Bansberg, Stephen F.

ObjectiveThe purpose of this review is to describe the recent advances in characterizing spasmodic dysphonia. Spasmodic dysphonia is a task‐specific focal laryngeal dystonia characterized by irregular and uncontrolled voice breaks. The pathophysiology is poorly understood, and there are diagnostic difficulties.Data SourcesPubMed, Google Scholar, and Cochrane Library.Review MethodsThe data sources were searched using the following search terms: (spasmodic dysphonia or laryngeal dystonia) and (etiology, aetiology, diagnosis, pathogenesis, or pathophysiology).ConclusionThe diagnosis of spasmodic dysphonia can be difficult due to the lack of a scientific consensus on diagnostic criteria and the fact that other voice disorders may present similarly. Confusion can arise between spasmodic dysphonia and muscle tension dysphonia. Spasmodic dysphonia symptoms are tied to particular speech sounds, whereas muscle tension dysphonia is not. With the advent of more widespread use of high‐speed laryngoscopy and videokymography, measures of the disruptions in phonation and delays in the onset of vocal fold vibration after vocal fold closure can be quantified. Recent technological developments have expanded our understanding of the pathophysiology of spasmodic dysphonia.Implications for PracticeA 3‐tiered approach, involving a questionnaire, followed by speech assessment and nasolaryngoscopy is the most widely accepted method for making the diagnosis in most cases. More experimental and invasive techniques such as electromyography and neuroimaging have been explored to further characterize spasmodic dysphonia and aid in diagnosing difficult cases.

ObjectiveCompare nasal endoscopy with 3 mm versus conventional 4 mm rigid 30° endoscopes for visualization, patient comfort, and examiner ease.MethodsTen adults with no previous sinus surgery underwent bilateral nasal endoscopy with both 4 mm and 3 mm endoscopes (resulting in 20 paired nasal endoscopies). Visualization, patient discomfort and examiner's difficulty were assessed with every endoscopy. Sino‐nasal structures were checked on a list if visualized satisfactorily. Patients rated discomfort on a standardized numerical pain scale (0–10). Examiners rated difficulty of examination on a scale of 1–5 (1 = easiest).ResultsVisualization with 3 mm endoscope was superior for the sphenoid ostium (P = 0.002), superior turbinate (P = 0.007), spheno‐ethmoid recess (P = 0.006), uncinate process (P = 0.002), cribriform area (P = 0.007), and Valve of Hasner (P = 0.002). Patient discomfort was not significantly different for 3 mm vs. 4 mm endoscopes but correlated with the examiners' assessment of difficulty (r = 0.73). The examiner rated endoscopy with 4 mm endoscopes more difficult (P = 0.027).ConclusionsThe 3 mm endoscope was superior in visualizing the sphenoid ostium, superior turbinate, spheno‐ethmoid recess, uncinate process, cribriform plate, and valve of Hasner. It therefore may be useful in assessment of spheno‐ethmoid recess, nasolacrimal duct, and cribriform area pathologies. Overall, patients tolerated nasal endoscopy well. Though patient discomfort was not significantly different between the endoscopes, most discomfort with 3 mm endoscopes was noted while examining structures difficult to visualize with the 4 mm endoscope. Patients' discomfort correlated with the examiner's assessment of difficulty.

The effects of timed‐release pellets of triamcinolone acetonide on sciatic nerve regeneration were studied. Bilateral nerve defects were created in 18 rats. One defect was sutured primarily, while the contralateral side was grafted with a 1 cm autogenous graft. Nerve regeneration was assessed at 20 weeks by muscle‐twitch strength and compound action potential parameters measured proximal and distal to the repair site. Conduction velocity and regenerative index (ratio of distal to proximal compound action potential area) were calculated. Significant improvement of the regenerative index and twitch strength occurred in animals treated with a 0.5 mg 21‐day‐release pellet. Improvement occurred in animals treated with 0.5 mg 60‐day pellets, but the difference was not significant. The findings suggest that regeneration was enhanced as a result of increased numbers of axons that made distal connections in the animals that received 21‐day‐release triamcinolone systemically. Corticosteroid therapy may benefit motor nerve repair.

Restricted exposure and inconsistencies in sinus pneumatization place the optic nerve at risk during operations on the sphenoid sinus and posterior ethmoid cells. In this study, computed tomography was used to examine these relationships. We reviewed 80 patients who underwent high‐resolution computed tomographic scanning for ophthalmologic complaints in which the scan was negative. Forty‐eight percent of posterior ethmoid cells are separated from the optic nerve by the thin bony lamina of the optic canal. Nearly 90% of sphenoid sinuses contact the ipsilateral optic nerve and 10% contact both nerves. Eight percent of posterior ethmoid cells override the ipsilateral sphenoid sinus and contact the optic nerve on that side. Paraxial reformatted displays allowed estimation of the degree of projection of the optic nerve into adjacent sinus cavities. Three percent of optic nerves have significant projection into the posterior ethmoid cell, and 23% project significantly into the sphenoid sinus. The width of the bony plate that separates the optic nerve from the sinus cavity was the same for sphenoid and ethmoid sinuses. Although sinus pneumatization varies among individuals, right and left sides are generally similar within one person.

Lymphoepithelioma is common in the nasopharynx, but its presence elsewhere in Waldeyer's ring is rare. Thirteen patients with lymphoepithelioma in the tonsil and base of the tongue have been treated at our institution. At Initial examination, all 13 patients had advanced clinical disease. Five years after their initial treatment, seven patients were alive and free of disease. Radiation therapy controlled local and regional disease in 10 (77%) patients, yet three of these died of distant metastasis. Patients with lymphoepithelioma have a significantly better prognosis (p < 0.05) than do patients with either nonkerafinizing or keratinizing high‐grade oropharyngeal carcinoma. Early recognition and combined therapy may further improve the prognosis. Differentiation of lymphoepithelioma from other high‐grade squamous cell carcinomas of the oropharynx is important to guide treatment and to provide prognostic information.

High‐grade carcinoma of the oral cavity is considered to be an aggressive malignancy associated with a poor prognosis. The tumors are often considered to be relatively radiosensitive. Because previous reviews of oral cavity cancer have contained few patients with grade 4 lesions, little is known about the true behavior of these tumors. Information was collected on 80 patients with high‐grade carcinoma of the oral cavity to determine the clinical findings and optimal treatment of this tumor. Primary tumor location, presence of neck metastasis, and clinical stage did not affect survival. Tumor size was a significant risk factor. The 5‐year survival rate for patients with high‐grade carcinoma treated by combination surgery and radiation (52%) was significantly greater (p ≤ 0.05) than that for patients treated by radiation alone (28%) or surgery alone (24%). This study is the first to describe the clinical course of a large number of patients exclusively with high‐grade carcinoma of the oral cavity.

Objective: Analyze demographic data collected over a 25-year experience of 718 patients with spasmodic dysphonia (SD) who have been treated with botulinum toxin-A (BoNT-A) and compare our data with previously published studies. Methods: Seven hundred eighteen patients with SD were treated with 6621 BoNT-A injections at Mayo Clinic Arizona between 1989 and 2014. All patients were treated by the same physician team. Background demographic data for each patient were recorded. Results: Of 718 patients, 557 patients were female (77.6%). Six hundred sixty of 718 (91.8%) patients had adductor SD (AdSD), and 58 of 718 (8.1%) patients had abductor SD (AbSD). Average age of onset was 51 years. Of 718 patients, 378 (52.6%) had vocal tremor (VT); VT was present in 54.4% of AdSD patients and 32.1% of AbSD patients. Thirty-seven of 718 (5.2%) patients had other dystonias, including cervical dystonia (2.3%), blepharospasm (1.4%), limb dystonia (1.1%), and oromandibular dystonia (0.3%). A positive family history of SD was present in only 6 of 718 patients (0.8%) and of other dystonias in 11 of 718 patients (1.5%). Conclusions: Spasmodic dysphonia is a chronic and potentially disabling focal laryngeal dystonia. The Mayo Clinic Arizona SD experience compares to prior reports and reveals a female preponderance, onset in middle age, infrequent hereditary pattern, high co-occurrence of VT, and low co-occurrence of other dystonias.