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COLLAGEN INJECTIONS AID PARKINSON'S PATIENTS WITH HYPOPHONIA
A simple procedure can help elderly patients with voices weak due to uncoordinated vocal muscles
Denver, CO -- Of the nearly two million Americans who suffer from idiopathic (of unknown cause) Parkinson's disease (IPD), nearly a third of these patients will cite voice or speech abnormalities as the most debilitating consequence. Patients with IPD are often described as having a breathy quality to their voice. This breathiness, or hypophonia, is thought to occur with glottic incompetence that affects the voice function of the larynx, increased muscle rigidity, and decreased ability for movement of the thyroarytenoid muscle.
Percutaneous laryngeal collagen augmentation (collagen injection by needle into the vocal chords) for Parkinsonian hypophonia and glottic incompetence in elderly patients seems ideal because of the procedure's ease, lack of complications, and the avoidance of risk of anesthesia. Theoretically, patients with glottic incompetence but mobile vocal chords should be amenable to vocal chord augmentation that would permit adequate glottic closure.
In a previous study, patients with severe speech unintelligibility and dysphonia/aphonia were typically not aided by collagen injection. On the other hand, the speech intelligibility of some patients with less severe dysphonia appeared to improve after injection. Accordingly, a hypothesis evolved asserting that the treatment of hypophonia in some patients would improve speech by new treatments.
A research team elected to report on a series of 18 patients, all of who were diagnosed with IPD at the time of the procedure and were suffering from distressing hypophonia. All patients underwent pre-operative videostroboscopic examination and were confirmed to have glottic insufficiency. The findings are offered in "Percutaneous Laryngeal Collagen Augmentation for Treatment of Parkinsonian Hypophonia," presented by Soo H. Kim MD, Jim Kearney MD, and Joseph P. Atkins, MD, all from the Department of Otolaryngology, University of Pennsylvania Medical School, Philadelphia, PA. Their results were presented on September 11 at the American Academy of Otolaryngology--Head and Neck Surgery Annual Meeting/OTO EXPO, being held September 9-12, at the Colorado Convention Center, Denver, CO.
The authors believed that laryngeal collagen augmentation has been shown preliminarily to have a beneficial effect on a select group of Parkinsonian patients. They hoped to further define these criteria in an attempt to avoid performing collagen augmentation in those patients who are not likely to have a favorable outcome.
Methodology: Eighteen patients with diagnosed Parkinson's disease of various duration and unknown causes were selected for the study. Patients with Parkinson's disease and vocal chord paralysis were not included in the study. All 18 patients had been on medication prior to the collagen injection and exhibited incomplete glottic closure on maximal adduction as documented on videostoboscopic examination. All patients received bilateral vocal chord injections and were noted to achieve glottic closure immediately after injection. Additionally, all the test subjects complained of severely debilitating speech or voice difficulties.
Due to calcification of the thyroid cartilage in many elderly patients, needle entries were performed routinely through the cricothyroid membrane. After a nasopharyngoscope was placed to adequately visualize both vocal chords during injection, the patient's neck was hyperextended and a 27 gauge needle attached to a syringe containing cross-linked collagen (Zyplast brand) was inserted into the cricothyroid membrane and advanced superiorly to the level of the true vocal chords. Collagen was injected at the level of the medial mid-chord, typically in a sub-lamina propria plane in the medial thyroarytenoid muscle. Injection amounts varied by individual but all achieved glottic closure post-injection.
The charts as well as the videostroboscopic examinations of the patients were reviewed in detail. The amount of cross-linked collagen injected on either side was noted. Patient satisfaction or voice quality immediately after injection was also noted. In addition, all patients were telephoned and asked about general satisfaction, duration of effect if any, and complications. Patients or their spouses/caretakers were also asked about their pre-procedure speech deficits. Pre-procedure hypophonia, aphonia, delay in speech onset, or decreased clarity were noted. Patients were also asked of their general neurologic status at the time of the procedure - any significant ambulatory difficulty or dysphagia was noted.
Results: The procedure was considered successful if the patient or the patient's spouse/caretaker noted an improvement in either the patient's hypophonia or speech clarity of intelligibility for a period of at least two months. Success was not based on reversal of glottic insufficiency as per videostroboscopy. Of the 18 patients, 11 patients noted improvement in their voice for at least two months (an efficacy of 61 percent). Additional findings included:
* Duration of speech improvement in the 11 patients ranged from two months to seven months, with the average being 3.2 months.
* The amount of collagen injected ranged anywhere from 0.3 to 1.0 ml. The amount of collagen injected appeared to have no correlation with efficacy or success of the injection.
* Seven of 18 patients reported either no change in their voice or improvement lasting less than the arbitrated two-month period. Of the seven patients, five suffered from significant dysphagia and difficulty with initiating speech at the time of the procedure. Four of the seven patients were not ambulatory at the time of the procedure.
Conclusions: Percutaneous laryngeal collagen augmentation appears to be beneficial a substantial percentage of patients with Parkinsonian hypophonia. In our study, 61 percent of patients reported at least a two-month period of voice improvement. According to our preliminary data, it appears that patients who suffer from hypophonia without delay in speech onset and without advanced neurologic disease are most likely to benefit from this exciting procedure.
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