions of pathological voices were statistically higher than normal voices. Receiver operating characteristic analysis was used to evaluate the diagnostic performances of jitter, shimmer, and correlation dimension. High sensitivity and specificity of these three acoustic analyses in distinguishing unilateral laryngeal paralysis patients from normal subjects were found. We concluded that combining traditional perturbation analysis and nonlinear dynamic analysis might provide efficient descriptions of pathological voices and represent a valuable tool for clinical diagnosis of laryngeal paralysis.

Adolescent↗
PubMed2004

Mutation screening in Korean hypokalemic periodic paralysis patients: a novel SCN4A Arg672Cys mutation.

Familial hypokalemic periodic paralysis is an autosomal-dominant disorder with features of both genetic and phenotypic heterogeneity. Mutation screening was performed on Korean hypokalemic periodic paralysis patients to locate the corresponding mutations and to specify the clinical features associated with the mutations. Target-exon PCR, direct sequencing, and restriction fragment length polymorphism analysis were used. A novel SCN4A Arg672Cys mutation and a known CACNL1A3 Arg528His mutation were identified. Incomplete penetrance in women with Arg672Cys mutation was evident. A comparison of the present study with previous studies raises the possibility that hypokalemic periodic paralysis is an allelic-specific or mulfactorial, rather than a gene-specific, disorder. Reported herein are two Korean hypokalemic periodic paralysis families, one carrying a novel SCN4A Arg672Cys mutation with incomplete penetrance in women, and the other carrying a CACNL1A3 Arg528His mutation, with the onset of characteristics of hypoPP developing at an earlier age, as well as a higher penetrance rate in women.

Action Potentials↗
PubMed2005

Reliability of the "Sydney," "Sunnybrook," and "House Brackmann" facial grading systems to assess voluntary movement and synkinesis after facial nerve paralysis.

OBJECTIVE: To investigate the extent of within-system reliability and between-system correlation for the "Sydney" and "Sunnybrook" systems of grading facial nerve paralysis, and to examine the interobserver reliability and agreement of the "House Brackmann" grading system. STUDY DESIGN: A fixed-effects reliability study in which 6 otolaryngologists viewed videotapes of patients with facial nerve paralysis. SETTING: University and medical Centers. PATIENTS: Patients with unilateral lower motor neurone facial nerve dysfunction greater than 1 year after onset, none of whom had undergone surgical reanimation procedures. Intervention Twenty-one patients with facial nerve paralysis were videotaped while they performed a protocol of facial movements. Six otolaryngologists viewed the videotapes and scored them with the Sydney and Sunnybrook systems, and then gave a House Brackmann grade. MAIN OUTCOME MEASURE: The 3 systems of grading facial nerve paralysis were evaluated and compared with the use of intraclass correlation coefficients, Pearson's weighted kappa, and percentage exact agreement values. RESULTS: The Sydney and the Sunnybrook systems had good intrasystem reliability and high intersystem association for the assessment of voluntary movement. Grading of synkinesis was found to have low reliability both within and between systems. The House Brackmann system had substantial reliability as shown by weighted kappa but had a percentage exact agreement of 44%. CONCLUSIONS: For clinical grading of voluntary movement, there is good correlation between ratings given on the Sydney and Sunnybrook systems, and within each system there is good reliability. The assessment of synkinesis was far less reliable within, and less related between, systems. Although the reliability of the House Brackmann system was found to be high, examination of individual grades revealed some wide variation between trained observers.

Adult↗
PubMed2005

Bilateral congenital vocal cord paralysis: a 16-year institutional review.

OBJECTIVE: To review the management and outcome of bilateral congenital true vocal cord paralysis in 22 patients treated over a 16-year period and to review the role of tracheostomy in these patients. DESIGN: Retrospective chart review. SETTING: Pediatric tertiary hospital. PATIENTS: Twenty-two pediatric patients diagnosed with bilateral congenital true vocal cord paralysis. INTERVENTIONS: Flexible or rigid diagnostic evaluation, tracheostomy, and vocal cord lateralization procedures. MAIN OUTCOMES MEASURES: Vocal cord recovery and decannulation. RESULTS: With a mean follow up of 50 months, 15 of 22 patients (68%) with bilateral vocal cord paralysis required tracheostomy for airway securement. Of the 15 tracheotomized patients, 10 were successfully decannulated (8 had spontaneous recovery, whereas 2 required lateralization procedures). Eleven of these patients with tracheostomy had comorbid factors, including neurologic abnormalities (midbrain/brainstem dysgenesis, Arnold-Chiari malformation, global hypotonia, and developmental delay). Of the 7 patients not requiring tracheostomy, 6 recovered vocal cord function (86%). CONCLUSION: In our series of 22 patients with bilateral vocal cord paralysis, 14 had spontaneous recovery of function. Patients managed with tracheostomy were noted to have a high incidence of comorbid factors. In this series, recovery rates were found to be higher in nontracheostomized patients than in tracheostomized patients. Patients can be carefully selected for observation versus tracheostomy at the time of diagnosis based on underlying medical conditions.

Cohort Studies↗
PubMed2004

Pediatric tick paralysis: discussion of two cases and literature review.

This report describes two cases of tick paralysis in children diagnosed within a 3-month period (May-July 2002) in rural South Carolina. Differing presenting symptoms consisted of acute onset of ataxia in one patient and acute ascending paralysis in the other. Ticks were present on the scalp of both patients and were removed immediately. Both girls demonstrated improvement of signs and symptoms within hours and complete recovery within 24 hours of tick removal. The diagnosis of tick paralysis must be considered in any patient, particularly children, who present with either acute ataxia or acute ascending paralysis. As in any clinical encounter, careful history and thorough general and neurologic examinations must be performed to exclude the possibility of tick attachment.

Child↗
PubMed2001

Correlation of cleavage of SNAP-25 with muscle function in a rat model of Botulinum neurotoxin type A induced paralysis.

Injection of botulinum neurotoxin serotype A (BoNT/A) into muscle results in cleavage of the synaptosomal associated protein of 25 kDa (SNAP-25) and relatively long-term paralysis. However, nerve-terminal sprouting, which appears to require intact SNAP-25, has been reported to occur much earlier. The difference between the long-term paralysis induced by injection of BoNT/A and the short time needed for sprouting led us to investigate the relationship between BoNT/A catalyzed cleavage of SNAP-25 and muscle function. The effect of BoNT/A on SNAP-25 present in nerve endings innervating gastrocnemius muscles of rats was monitored over time. Cleaved SNAP-25 was found in nerve terminals innervating the muscles within 24h of inoculation with BoNT/A and was present more than 2 months later. Comparison of the ratios of cleaved to intact SNAP-25 from the onset of BoNT/A-induced paralysis until function was regained indicated that paralysis was probable when the ratio of cleaved to intact SNAP-25 was greater than 0.35.

Animals↗
PubMed2000

Antagonism of botulinum toxin A-mediated muscle paralysis by 3, 4-diaminopyridine delivered via osmotic minipumps.

The ability of 3,4-diaminopyridine (3,4-DAP) to antagonize muscle paralysis following local injection of botulinum neurotoxin A (BoNT/A) complex was evaluated in the in situ rat extensor digitorum longus (EDL) preparation. The minipumps were implanted 6 h prior to BoNT/A administration and delivered their contents over a 7-day period producing a steady plasma 3,4-DAP concentration of 27-29 microM. In the absence of 3,4-DAP, a local injection of five mouse LD(50) units of BoNT/A led to total paralysis of EDL muscles within 24 h of application. Recovery from paralysis was slow, remaining at <30% of control 14 days after toxin injection. 3,4-DAP delivery by osmotic minipumps antagonized the actions of BoNT/A on neuromuscular transmission. Seven days after the onset of 3,4-DAP infusion, indirectly elicited twitch and tetanic tensions in BoNT/A-injected EDL muscles were 72.4 and 46.9% of control, respectively. In the absence of 3,4-DAP, twitch and tetanic tensions were only 5.4 and 15. 1% of control. The benefits conferred by 3,4-DAP treatment were not maintained after minipumps were removed. Seven days after cessation of 3,4-DAP infusion, twitch and tetanic tensions were not significantly different from those observed in muscles receiving BoNT/A alone. It is concluded that 3,4-DAP may be useful for treatment of BoNT/A-induced muscle paralysis, but sustained delivery of the drug would be required for the entire period of BoNT intoxication to maintain muscle function.

4-Aminopyridine↗
PubMed1997

Neurophysiological evaluation of acute facial paralysis in children.

Objective evaluation of facial nerve paralysis represents a unique challenge to the clinician. Electroneurography (ENoG) and the acoustic reflex (AR) have been widely used as neurophysiological tests in an assessment of facial nerve function. However, ENoG or AR alone does not suffice diagnostic and prognostic purposes of facial function evaluation in children. To further investigate the diagnostic aspects of facial nerve paralysis, the prognostic value of AR and ENoG, and the time course of the disease in pediatric population, a series of 30 children with acute facial paralysis were investigated by correlation of findings from video-taped House-Brackmann facial grading system. AR and ENoG. The results showed that AR was absent or abnormal for thresholds in 68.2% of patients with Bell's palsy and normal middle ear function. Shorter duration and higher percentage of recovery were found in the children with a normal AR than those with an abnormal AR. Three children showed an abnormal tympanogram and hearing loss associated with acute facial paralysis. These findings should alert the clinician to the presence of a specific, treatable disease in the evaluation of Bell's palsy. The percentage of electroneurographic response varied with different days after onset. ENoG showed minimal responses at weeks 1 3 after onset of Bell's palsy in most patients. The study of the time-course in the children with Bell's palsy demonstrated a functional gap in the early (< 1 week) and late clinical stage (after 6 weeks) of the disease, suggesting that ENoG predicted well only during weeks 1-4 after onset. In general, ENoG showed a good recovery in children, however, recurrent Bell's palsy becomes a concern. The need for neurophysiological follow-up for possible incomplete recovery of the facial nerve is emphasized. It is recommended that AR and ENoG should be included in the diagnostic workup when evaluating pediatric facial function.

Acoustic Impedance Tests↗
PubMed1985

Functional reconstruction for unilateral recurrent laryngeal nerve paralysis caused by thyroid cancer.

Surgery for unilateral recurrent laryngeal nerve paralysis, which is caused by thyroid cancer, appearing within the past six months, should be aimed at improvement of the asymmetrical vocal cord and preservation of the stiffness and the mass of the vocal fold. To accomplish these aims, reconstructive surgery of the neuromuscular systems is available and it should be performed at the same time as thyroidectomy. Our surgical procedures for unilateral recurrent laryngeal nerve paralysis caused by thyroid cancer are reported along with some experimental investigations in dogs. Experimentally, muscle atrophy was prevented by neurorrhaphy or by free nerve grafting of the recurrent laryngeal nerve, although movement of the vocals cord was not recovered due to misdirected reinnervation and reduction of the end plates. In our study of functional reconstruction for unilateral recurrent laryngeal nerve paralysis, end-to-end anastomosis or free nerve grafting between the recurrent laryngeal nerve after extirpating the abductor muscle branch of this nerve was the most effective and practical method for improvement of the adductor function. Clinically reconstructive surgery was performed on five females suffering from thyroid cancer with unilateral recurrent laryngeal nerve paralysis. The abductor branch was cut selectively in four cases, followed by free nerve grafting of the ansa cervicalis and pedicle nerve muscle graft of the thyrohyoid muscle implanted in one case. Vocal cord atrophies were not observed and phonations were good in all cases six months after of operation. However, obvious adduction of the operated vocal fold at phonation was obtained only in two cases and other two cases showed slight adduction.

Adult↗
PubMed2003

Diagnosing thyrotoxic periodic paralysis in the ED.

Thyrotoxic periodic paralysis (TPP) and sporadic periodic paralysis (SPP) are the most common causes of hypokalemic periodic paralysis (HPP) in EDs in Asia. Their neuromuscular presentations are almost indistinguishable. We conducted this study to identify clinical clues that can help EPs distinguish between TPP and SPP. Thirty-four patients presenting to the ED with HPP were enrolled during a 3-year period. They did not have known hyperthyroidism before the attack and no family history of paralysis. They all had low K(+) excretion rates. Vital signs and blood biochemistry, including acid-base and electrolytes, were measured. TPP was subsequently established by thyroid function tests. Twenty patients had TPP and 14 patients had SPP. There was no significant difference in age and sex distribution between them. Systolic (SBP) but not diastolic blood pressure (SBP 145 +/- 4 vs 128 +/- 4 mm Hg, P < 0.001) and heart rate (106 +/- 3 vs 73 +/- 3 beats/min, P < 0.001) were significantly higher in those experiencing TPP than SPP. Among the biochemical factors, only plasma phosphate concentration (2.2 +/- 0.2 vs 3.2 +/- 0.2 mg/dL, P < 0.001) was significantly lower in those experiencing TPP than SPP. Systolic hypertension, tachycardia, and hypophosphatemia are clinical clues favoring the diagnosis of TPP.

Adult↗
PubMed2000

Voice-related quality of life (V-RQOL) following type I thyroplasty for unilateral vocal fold paralysis.

Unilateral vocal fold paralysis is a common clinical problem which frequently causes severe dysphonia. Various treatment options exist for this condition, with the type I thyroplasty being one of the more commonly performed surgical procedures for vocal rehabilitation. The Voice-Related Quality of Life (V-RQOL) Measure is a validated outcomes instrument for voice disorders. This study measured the V-RQOL of patients with unilateral vocal fold paralysis who had undergone a type I thyroplasty and compared these scores to those of patients with untreated and uncompensated unilateral vocal fold paralysis and to normals. Treated patients had significantly higher domain and overall V-RQOL scores than untreated patients, but also scored lower than normals. These differences were true across gender and age. Patients who were more distant from surgery had lower V-RQOL scores than those who had more recently been treated. It is concluded that type I thyroplasty leads to a significantly higher V-RQOL for patients with unilateral vocal fold paralysis. This study also demonstrates further the utility of patient-oriented measures of treatment outcome.

Female↗
PubMed2003

Vocal fold paralysis following radiotherapy for nasopharyngeal carcinoma: laryngeal electromyography findings.

Laryngeal electromyography was used to study the pattern of neurological injury in three patients with unilateral vocal fold paralysis following radiotherapy for nasopharyngeal carcinoma. The thyroarytenoid and cricothyroid muscles were assessed to give an indication of recurrent and superior laryngeal nerve function. Two patients demonstrated both recurrent and superior laryngeal neuropathy suggesting injury at the skull base. The other patient had only recurrent laryngeal neuropathy indicating more distal involvement. Subclinical neuropathic changes were seen in two cases on the side contralateral to the vocal fold paralysis. These patients may be at increased risk of developing bilateral vocal fold paralysis and potentially life-threatening airway obstruction. Long-term follow-up is recommended for such patients, especially if medialization thyroplasty is being considered. This is the first report describing the use of electromyography to determine the pattern of nerve injury in patients with vocal fold paralysis following head and neck radiotherapy.

Carcinoma↗
PubMed2003

Sarcoidosis presenting as bilateral vocal fold paralysis.

Sarcoidosis with cranial polyneuritis and mediastinal granulomatous compression as a cause of unilateral left vocal fold paralysis has been reported infrequently. No case of sarcoidosis causing bilateral vocal fold paralysis in the abducted position has been reported in the Otolaryngology/Voice literature. Vocal fold function can be impacted in sarcoidosis by direct laryngeal involvement or by neural pathways. In the patient described in this case, sarcoid cranial polyneuritis coupled with bilateral paratracheal and mediastinal adenopathy resulted in bilateral vocal fold paralysis. This patient had a dramatic response to treatment with steroids. Sarcoidosis should be included in the differential diagnosis of unilateral or bilateral vocal fold paralysis.

Adult↗
PubMed1998

Voice range in superior laryngeal nerve paresis and paralysis.

Evaluation of Physiologic Frequency Range (PFR) and Musical Frequency Range (MRP) of Phonation was performed on 56 adults (singers and nonsingers) presenting with superior laryngeal nerve (SLN) paresis or paralysis confirmed by laryngeal electromyography. The most common etiology was neuritis (69.7%), followed by iatrogenic and unknown causes,each accounting for 10.2% of cases, and finally trauma (8.9%). Both female and male singers with SLN paresis or paralysis had significantly higher PFR and MPR than nonsingers. Female classical singers presented PFR and MPR of up to 10 semitones (ST) higher than nonclassical singers and nonsingers. The lowest PFR and musical ranges were found in patients with SLN paresis associated with recurrent laryngeal nerve paresis or paralysis. The authors suggest that voice range measurement is a useful parameter for analyzing the effects of SLN paresis or paralysis on voice and that it may also assist in measuring outcome following voice therapy.

Adult↗
PubMed2002

Vocal cord paralysis after open-heart surgery.

Vocal cord paralysis is a known entity often described as a complication of neck surgery. A less frequent site of injury to the recurrent laryngeal nerve is the chest. The left side is usually more affected than the right side in view of its long intrathoracic segment. Only few cases of right vocal cord paralysis following open-heart surgery are reported in the literature. The purpose of this article is to review the common possible mechanisms of injury to the right recurrent laryngeal nerve following open-heart surgery in order to draw the attention of the caring physician to the clinical significance of such a complication. In fact, transient hoarseness following open-heart surgery may be an ominous sign of recurrent laryngeal nerve injury. It should not be assumed to be secondary to intralaryngeal edema. Several mechanisms of injury to the recurrent laryngeal nerve have been suggested: (1) through central venous catheterization; (2) by traction on the esophagus; (3) by direct vocal cord damage or palsy from a traumatic endotracheal intubation; (4) trauma by compression of the recurrent laryngeal nerve or its anterior branch at the tracheoesophageal groove by an inappropriately sized endotracheal tube cuff; (5) by a faulty insertion of a nasogastric tube; (6) median sternotomy and/or sternal traction pulling laterally on both subclavian arteries; (7) direct manipulation and retraction of the heart during open-heart procedures; (8) hypothermic injury with ice/slush. If vocal cord paralysis was overlooked as a possible complication of open-heart surgery, the patient may suffer from dysphonia in addition to problems of paramount importance such as inefficient cough and aspiration. Although it is true that the incidence of vocal cord paralysis remains very low, yet its presence is alarming and necessitates close follow up on the patient for the possible need of surgical intervention if recovery fails.

Cardiac Surgical Procedures↗
PubMed1999

Does hoarseness of voice from recurrent nerve paralysis after esophagectomy for carcinoma influence patient quality of life?

BACKGROUND: Recurrent laryngeal nerve injury caused by esophageal cancer surgery is worrisome but often temporary; it is unclear when and how the paralysis is resolved. Hoarseness of voice from vocal cord paralysis (VCP) can have detrimental effects on postoperative patients. The aims of this study were to clarify the progress of nerve paralysis related to difficulty in talking after surgery and to assess whether hoarseness influences patient quality of life. STUDY DESIGN: Between 1985 and 1996, 141 esophageal cancer patients undergoing a resection by the Akiyama procedure were cancer free 1 year after surgery. Among them, 51 patients with VCP on discharge from the hospital were retrospectively reviewed. Their VCPs, body weights, and pulmonary functions were examined yearly. They were given a questionnaire relating to the difficulty in talking 1 year after surgery. RESULTS: VCP on discharge spontaneously healed within 1 year of surgery in 21 patients (41.2%), with the mean duration of difficulty in talking 5.7 months. The remaining 30 patients had persistent VCP 1 year after surgery; 4 VCPs spontaneously healed approximately 2 years after surgery. Eleven of the 30 patients with persistent VCP, who complained of severe hoarseness at 1 year postoperatively from inability to close the glottis during exertion, showed debilitation in performance status, abilities to go up stairs, and swallowing. In the group of patients with severe hoarseness, the percentage of ideal body weight (90.6%+/-11.0%) preoperatively and pulmonary functions at 3 years postoperatively were deteriorated, resulting in 3 patients with repeated aspiration pneumonia. CONCLUSIONS: The inability to compensate for aspiration, presenting as severe hoarseness, may be dependent on the preoperative nutritional state of patients along with degree of vocal cord atrophy and a decrease in pulmonary support. Persistent nerve paralysis deteriorates quality of life until it is adequately treated.

Airway Obstruction↗