神经肌电图监测下经皮肉毒素A喉肌注射治疗痉挛性发音障碍

目的　探索神经肌电图监测下经皮肉毒素A注射治疗痉挛性发音障碍的效果和价值。方法　根据喉内镜、嗓音学检查后诊断为痉挛性发音障碍的患者18例,进 行神经肌电图监测下经皮肉毒素A,根据痉挛的部位,注射部位为甲杓肌、甲会厌肌、环杓后肌等,剂量为0.1～1.0U,注射频率为每月1次,行频闪喉镜检查和嗓音障碍指数（voice handicap index,VHI）主观评分以及客观嗓音分析,包括喉肌电图检查（EMG）、基频微扰（jitter）、振幅微扰（shimmer）以及最大发音持续时间（maxium phonationtime,MPT）测定等来评估患者的嗓音质量。结果　18例患者注射后24小时起效,发音震颤及中断症状明显改善,发音流利、平稳,无音质紧张,疗效均持续1个月,经过3次注射后,患者喉内镜下见声带震颤症状明显消失,患者发音流利,嗓音主观评估和客观嗓音分析明显改善,注射前声 带闭合时挤压明显,声门上区代偿;注射后声带闭合时节奏感,声门上区代偿减轻。喉肌电图和多维嗓音分析程序（MDVP）提示注射后比注射前改善明显。所有患者术后均并发程度不等的声嘶症状,一般在注射后2天出现,持续3~5天,3例患者出现饮水呛咳,所有患者无呼吸困难。所有患者随访6~36个月,发音良好。结论　神经肌电图监测下经皮肉毒素A喉肌注射是治疗痉挛性发音障碍的有效方法。     

痉挛性发音障碍的喉功能特点

目的 为了探讨痉挛性发音障碍的喉功能特点及其发音障碍的表现形式。方法 对24例痉挛性发音障碍患者（男4例,女18例）的发病诱因、发音障碍特征、喉镜所见、喉肌电及喉空气动力学改变进行了分析。结果 痉挛性发音障碍主要表现为音韵及声音的流畅性障碍,主观听觉上以紧张性发音障碍为特点;喉镜检查可看到痉挛性发音时声带过度内收,室带不同程度的内收超越,重者声带强烈内收,会厌、室带以及整个喉呈闭锁状态;典型的喉肌电图所见为束发性放电;喉呼气流率明显减少。结论 痉挛性发音障碍伴随着紧张性发音的同时声带或整个喉强烈内收痉挛,同时伴有呼气流率下降,典型病例可看到喉肌电的改变。     

重症肌无力的咽喉部临床特点

目的 研究重症肌无力患者咽喉部表现特点及喉肌电图特点.方法 分析30例重症肌无力患者咽喉科的症状、体征和嗓音声学检测、喉肌电图检查及喉神经重频刺激肌电反应检查结果,并与健康对照组比较分析.结果 重症肌无力患者中36.7%(11/30)有声嘶、声低、吞咽费力等咽喉部症状,频闪喉镜下发现16.7%(5/30)患者有声带活动略无力,声门闭合有缝隙.嗓音频谱分析结果:重症肌无力患者嗓音振幅(68.3±14.6)dB(-x±s,以下同),最长发声时间(15.1±4.0)s,均显著低于健康对照;振幅微扰(2.43±1.19)%,标准化噪声能量(-9.6±3.3)dB,均显著高于健康对照.喉肌电图检查结果:重症肌无力患者喉肌肌电干扰型波幅除杓间肌外,均明显低于健康对照,甲杓肌和环甲肌尤为显著,低、中、高调时甲杓肌波幅分别为(215±69)μV、(298±113)μV和(380±153)μV;环甲肌分别为(253±92)μV、(361±116)μV和(486±155)μV;转折数多稍高于健康对照,但差异无统计学意义.喉肌重频刺激反应结果:83.3%(25/30)患者喉肌重频刺激反应阳性,平均受累喉肌数2.2±1.3,平均重频衰减率(27.9±19.2)%.结论 重症肌无力患者虽仅少部分表现出咽喉部症状,但大部分有喉肌受累.对于因声弱声嘶、发音费力而就诊的患者,应将重症肌无力作为一项必要的鉴别诊断.喉肌重频刺激可用于重症肌无力的早期诊断.     

声带运动不良的喉肌电图特征

目的探讨声带运动不良的喉肌电及诱发肌电变化特征。方法对108例声带活动不良患者临床表现、喉肌电图(自发电位、运动单位电位及募集电位等)及神经诱发电位特征(潜伏期、时程、波幅)进行分析。结果喉返神经麻痹者患侧甲杓肌、环杓后肌可检测到失神经电位如纤颤波和正锐波及再生电位。完全麻痹者肌电为电静息,相应喉内肌诱发电位消失。神经不完全损伤者患侧相应喉肌正常运动单位电位中夹杂失神经电位或再生电位,募集电位为单纯相或混合相,神经诱发电位较弱,其中患侧甲杓肌(2.2±1.0)ms(±s,以下同)、环杓后肌(2.4±1.0)ms 诱发电位平均潜伏期均大于正常受试者(P<0.05);诱发电位波幅离散程度较大,患侧甲杓肌(0.9±0.7)mV、环杓后肌(1.2±1.0)mV 平均诱发电位波幅均明显小于正常受试者(P<0.05)。环杓关节运动障碍者喉肌电正常或稍活跃,神经诱发电位参数与正常无统计学差异。肿瘤侵犯喉肌患者肌电减弱,神经诱发电位潜伏期正常,波幅减小。结论声带活动不良可以通过常规喉肌电图进行初步定性筛查,后经喉神经诱发电位进一步进行半定量分析。     

选择性喉内收肌去神经再神经移植:新的治疗喉内收肌痉挛性发音困难的手术方法

甲杓肌 (TA)对喉的生物力学和发声有很大影响 ,是组成声皱襞的主要成分 ,尤其当喉肌收缩时 ,比其它喉内肌对气道阻力影响更大。喉肌过度内收同 TA肌强烈收缩有关。研究显示 ASD(内收肌痉挛性发音困难 )病人的症状与 TA肌过度活动相关。TA肌还起着决定声皱襞弹性度的作用 ,这同声皱襞僵硬度有直接关系。僵硬度使声门内压增高。甲杓肌选择性麻痹能使内收肌痉挛性发音困难病人产生有利的生理变化 ,改善发音。这些作用已被用肉毒杆菌毒素注入甲杓肌方法证实 ,作为 ASD治疗的选择标准。应用肉毒杆菌毒素能产生令人满意的生理效应 ,但也有局…     

肉毒杆菌毒素治疗痉挛性发音困难(喉肌张力障碍):12年来治疗900多例患者的经验

该文对１２年来肉毒杆菌毒素治疗的９１３例痉挛性发音困难的病例进行回顾性分析，其中内收肌痉挛性发音困难（挤卡音）７４７例（８１．８％），外展肌痉挛性发音困难（耳语音）１５４例（１６．９％），内收肌呼吸性发音困难（声带矛盾运动）１２例（１．３％）。所有患者均进行全面的头颈部及神经系统检查，纤维光源喉动态镜检查，声学和空气动力学测试，发音评估，包括国际痉挛性发音困难分级和喉肌电图检查。在肌电图指导下对受累肌肉注射向毒杆菌毒素。患者仰卧，伸颈，用涂有聚四氟乙烯的单极空心ＥＭＧ针抽吸肉毒杆菌毒素Ａ（ＢＯＴ…     

正常喉肌电生理特点研究

目的:研究正常喉肌电生理特点,了解其与喉功能的关系。方法: 对36例正常受试者行喉肌电图检查,包括喉肌运动单位肌电测量、喉肌肌电干扰相波幅-转折数分析,并分析喉肌肌电与喉功能的关系。结果:(1)各喉肌几乎无完全电静息,平静时仍有少量肌电位发放,环杓后肌和杓间肌甚至多呈轻度和中度干扰相。(2)喉肌轻度、中度、高度收缩时喉肌募集增强,肌电发放率增加,波幅增大,其中甲杓肌、环甲肌和环杓后肌肌电波幅和转折数增大幅度形似,而环杓侧肌和杓间肌肌电转折数增大明显较波幅显著。(3)各喉肌肌电均在其相应喉功能活动前活跃或抑制。结论:各喉肌正常运动单位电位及不同收缩力量干扰相波幅-转折数量化分析等参数的正常值不相同,与其各自的解剖生理特点相关;各喉肌共同协作完成喉的各种正常的功能活动,是一个统一的整体,缺一不可。图3 表5参10     

正常喉肌电生理特点研究

目的研究正常喉肌电生理特点，了解其与喉功能的关系。方法对36例正常受试者行喉肌电图检查，包括喉肌运动单位肌电测量、喉肌肌电干扰相波幅-转折数分析，并分析喉肌肌电与喉功能的关系。结果(1)各喉肌几乎无完全电静息，平静时仍有少量肌电位发放，环杓后肌和杓间肌甚至多呈轻度和中度干扰相。(2)喉肌轻度、中度、高度收缩时喉肌募集增强，肌电发放率增加，波幅增大，其中甲杓肌、环甲肌和环杓后肌肌电波幅和转折数增大幅度相似，而环杓侧肌和杓间肌肌电转折数增大明显较波幅显著。(3)各喉肌肌电均在其相应喉功能活动前活跃或抑制。结论各喉肌正常运动单位电位及不同收缩力量干扰相波幅-转折数量化分析等参数的正常值不相同，与其各自的解剖生理特点相关；各喉肌共同协作完成喉的各种正常的功能活动，是一个统一的整体，缺一不可。     

喉返神经麻痹的肌电特点及相关研究

目的：研究喉返神经麻痹患者不同时间和损伤程度的喉肌电特点。方法：根据发病时间将87例喉返神经麻痹患者分为7组,分析其喉肌电特点,并与30例正常受试者进行对比研究。结果：①发病2周时,最早5d在受累甲杓肌、环杓后肌和环杓侧肌即可出现纤颤波和正锐波等失神经电位;2周-3个月失神经电位增多,可见再生电位;3个月后失神经电位渐少,再生电位渐多;36个月后失神经电位消失。②受累喉肌肌电募集减弱甚至无明显干扰相,干扰相波幅和转折数显著低于正常对照组,其中转折数减低更为明显,未受累喉肌募集电位明显增大。③部分患者受累喉肌诱发电位消失,其他患者可见波幅小、潜伏期长的诱发电位。结论：喉肌电图对于喉返神经麻痹的诊断和鉴别具有重要意义,失神经电位和再生电位特点与神经损伤的程度和时间相关,异常的诱发电位可提示神经损伤的程度。     

咽喉科学

不同剂量肉毒素治疗内收型痉挛性发音障碍的长期疗效观察；性别及注射部位不同对声带填充术的影响；声带息肉的罕见并发症：气道梗阻；不同激光系统下行悬雍垂腭咽成形术的术后康复情况比较。     

Botulinum toxin for the treatment of spasmodic dysphonia

Spasmodic dysphonia is a focal laryngeal dystonia. Laryngeal dystonia presents as: adductor spasmodic dysphonia with the characteristic strain-strangle voice; abductor spasmodic dysphonia with hypophonia and breathy breaks in connected speech; and adductor respiratory dystonia with paradoxical vocal fold motion and intermittent stridor. Current treatment with periodic laryngeal intramuscular injections of botulinum toxin A has allowed patients to function more normally. In this article, the authors' treatment paradigm and experience in treating over 900 patients with laryngeal dystonia are discussed.     

Diagnostic and therapeutic difficulties in laryngeal dystonia

Spasmodic dysphonia is a focal laryngeal dystonia. It presents as: adductor spasmodic dysphonia with the strain-strangle voice; abductor spasmodic dysphonia with whispering voice and breathy breaks in connected speech; and adductor respiratory dystonia with paradoxical vocal fold movements and stridor. It is most commonly treated by the intramuscular injection of botulinum toxin. In this article, the authors discuss difficulties in making diagnosis and treatment in patients with laryngeal dystonia concerning their own cases.     

Listening: the key to diagnosing spasmodic dysphonia

Spasmodic dysphonia (SD) is a focal dystonia of the larynx. Adductor spasmodic dysphonia (ADSD) involves the laryngeal adductor muscles, and symptoms of vocal roughness, staccato-like sounds, and stops in phonation. Abductor spasmodic dysphonia (ABSD) affects the laryngeal abductor muscles, resulting in a breathy or whispered voice quality and voice breaks. SD has a significant impact on the quality of life. This article discusses symptoms of SD and the standard treatment of SD.     

Effects of Botulinum Toxin Type A Injections on Aerodynamic Measures of Spasmodic Dysphonia

The effects of botulinum toxin type A (BOTOX^®) injections on aerodynamic measures of phonation were examined in 30 patients with adductor spasmodic dysphonia. Patients received bilateral injections of 2.5 U of botulinum toxin type A in each thyroarytenoid muscle. Measures of air pressure, average airflow, coefficient of variation (CV) of airflow, and laryngeal resistance were obtained before the injections and at 2 and 10 weeks after the injections. These measures were also obtained from 12 normal subjects. Compared with normal subjects, the spasmodic dysphonia patients had significantly higher preinjection values for air pressure, CV of airflow, and laryngeal resistance. At 2 and 10 weeks after the botulinum toxin type A injections, the spasmodic dysphonia patients showed a significant increase in the average airflow values and a significant decrease in the CV of airflow values and the laryngeal resistance values. At 10 weeks after the injections, the values for the three measures began to approach the preinjection values. It is concluded that these aerodynamic measures of phonation can provide useful measures of treatment outcome in adductor spasmodic dysphonia.     

Laryngeal dystonia: a series with botulinum toxin therapy

Laryngeal dystonia is a syndrome characterized by action-induced, involuntary spasms of the laryngeal muscles. Most patients have involvement of the adductor laryngeal muscles producing uncontrolled spasms during phonation, and a "strain-strangle" speech pattern commonly termed "spastic dysphonia." Other patients have involvement of the abductor muscles producing "whispering dysphonia." Rare patients have paradoxical vocal cord motion during respiration with adductor spasms on inspiration. Over the past 5 years we have used botulinum toxin (BOTOX) to treat more than 200 patients with laryngeal dystonia. This group includes patients with adductor involvement (phonatory dystonia, recurrent laryngeal nerve section failure, respiratory dystonia) and those with abductor involvement (whispering dystonia). Patients received benefit within 24 to 72 hours, with sustained improvement for 2 to 9 months with an average of 4 months. Patients improved to an average of 90% of normal function. Clinically significant adverse effects included extended breathy dysphonia and mild choking on fluids. BOTOX has become our treatment of choice for dystonic conditions of the larynx.     

Alternating Unilateral Botulinum Toxin Type A (BOTOX®) Injections for Spasmodic Dysphonia

Injection of botulinum toxin type A (BOTOX^®) into both thyroarytenoid muscles is an accepted treatment for spasmodic dysphonia. The authors of this study identified patients who could not tolerate the interval of breathy voice that immediately follows bilateral injections. These patients were offered a protocol in which the injection side was alternated on subsequent treatments. Eighteen patients who received at least two bilateral injections and two unilateral injections were reviewed. Alternating unilateral injections yielded a shorter breathy interval by an average of 12.7 days (P=.0007) and a shorter duration of return of spasmodic symptoms by an average of 26.0 days (P=.0006). Compared with bilateral injections, alternating unilateral injections yielded an average(median) of 3.2 more days of strong voice per day of breathy voice (P=.001). However, unilateral injections had a shorter average interval of strong voice (27.4 days; P=.007), as well as a slightly higher failure rate (4.9% vs. 1.1%). The authors conclude that alternating unilateral botulinum toxin type A injections are useful in patients with spasmodic dysphonia who have difficulty with the breathy voice that follows bilateral injection.     

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 otolaryngol-ogist, and a neurologist. The toxin or saline was injected into each thyroarytenoid muscle under electro-myographic 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.     

Long-term therapy for spasmodic dysphonia: acoustic and aerodynamic outcomes

OBJECTIVE: To evaluate the long-term aerodynamic, acoustic, and electromyographic effects of serial botulinum toxin (BT) injections in patients with adductor spasmodic dysphonia. DESIGN: Two-year, nonrandomized, controlled, before-after study. SETTING: Ambulatory care clinic at a single academic medical center. PATIENTS: A convenience sample of 91 patients with adductor spasmodic dysphonia evaluated and treated during 2 years and 64 age- and sex-matched controls. INTERVENTIONS: Injections of BT into the thyroarytenoid muscles in conjunction with electromyographic evaluation and acoustic and aerodynamic evaluation before and after serial BT injections. MAIN OUTCOME MEASURES: Translaryngeal airflow, jitter, shimmer, signal-to-noise ratio, fundamental frequency, standard deviation of fundamental frequency, maximum phonation time, and inappropriate muscle activity by electromyography. RESULTS: Translaryngeal airflow, jitter, and shimmer improved significantly after serial BT treatments and showed sustained improvement over time. Fundamental frequency, standard deviation of fundamental frequency, and signal-to-noise ratio did not change significantly after BT treatment. Electromyographic data suggested decreased inappropriate muscle activity with repeated BT injections. CONCLUSION: Treatment with BT provides ongoing relief of voice perturbations in patients with adductor spasmodic dysphonia who undergo long-term cumulative therapy.     

Botulinum toxin management of spasmodic dysphonia (laryngeal dystonia): A 12-year experience in more than 900 patients

Objectives: This paper reviews a 12-year experience in more than 900 patients with spasmodic dysphonia who have been treated with botulinum toxin. Study Design: This is a retrospective analysis of patients with adductor spasmodic dysphonia (strainstrangled voice), abductor spasmodic dysphonia (whispering voice), and adductor breathing dystonia (paradoxical vocal fold motion), all of whom have been treated with botulinum toxin injections for relief of symptom. Methods: All of the patients were studied with a complete head and neck and neurologic examination; fiberoptic laryngostroboscopy; acoustic and aerodynamic measures; and a speech evaluation including the Universal spasmodic dysphonia rating scale. Some were given electromyography. All patients received botulinum toxin injections into the affected muscles under electromyographic guidance. Results: The adductor patients had an average benefit of 90% of normal function lasting an average of 15.1 weeks. The abductor patients had an average benefit of 66.7% of normal function lasting an average of 10.5 weeks. Adverse effects included mild breathiness and coughing on fluids in the adductor patients, and mild stridor in a few of the abductor patients. Conclusion: Botulinum toxin A injection of the laryngeal hyperfunctional muscles has been found over the past 12 years to be the treatment of choice to control the dystonic symptoms in most patients with spasmodic dysphonia. Laryngoscope, 108:1435–1441, 1998     

Supraglottal Injection of Botulinum Toxin Type A in Adductor Type Spasmodic Dysphonia With Both Intrinsic and Extrinsic Hyperfunction

Patients with adductor type spasmodic dysphonia (SD) often exhibit both glottal and supraglottal hyperfunction. Based on the hypothesis that a “ventricular muscle” may contribute to the hyperfunction in these cases, eight patients with adductor type SD were treated with bilateral injection of botulinum toxin type A into the ventricular folds. Four weeks after injection, ventricular fold hyperfunction was absent in all cases. Number of voice breaks, standard deviation of fundamental frequency, and shimmer were significantly improved. Voice range profiles of the speaking voice were significantly extended in dynamic and frequency range. Side effects were a breathy phonation and mild swallowing difficulties without aspiration for about 1 week. Patients' self-rating concerning strangled and breathy voicing demonstrated an interval of acceptable voice quality between 1 week and 4 months after injection in all cases. Results suggest that supraglottal injection in patients with SD of both glottal and supraglottal hyperfunction, as a new approach, can normalize supraglottal activity and improve glottal voicing. Based on our experience with other patients with adductor type of SD, this injection technique is as efficient as injection into the thyroarytenoid muscle. Nevertheless, it remains to be proved that a pathologic ventricular muscle activity is addressed by this technique or if it is based on spreading to the thyroarytenoid muscle.