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.

Read More

Olympic Athlete Hopeful With Vocal Cord Dysfunction

There was a recent article about Hannah Lupton, a heptathlete, who suffers from vocal cord dysfunction. This disorder is basically when the vocal cords come together during inhalation when it should be apart resulting in shortness of breath localized to the throat area.

Normally, during breathing, the vocal cords are apart as shown in the picture. When talking or swallowing, the vocal cords come together (TVC is True Vocal Cord).

Laryngospasm, which is the most severe form of vocal cord dysfunction, is when the vocal cords come together completely preventing any air from moving into the lungs resulting in a high pitched squeal when trying to breath. People may even faint due to lack of oxygen when this happens.

The vocal cord exercises as described in the news article may encompass these strategies among others:

METHOD 1: Breathing Technique
There are 3 steps to this particular method.

1. As soon as one feels an attack coming, SLOWLY breath in through the NOSE. DO NOT BREATH IN THROUGH THE MOUTH! Sometimes deliberately holding breath for 5 seconds prior to nasal inhalation helps.
2. More quickly exhale out the mouth with pursed lips.
3. Continue slow nasal inhalation, and quick mouth exhalation with pursed lips until the episode passes.

Why does this work? For some reason, nasal breathing reinforces the brain to keep the vocal cords apart when inhaling. Quick inhalation through the mouth seems to do the opposite and encourage the vocal cords to close which exacerbates the problem. Also, quick inhalation reinforces the Bernoulli Principle that as a fluid (air in this case) passes through a pipe that suddenly narrows (the vocal cords), the pressure actually decreases which encourages further narrowing (or vocal cord closure). Therefore, SLOW breathing helps keep the vocal cords apart! You can test this principle yourself by sucking air on a narrow short straw slowly and than quickly. You will find that the straw will tend to collapse when sucking in quickly.

METHOD 2: Straw Breathing

This method essentially forces a person to decrease the speed of breathing allowing for vocal cord relaxation. In essence, cut a regular drinking straw to half its length. When an attack occurs, place the straw in your mouth and make a tight seal. Breath thru the straw (via mouth) until attack passes.

Patients with recurrent laryngospasm attacks typically keep a straw in their pocket/purse to have immediately on hand.

METHOD 3: Pressure Point

Another manuever that may work is firm pressure in the "laryngospasm notch." Basically, with an attack, quickly with your (or somebody else's) index fingers, press very firmly just behind both your earlobes where there is a notch between the bone of your mastoid process and ear. Press deep and forward towards the nose. It should hurt. If it doesn't hurt, you are not pressing hard enough. The attack should resolve within 10 seconds. Here is an article describing this method.

METHOD 4: CPAP

This particular method applies only if laryngospasm attacks occur mainly at night while sleeping. Essentially, one uses a CPAP machine which blows air into your lungs while you sleep. This treatment helps by preventing the body from believing it is "drowning" which would result in vocal cord adduction. By having a persistent positive airflow from the CPAP device, it also reinforces to the brain to keep the vocal cords apart. At worst case, if an attack occurs, the CPAP machine helps push air into your lungs past the vocal cords. Indeed... if you ask any anesthesiologist what they do when a laryngospasm attack occurs during intubation, they'll say apply strong positive pressure by mask (along with other things of course).

Make sure you use heated humidification. Please be aware that the air pressure being applied MAY actually cause laryngospasm due to direct vocal cord irritation of the forced air. Unfortunately, there's no way to predict someone who will respond vs someone who will do worse with this treatment method.

Other Treatments

Oftentimes, the above strategies help enough that a patient finds these attacks occur less frequently with decreasing severity over time until they altogether stop. Rarely, a benzodiazepine medication will be prescribed for these attacks to help with the anxiety aspect until the strategy is internalized. Working with speech pathology has also been found to be helpful. In certain situations, laryngeal sensory neuropathy (LSN) may be contributing to VCD and treatment geared towards LSN improves VCD. Of course, treatment of the trigger whether it be allergy, asthma, or reflux is important.

In rare cases, I will consider injecting BOTOX into the vocal cords which will physically prevent the vocal cords from coming together and as such, prevent the difficulty in breathing should an attack occur. In some people, it decreases not only the severity, but also the frequency of attacks. The way BOTOX is injected into the vocal cords is shown below in the video. Please note that the vast majority of patients upon whom I perform vocal cord BOTOX injections are those suffering from spasmodic dysphonia.



Read the news article here.

Read more about vocal cord dysfunction here.

Read More

Patulous Eustachian Tube Video

In perhaps one of the most flagrant cases of patulous eustachian tube I've ever seen, the New England Journal of Medicine published a video showing the eardrum moving with respiration.

Normally, the eustachian tube (which extends from the back of the nose to the ear) is closed unless one pops the ears (like when flying in an airplane). As such, one does not normally see the eardrum moving to and fro with breathing.

Symptoms this poor patient with patulous eustachian tube may exhibit include hearing one's own breathing inside the ear as well as autophonia (hearing yourself talk in the ear). Symptoms improve transiently when the head is placed in a dependent position (head between the knees).

Treatment is very difficult. Some medical treatments that can be tried that often is ineffective include placement of ear tubes, SSKI (super-saturated potassium iodide), premarin drops, and reserpine. Perhaps the best treatment I've seen for Patulous Eustachian Tube is that provided by Dr. Dennis Poe at Massachusetts Eye and Ear Infirmary in Boston, MA. He performs a minimally invasive endoscopic insertion of a tiny catheter into the eustachian tube. The catheter is just the right size that one can still pop ears easily to prevent eustachian tube dysfunction, but large enough so that one does not suffer the symptoms of patulous eustachian tube.

The most common problem seen in the clinic regarding the eustachian tube is actually the complete OPPOSITE problem of patulous eustachian tube. It is eustachian tube dysfunction or the "clogged" ears whereby the ear feels full of pressure and one just is not able to pop the ears to release the pressure. In this situation, the eustachian tube stays closed, even when trying to pop the ears.

Check out the video below or here illustrating the problem with patulous eustachian tube.

Read More

U.S. Rep. Gabrielle Gifford Gets a Tracheostomy After 7 Days of Intubation

U.S. Rep. Gabrielle Gifford who is recovering from a gunshot wound to the head 7 days earlier had her breathing tube removed and a tracheostomy tube placed on January 15, 2011.

Many people will wonder why a tracheostomy tube was placed when she's been intubated for only 7 days and even though she has been able to breath on her own since Tuesday. Along with the trach tube, a stomach feeding tube was also placed.

A tracheostomy tube is a small tube placed through an opening in the neck allowing for airway protection, improved ease of breathing, and improved pulmonary care.

It is unusual to keep a patient intubated for greater than 7 days due to risk of tracheal stenosis due to mucosal ulcerations that occur with prolonged intubation. Such ulcerations not only occur in the airway and throat, but also the mouth and lip regions. The exact timing to trach is still controversial however.

However, a tracheostomy tube does appear to speed overall recovery and decrease the number of days of hospitalization.

Though many family members (and patients) may be appalled by the cosmetic appearance of a trach tube, everyone needs to remember a trach tube is TEMPORARY and can be removed without much fuss once the patient regains strength.

Read more about trach here.

Read the Reuters article here.

Watch a video of a trach.



Reference:
Tracheostomy: why, when, and how? Respir Care. 2010 Aug;55(8):1056-68.

Early versus late tracheostomy in patients with acute severe brain injury. J Bras Pneumol. 2010 Feb;36(1):84-91.

Early tracheostomy in intensive care unit: a retrospective study of 506 cases of video-guided Ciaglia Blue Rhino tracheostomies. J Trauma. 2010 Feb;68(2):367-72.

The impact of time to tracheostomy on mechanical ventilation duration, length of stay, and mortality in intensive care unit patients. J Crit Care. 2009 Sep;24(3):435-40. Epub 2009 Jan 17.

Read More