26 Idiopathic Flashcards
What condition would cause a tense sounding voice, vocal fatigue, and a prolonged closed phase with reduced vibratory and mucosal wave amplitude during videostrobe?
Glottic hyperabduction dysphonia
What kind of dystonia is spasmodic dysphonia (SD)?
Focal
What are the characteristics of focal dystonias?
Inappropriate and excessive efferent activity of motor neurons in small areas
What are 2 types of SD
Adductor and Abductor
Which type of SD is more common
Adductor
What type of SD is characterized by a harsh, strained voice w/ inappropriate pitch breaks, breathiness, and glottal fry
Adductor SD
What are the typical features of abductor SD
Breathy, effortful hypnotic voice w/ abnl whispered segments of speech
The inability to sustain vowels during speech is suggestive of what d/o?
Adductor SD
Voiceless consonant is suggestive of what d/o?
Abductor SD
What percent of SD is familial
12%
Which muscles are responsible for adductor SD?
Thyroarytenoid and LCA
Which muscle is responsible for abductor SD?
PCA
What is preferred method of tx for SD?
Chemical denervation w/ botox
What are the 2 ways to deliver botox to PCA
Transcricoid and retrograde (rotating the larynx away from side of injxn)
How can one confirm placement of needle in PCA?
Using EMG guidance, have pt sniff
What can be done if SD sx persist after complete paralysis of PCA?
Inject the CONTRA PCA with very small increments of toxin or inject the cricothyroid muscle
How is injection into cricothyroid muscle accomplished and how is proper placement confirmed
Peroral route; confirm by having pt sing an ascending scale and observing the increase in EMG activity as pitch increases
What are the adverse effects of PCA injxn?
Stridor (particularly w/ exertion), airway compromise, dysphagia, aspiration
What is the adductor laryngeal breathing dystonia?
Paradoxical adduction of the VF during inspiration, causing inspiratory stridor that worsens with exertion and disappears during sleep
What effect does adductor laryngeal breathing dystonia have on the voice
None
What syndrome is a/w blepharospasm
Meige’s syndrome
Which muscles are involved in blepharospasm
Orbicularis oculi, procerus, and corrugator supercilii
What causes hemifacial spasm
A vascular loop, most commonly of the anterior or posterior inferior CBL art, impinging on root of CN VII
What is initial tx for hemifacial spasm?
What is the procedure of choice for these pts?
- baclofen
- microvascular decompression
Which muscles are injected when using botox for hemifacial spasm
Zygomaticus major and minor, levator anguli oris, risorius
What muscles are injected when using botox to tx oromandibular dystonia
masseter, temporalis, and medial and lateral pterygoids
What percent of pts w/ unilateral tinnitus have retrocochlear pathology
11%
What is the m/c cause of venous pulsatile tinnitus
Idiopathic intracranial hypertension syndrome (pseudotumor cerebri, benign intracranial HTN)
What is m/c cause of pulsatile tinnitus in young female pts
IIH
What are six etiologies of pulsatile tinnitus
- IIH
- Jugular bulb abnlities
- Hydrocephalus a/w stenosis of sylvian aqueduct
- Inc ICP a/w Arnold-chiari synd
- Abnl condylar and mastoid emissary veins
- Idiopathic or essential tinnitus
What is the tx for IIH
Weight reduction and acetazolamide (250 mg TID) or lasix (20 mg BID)
Lumbar-peritoneal shunt for pts w/ visual deterioration, persistent HA, or disabling tinnitus
What is the definition of sudden sensorineural hearing loss
> 20 dB HL over at least three contiguous frequencies occurring w/in 3 days
In what percent of sudden SNHL can a definitive cause be determined?
10%
What % of SSNHL will turn out to have a vestibular schwannoma
4%
What are 2 common theories of etiology of idiopathic SSNHL
Circulatory disturbance and inflammatory reaction (usu viral)
What is current standard of care for w/u and tx of idiopathic SSNHL
Otologic exam, audio, r/o retrocochlear pathology –tx w/ steroids, +/- antivirals (no), +/- diuretics
What lab studies are useful in w/u of idiopathic SSNHL
Coag profile (CBC, PT, PTT), viral studies, ESR
What is prognosis of idiopathic SSNHL
Overall recovery to functional hearing levels in 65-69%; no conclusive evidence that outcome is improved by medical tx
When is spontaneous recovery of hearing in SSNHL more likely
If pt is w/o vestibular sx and suffers only partial HL, particularly low freq (better prog if apex of cochlea involved)
What tx are used to try to optimize cochlear blood flow
Vasodilators (histamine, papaverine, verapamil, CO2) and blood thinners (defibrinogenation therapy, dextran, papaverine)
What evidence supports use of CO2 for SSNHL
Fisch et al. (1983) compared carbogen (95% oxygen and 5% carbon dioxide) inhalation therapy daily for 5 days with papaverine and low-molecular-weight dextran for 5 days and found a statistically significant improvement in hearing levels with carbogen therapy. These findings have not been replicated.
What evidence supports use of corticosteroids for SSNHL
Steroid therapy is among the few treatment methods in ISSNHL to have single modality, randomized, prospective studies demonstrating effectiveness.
What evidence supports use of antivirals for SSNHL
No randomized prospective studies have demonstrated effectiveness
What factors lead to best rate of recovery after SSNHL
Pts treated with steroids and vasodilators with worse initial PTA and SDS, younger age, and greater number of treatments are most likely to improve
When is middle ear exploration indicated in SSNHL
If loss occurs in an only hearing ear – to r/o a fistula
What type of bony EAC growth is usu attached to tympanosquamous suture line
Osteoma
Indications for removal of EAC exostoses
Less than 1 mm aperture, recurrent otitis externa, and water trapping
What are sx of patulous ET
- Aural fullness
- Autophony
- Tympanophonia that improve when head is placed down b/w the legs
- Onset occurs w/ wt loss or after RT to NP
What is tympanophonia
Audition of one’s own breath sounds
What are some tx for patulous ET
- Reassurance
- Wt gain
- SSKI (10 gtt in juice po TID)
- Premarin nasal spray (25 mg in 30 cc NS, 3 gtt per nose TID)
- Occlusion of ET
- Myringotomy and tympanostomy tube placement
