Vocal Cord Botox Injections to Treat Asthma???

Yup... It's true...

A clinical trial is under way in Australia to see if botox injections to the vocal cords can improve the shortness of breath some asthmatics have. Though nobody disputes that asthma is a pulmonary problem, it is not uncommon that the vocal cords in asthmatics may be dysfunctional exacerbating the breathing problem.

What is meant by dysfunctional? It's when the vocal cords come together when the person is trying to breath. It is also known as paradoxical vocal cord motion, vocal cord dysfunction, or laryngospasm at its worst. Read more here.

Botox injections will paralyze the vocal cord muscles preventing the vocal cords from coming together thereby allowing easier airflow into the lungs... or at least that's the hope. This procedure is commonly performed in patients suffering from spasmodic dysphonia and the technique used to treat these patients would be the same as that proposed for asthmatics. Watch a video here on how this is performed.

What's the downside? Aspiration, breathy voice, and trouble swallowing are common but temporary side effects. Problem is if aspiration occurs in a patient with significant pulmonary compromise, it can potentially be devastating leading to asthma exacerbation and even pneumonia.

Read a news article regarding this clinical trial here.

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Speech Therapy Found to be of NO Benefit for Spasmodic Dysphonia

A recent study was published that has found that speech therapy had minimal if any significant beneficial effect on spasmodic dysphonia (a spastic vocal disorder) in a study cohort of 31 patients.

The study was divided in 3 patient treatment groups:

- One-third received no further intervention after botox injection which is considered standard of care in the treatment of spasmodic dysphonia
- One-third received a standard 5-week course of voice therapy after botox injection
- One-third received a 5-week course of sham voice therapy after botox injection

All patients regardless of treatment group experienced improved voice quality in response to botox injection.

However, patients who received voice therapy after botox injection did not experience longer injection effect duration or significantly greater improvements in vocal quality than patients in botox only or botox plus sham therapy groups.

Theoretically, it was felt that speech therapy could help reduce any muscle tension dysphonia that is often present in patients suffering from spasmodic dysphonia. However, this study does bring into question whether this actually happens.... or if botox alone eliminates the trigger and therefore the abnormal compensatory behavior making therapy unnecessary.

However, given the small study group size, more research is required to truly determine whether speech therapy has a role or not in the treatment of spasmodic dysphonia.

That said, voice therapy is THE main way to treat muscle tension dysphonia.


Reference:
Combined Modality Treatment of Adductor Spasmodic Dysphonia. J Voice. 2011 Feb 2. [Epub ahead of print]

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Dr. Chang to Give Lecture on Spasmodic Dysphonia in Richmond, VA

Dr. Christopher Chang will be a guest lecturer on the topic of spasmodic dysphonia in Richmond, VA on June 11, 2011. Dr. Chang was invited to give a 3 hour long talk to the Central Virginia SD Group at the CJW Medical Center Johnston-Willis Campus in the Board Room starting at 12PM.

Dr. Chang is a Yale and Duke trained, board-certified otolaryngology-head and neck surgeon with fellowship training in laryngology. He is considered an expert on spasmodic dysphonia and has patients coming from as far as the Philippines (yes... the one on the other side of the world) every 3-6 months to receive treatment for this rare condition.

Read more about this condition here.

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Books on voice therapy that MIGHT be a useful ADJUNCT to botox injections:

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Migraine Headaches Associated with Allergies & Response to Allergy Shots

A recent study published this month in the journal Headache reported an association of migraine headaches with allergy severity and response to allergy shots... but only in those less than 45 years of age.

The study suggested that lower "degrees of atopy" (or allergy) were associated with less frequent and disabling migraine headaches in younger subjects while higher degrees were associated with more frequent migraines. The administration of allergy shots was associated with a decreased prevalence, frequency, and disability of migraine headache in younger subjects.

The age cut-off used to described "younger" subjects depending on the measure described was either 40 years or 45 years.

Read the abstract here.

Of course, one must consider the possibility that perhaps what these patients are suffering from is not migraine headaches, but allergy triggered sinus headaches.

Our office provides allergy testing, allergy shots, and allergy drops. We also offer botox injections in the treatment of migraine headaches.

Reference:
Allergy and immunotherapy: are they related to migraine headache? Headache. 2011 Jan;51(1):8-20. doi: 10.1111/j.1526-4610.2010.01792.x. Epub 2010 Nov 4.

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Physician Marketing Using Groupon

For those not in the know, Groupon is a website that offers coupons and other savings on local merchandise and services. Groupon also has recently rejected a takeover bid by Google.

I recently encountered this amazing deal on Groupon offered by an ENT colleague, Dr. Ghaheri:

"$149 for Four Laser Hair-Removal Treatments at The Center for Aesthetic Medicine at The Oregon Clinic (Up to $1,000 Value)"

I wonder if such marketing and medical discount offerings like this will become the future. Clearly, procedures and other types of medical treatments that are not covered by insurance will be applicable.

For example... here are some medical treatments/services I am considering to discount on Groupon:

1) Injection snoreplasty for snoring
2) Botox injections for facial wrinkles
3) Hearing services and products including hearing aids
etc

Click here to check out Groupon and create an account!

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Distributed Botox Injection for Spasmodic Dysphonia (Rather than Single Injection)

For many patients with spasmodic dysphonia, botox injections to the vocal cords are a regular right of passage every few months towards a clearer voice. Spasmodic dysphonia characterized by spastic or breathy voice breaks while talking causes much problems socially as well as misunderstandings.

For many physicians who perform botox injections for spasmodic dysphonia, a single injection is performed to either one or both vocal cords.

However a few and perhaps growing number of physicians are now using a more sophisticated method of injection where not only one, but multiple "mini"- injections are performed to the vocal cord during an injection.

Why would multiple injections be performed when one will do?

For that, I would like to take the reader to the world of cosmetic botox injections for facial wrinkles.

For the millions more sufferers of facial wrinkles, patients know that from the point of injection, there is a limited region of affect... typically no more than a dime to nickle area in size depending on the volume used. SO... in order to get rid of forehead wrinkles, 5 or more injections are required as shown here by the "x" marks.

The point is... in order for a great outcome in forehead wrinkles... multiple injections are performed. Not one single injection.

The same holds true for the vocal cord muscles. Rather than a single large injection to one spot in the vocal cord muscle, there is a growing belief that multiple "mini"-injections should be performed throughout the vocal cord muscle in order to produce a better outcome... a distributed injection. No specific research to prove this, but rather anecdotal.

Here is a video of botox being injected in a patient with spasmodic dysphonia.

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There are FOUR Different Types of Botox Available in the Market

Not many people know that there are FOUR different types of botox available and FDA approved for use in the United States.

The four botox products are as follows:

1) Botox by Allergan
2) Myobloc by Solstice Neurosciences
3) Dysport by Ipsen, Ltd
4) Xeomin by Merz

Obviously, Botox by Allergan was the first and most popular to the point where its product name "botox" is being used interchangeably to mean any botulinum toxin product; much like "Kleenex" is used to mean any tissue product to blow the nose with or "Google" to mean "to search for" even if you use Bing.

Although all four products are made from the Clostridium botulinum bacteria, the four products are isolated from different strains of bacteria, have different molecular structures, and attach to different parts of the nerve. What does this mean for the end-user? It means that dosages are not equivalent across product lines. In other words, 1 unit of botox is NOT the same as 1 unit of myobloc. Furthermore, duration of effect may be different as well as immune response.

Also as an FYI, Botox, Xeomin, and Dysport are Botulinum toxin type A whereas Myobloc is type B.

Dr. Chang performs botox injections for a variety of problems using Botox by Allergan.

At least for spasmodic dysphonia, the conversion factor is 52.3:1 Myobloc (BTX-B) to Botox (BTX-A)

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Botox Approved for Migraine Headaches in the United States

On October 15, 2010, the FDA approved botox for use in migraine headaches. It is hoped that eventually, this procedure will soon be covered by most health insurance companies rather than the few who do so now.

Dr. Chang has been performing botox injections for migraine headaches since 2005 along with for wrinkles, spasmodic dysphonia, cervical dystonias, oral-mandibular dystonias, etc.

Read the NYT article on the FDA approval here.

Read the FDA announcement here.

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Botox for "Sale" Due to Market Influences of Supply and Demand

The NYT wrote a somewhat humorous article on Oct 7, 2010 regarding botox injections for wrinkles from both a supply (physician) and demand (patient) viewpoint.

In NYC, one can now find neon colored signs advertising botox specials!

Read the NYT article here.

Of note, our clinic performs botox injections not for just cosmetic reasons (wrinkles), but also medical reasons including migraine headaches, TMJ, spasmodic dysphonia, torticollis, etc.

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Age Influences Botox Response in Patients with Spasmodic Dysphonia

Dr. Chang recently published a book chapter discussing how age influences response to botox injections in patients suffering from spasmodic dysphonia.

Introduction
Spasmodic dysphonia is a dystonia (muscle spasms) involving the muscles of the voicebox resulting in involuntary attacks of a strangled sounding voice. Treatment is botox injection to the involved muscles resulting in a decrease of such spasms thereby resulting in a more smooth-sounding voice.

Unfortunately, there are side effects with botox injections to the voicebox including aspiration, dysphagia, breathy voice, etc for a short period of time prior to the good voice. Typically, one week of side effects results in about 3 months of a good voice.

Research into this area typically has been to try and maximize the duration of a good voice while decreasing the duration of side effects.

A prior paper published by Dr. Chang tried to establish what the correct dose is to maximize a good voice and minimize side effects.

This book chapter tries to determine if age influences botox response.

Age and Botox Responses
What was found is a positive correlation between age and duration of normal voice and duration of side effects after botox injection. Age did not appear to play a role in the severity of side effects experienced by patients. However, the number of BTX-A injections received by a given patient was negatively correlated with duration of normal voice and side effects to a degree greater than age.

What does this mean?

Age must be taken into consideration when deciding on what dose of botox to inject since as a patient becomes older, one may see a slow increase in not only duration of normal voice, but also duration of side effects reported. Stated another way, for a given dose, the duration of side effects is larger for an older patient compared with a younger one. However, as the cumulative number of injections a patient receives increases over time, the duration of normal voice and side effects would be expected to decrease slowly.

Reference:
Age as a Factor in Responses to Botulinum Toxin Injection in Adductor Spasmodic Dysphonia Patients pp. 101-112

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Book Chapters Authored By Dr. Chang Published On Open Access

Dr. Chris Chang has co-authored two book chapters in a hardcover textbook entitled "Laryngeal Diseases: Symptoms, Diagnosis and Treatments". The book chapters Dr. Chang has co-authored are NOW available for download via Open Access. Melissa Mainville, a voice therapist at Fauquier Hospital, also co-authored one of the book chapters (Chapter 1).

CHAPTER 1: Psychogenic Voice Disorders
by Grace W. Johnson, Carmen T. Gonzalez, Christopher Y. Chang, Sarah L. Maines, Melissa M. Mainville, Amy J. Asbury (Download Chapter Here)

and

CHAPTER 6: Age as a Factor in Responses to Botulinum Toxin Injection in Adductor Spasmodic Dysphonia Patients
by Christopher Y. Chang, Peter Chabot, James P. Thomas, MD (Download Chapter Here)

This textbook can be purchased here.

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Two Book Chapters By Dr. Chris Chang Soon To Be Published!

Dr. Chris Chang has co-authored two book chapters in a soon to be published hardcover textbook entitled "Laryngeal Diseases: Symptoms, Diagnosis and Treatments". The book chapters Dr. Chang has co-authored are entitled:

Psychogenic Voice Disorders
by Grace W. Johnson, Carmen T. Gonzalez, Christopher Y. Chang, Sarah L. Maines, Melissa M. Mainville, Amy J. Asbury

and

Age as a Factor in Responses to Botulinum Toxin Injection in Adductor Spasmodic Dysphonia Patients
by Christopher Y. Chang, Peter Chabot, James P. Thomas, MD

This textbook is currently at press and anticipated to be released for purchase before the end of 2010. You can purchase it here.

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UK First Place in the World to Approve Botox for Migraine Headaches

Wall Street Journal reported on July 9, 2010 that the United Kingdom has become the first country in the world to approve botox injections for migraine headaches.

The U.K. approval could shortly precede a decision on migraine treatment from the U.S. Food and Drug Administration.

Botox treatment for migraines can be obtained currently in the US, but is rarely covered by insurance.

Dr. Chang has been performing botox injections for migraines since 2006.

Read the WSJ article here.

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Botox Bandits Rip Off Physicians

MSNBC reported on Aug 2, 2010 that there are patients who come and undergo thousands of dollars worth of botox injections and than skip out without paying...

Read the story here.

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FDA Potentially to Approve Botox for Migraines

As reported in MSNBC today, FDA regulators seem inclined to approve Allergan Inc's wrinkle drug Botox to prevent migraine headaches in millions of Americans, industry analysts said, based on information the drugmaker released on Monday.

That would be great news for current patients of mine who receive botox for migraines. However, once FDA has approved botox for migraines, it may take awhile before it becomes an insurance "covered" procedure.

Read the MSNBC article here.

Read more about botox here.

Dr. Chang provides botox injections for migraine headaches, TMJ, spasmodic dysphonia, torticollis, and other head and neck spastic disorders.

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New Video on Botox Injection for Spasmodic Dysphonia

A new video has been created and uploaded to our practice YouTube Channel describing botox injection for spasmodic dysphonia.

Two views are shown in the video... the first is what a patient sees as well as another view of what it looks like from inside the throat. Check it out!



Dr. Chang performs botox injections for spasmodic dysphonia every Friday afternoon. He also performs botox injections for facial wrinkles, torticollis, migraine headaches, TMJ, etc. Click here to see the full list.

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Botox - A National Security Threat???

Botox which is commonly used for cosmetic and medical reasons can also pose a national security threat according to a story in the June 2010 Scientific American.

Before this claim can be dismissed out-of-hand, consider that consumer demand for botox is fueling a proliferation of illegal botox distributors. Botox, which is botulinum toxin made by a bacteria in food gone bad, is actually a lethal poison which could potentially be used as a potent biological weapon in large enough quantities. Illegal botox distributors in their quest to make more money can sell botox to terrorists (or be terrorists themselves selling to make money to fund its use as a weapon).

Read more about the story here. Read a LA Times article here.

Read more about illegal botox distributors here.

On a lighter note, Dr. Chang performs botox injections for both cosmetic and medical purposes including facial wrinkles, torticollis, spasmodic dysphonia, etc. See the complete list here. We purchase our botox directly from Allergan, the manufacturer of botox.

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Botox for Chronic Cough

There was a new report in the May 2010 issue of Archives of Otolaryngology-Head & Neck Surgery that discussed the use of botox to achieve significant improvement, if not cure, in adult patients with a chronic cough due to sensory neuropathy. In this report titled "Use of Botulinum Toxin Type A for Chronic Cough: A Neuropathic Model", there are 4 case studies that were presented. The results they reported stated that cough relief occurred after a median of 7 injections with a mean dose of 4.0 Units per treatment session for a mean duration of 25.7 months. To watch a video of how the botox is injected into the voicebox to treat chronic cough, click here or watch below (the procedure is the same as that performed for spasmodic dysphonia).

Of note, this is the 2nd report on use of botox for chronic cough, the first was published in 2007 in ENT Journal and was done on kids. Click here to read that report.

I tend to use botox as a last resort when other medical management strategies have failed. Hidden triggers of cough including reflux, allergies, and asthma need to be addressed prior to consideration of botox. Often, I'll give a trial of neuropathic medications if laryngeal sensory neuropathy is suspected.

To read more about chronic cough, click here.

To read the actual report on use of botox to treat chronic cough, click here.

Botox is performed by Dr. Chang every Friday afternoon for spasmodic dysphonia, laryngospasm, as well as chronic cough! We also use botox for migraines, facial wrinkles, and torticollis.

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LECTURE: Dr. Chang Guest Lecturer on Spasmodic Dysphonia INOVA Fair Oaks

Dr. Chang will be a guest lecturer for the Northern Virginia Spasmodic Dysphonia Support Group. The lecture will be held on October 20, 2010 from 7-9PM at INOVA Fair Oaks Campus, Medical Plaza Building, Conference Room A. The lecture topic is on Spasmodic Dysphonia, a laryngeal dystonia that results in altered vocal quality due to involuntary muscular spasms of the voicebox.

The support group leader is Paula Cooper (Email: paulakcooper2004@yahoo.com).

Dr. Chang provides botox injections for spasmodic dysphonia every Friday afternoon.

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NYT: Can botox stop essential tremor (hand, face, etc)?

On April 22, 2010, the New York Times published a short story entitled "Can Botox Stop the Hands From Shaking?"

The story goes on to report that "Intramuscular injections of Botox, or botulinum toxin, may play a limited role in the treatment of wrist and voice tremors in patients with essential tremor."

Indeed, I do agree with the "limited" role botox has on essential tremor (emphasis on limited) whether the tremor involves the hand or head/neck region which is what I deal with more often.

Botox works GREAT when only 1 or 2 muscles are involved such as muscular dystonias where discrete muscles are afflicted such as torticollis (sternocleidomastoid muscle and/or trapezius muscles) and spasmodic dysphonia (thyroarytenoid muscle).

Unfortunately, in most cases of tremor (not dystonia), multiple different muscles are involved and it is very difficult to pinpoint and inject every single muscle that is suffering from tremor. A patient can end up with over a dozen injections to hit each affected muscle, and still not get a perfect outcome due to overall weakness from having so many injections.

Let's take vocal tremor... Vocal tremor often has both a laryngeal, oral, as well as neck component (patient's head often shakes while talking). As such, if one theoretically wanted to inject botox for vocal tremor, all these muscles may potentially need to be injected:

• thyroartenoid
• thyrohyoid
• sternothyroid
• infrahyoid
• omohyoid
• sternohyoid
• posterior cricoarytenoid
• lateral cricoarytenoid
• sternocleidomastoid
• superior pharyngeal constrictor
• middle pharyngeal constrictor
• inferior pharyngeal constrictor
• genioglossus
• hyoglossus
• styloglossus
• plalatoglossus
• levator veli palatini
• tensor veli palatini
• palatoglossus
• palatopharyngeus
• platysma
• etc.

That's a lot of muscles... which means a lot of injections... which means overall increased risk of overall weakness... AND the tremor may still be present.

However, botox injections may STILL be helpful to reduce symptoms of vocal tremor, but complete elimination of vocal tremor may be not be possible to achieve. Read more...

As many people already know, botox works great for wrinkles because discrete muscles are involved (just like for dystonia).

Our office provides botox injections for wrinkles, torticollis, spasmodic dysphonia, etc... but not for tremor UNLESS it is involving only a few muscles (very rare!).

Read the NYT article here.

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