Skip to main content
SpringerLink
Log in

Botulinum toxin injection in laryngeal dyspnea

  • Laryngology
  • Published:
European Archives of Oto-Rhino-Laryngology Aims and scope Submit manuscript

Abstract

Data, regarding the use of botulinum toxin (BT-A) in laryngeal dyspnea, are scarce, coming from some cases reports in the literature, including Vocal fold paralysis, laryngeal dystonia, vocal cord dysfunction also called paradoxical motion of the vocal fold (PMVF), and post-neuroleptic laryngeal dyskinesia. There is no consensus regarding the muscles and the doses to inject. The aim of this study is to present a retrospective review of patients treated in our ENT Department by BT-A injection in this indication. This study is a retrospective study describing patients who underwent an injection of botulinum toxin for laryngeal dyspnea in the ENT Department from 2005 to 2015 years. The inclusion criteria were a dyspnea associated with a laryngeal dysfunction, confirmed by flexible fiberoptic nasopharyngolaryngoscopy. Information concerning the causes of the dyspnea, the botulinum toxin BT-A injections procedure, post-injection follow-up, and respiratory outcome were collected for all patients included. In the group of 13 patients included, the main cause identified as principal factor linked with the short breath was: a bilateral VF paralysis (Patel et al., Otolaryngol Head Neck Surg 130:686–689, 7), laryngeal dystonia (Balkissoon and Kenn, Semin Respir Crit Care Med 33:595–605, 2), Anxiety syndrome associated with unilateral vocal fold paralysis or asthma (Marcinow et al., Laryngoscope 124:1425–1430, 3), and an isolated asthma (Zwirner et al., Eur Arch Otorhinolaryngol 254:242–245, 1). Nine out of the thirteen patients were improved by the injections. A BT-A-induced stable benefit for four patients led them to stop the injections in the follow-up. Good outcome was observed in five other patients (main cause: bilateral VP paralysis), allowing a progressive lengthening of the delay between BT-A injections. Four patients did not report a positive risk/benefit ratio after BT-A injections; two of them (with bilateral VF paralysis), because of respiratory side effects and lack of benefit without the side effects for the two others. This failure of effect was not related with BT-A doses injected. This study provides support for using BT-A injections as a symptomatic treatment of periodic laryngeal dyspnea, regardless of the etiologic context. From our data, we suggest that a small starting dose (of around 4 U BT-A Botox®) could be enough for a first injection to obtain a good benefit. The target muscle should be determined by the EMG analysis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Zwirner P, Dressler D, Kruse E (1997) Spasmodic laryngeal dyspnea: a rare manifestation of laryngeal dystonia. Eur Arch Otorhinolaryngol 254:242–245

    Article  CAS  PubMed  Google Scholar 

  2. Balkissoon R, Kenn K (2012) Asthma: vocal cord dysfunction (VCD) and other dysfunctional breathing disorders. Semin Respir Crit Care Med 33:595–605

    Article  PubMed  Google Scholar 

  3. Marcinow AM, Thompson J, Chiang T et al (2014) Paradoxical vocal fold motion disorder in the elite athlete: experience at a large division I university. Laryngoscope 124:1425–1430

    Article  PubMed  Google Scholar 

  4. Fève A, Angelard B, Fénelon G, Logak M, Guillard A, Lacau Saint-Guily J (1993) Postneuroleptic laryngeal dyskinesias: a cause of upper airway obstructive syndrome improved by local injections of botulinum toxin. Mov Disord 8:217–219

    Article  PubMed  Google Scholar 

  5. Woo P, Mangaro M (2004) Aberrant recurrent laryngeal nerve reinnervation as a cause of stridor and laryngospasm. Ann Otol Rhinol Laryngol 113:805–808

    Article  PubMed  Google Scholar 

  6. Azadarmaki R, Mirza N, Soliman AM (2009) Unilateral true vocal fold synkinesis presenting with airway obstruction. Ann Otol Rhinol Laryngol 118:587–591

    PubMed  Google Scholar 

  7. Patel NJ, Jorgensen C, Kuhn J, Merati AL (2004) Concurrent laryngeal abnormalities in patients with paradoxical vocal fold dysfunction. Otolaryngol Head Neck Surg 130:686–689

    Article  PubMed  Google Scholar 

  8. Vertigan AE, Theodoros DG, Gibson PG, Winkworth AL (2007) Voice and upper airway symptoms in people with chronic cough and paradoxical vocal fold movement. J Voice 21:361–383

    Article  PubMed  Google Scholar 

  9. Blitzer A, Brin MF (1991) Laryngeal dystonia: a series with botulinum toxin therapy. Ann Otol Rhinol Laryngol 100:85–89

    Article  CAS  PubMed  Google Scholar 

  10. Grillone GA, Blitzer A, Brin MF, Annino DJ Jr, Saint-Hilaire M-H (1994) Treatment of adductor laryngeal breathing dystonia with botulinum toxin type A. Laryngoscope 104:30–32

    Article  CAS  PubMed  Google Scholar 

  11. Truong DD, Bhidayasiri R (2006) Botulinum toxin therapy of laryngeal muscle hyperactivity syndromes: comparing different botulinum toxin preparations. Eur J Neurol 13(Suppl 1):36–41

    Article  PubMed  Google Scholar 

  12. Marion MH, Klap P, Perrin A, Cohen M (1992) Stridor and focal laryngeal dystonia. Lancet 22(339):457–458

    Article  Google Scholar 

  13. Ibrahim WH, Gheriani HA, Almohamed AA et al (2007) Paradoxical vocal cord motion disorder: past, present and future. Postgrad MedJ 83:164–172

    Article  Google Scholar 

  14. Maillard I, Schweizer V, Broccard A et al (2000) Use of botulinum toxin type A to avoid tracheal intubation or tracheostomy in severe paradoxical vocal cord movement. Chest 118:874–877

    Article  CAS  PubMed  Google Scholar 

  15. Goldstein R, Bright J, Jones SM, Niven RM (2007) Severe vocal cord dysfunction resistant to all current therapeutic interventions. Respir Med 101:857–858

    Article  CAS  PubMed  Google Scholar 

  16. van Griethuysen J, Al Yaghchi C, Sandhu G (2012) Use of bilateral suture lateralisation technique in severe paradoxical vocal fold movement, allowing removal of long-term tracheostomy: case report. J Laryngol Otol 126:328–330

    Article  PubMed  Google Scholar 

  17. Lekue A, García-López I, Santiago S, Del Palacio A, Gavilán J (2015) Diagnosis and management with botulinum toxin in 11 cases of laryngeal synkinesis. Eur Arch Otorhinolaryngol 272:2397–2402

    Article  PubMed  Google Scholar 

  18. Marie JP, Navarre I, Lerosey Y, Magnier P, Dehesdin D, Andrieu Guitrancourt J (1998) Bilateral laryngeal movement disorder and synkinesia: value of botulism toxin. A propos of a case. Rev Laryngol Otol Rhinol (Bord) 119:261–264

  19. Andrade Filho PA, Rosen CA (2004) Bilateral vocal fold paralysis: an unusual treatment with botulinum toxin. J Voice 18:254–255

    Article  PubMed  Google Scholar 

  20. Ongkasuwan J, Courey M (2011) The role of botulinum toxin in the management of airway compromise due to bilateral vocal fold paralysis. Curr Opin Otolaryngol Head Neck Surg 19:444–448

    Article  PubMed  Google Scholar 

  21. Ekbom DC, Garrett CG, Yung KC et al (2014) Botulinum toxin injections for new onset bilateral vocal fold motion impairment in adults. Laryngoscope 120:758–763

    Article  Google Scholar 

  22. Benninger MS, Hanick A, Hicks DM (2016) Cricothyroid muscle botulinum toxin injection to improve airway for bilateral recurrent laryngeal nerve paralysis, a case series. J Voice 30:96–99

    Article  PubMed  Google Scholar 

  23. Young DL, Halstead LA (2014) Pyridostigmine for reversal of severe sequelae from botulinum toxin injection. J Voice 28:830–834

    Article  PubMed  Google Scholar 

  24. Fahn S (2011) Classification of movement disorders. Mov Disord 26:947–957

    Article  PubMed  Google Scholar 

  25. Wolraich D, Vasile Marchis-Crisan C, Redding N, Khella SL, Mirza N (2010) Laryngeal tremor: co-occurrence with other movement disorders. ORL J Otorhinolaryngol Relat Spec 72:291–294

    Article  CAS  PubMed  Google Scholar 

  26. Blitzer A, Crumley RL, Dailey SH et al (2009) Recommendations of the neurolaryngology study group on laryngeal electromyography. Otolaryngol Head Neck Surg 140:782–793

    Article  PubMed  Google Scholar 

  27. Volk GF, Hagen R, Pototschnig C et al (2012) Laryngeal electromyography: a proposal for guidelines of the European Laryngological Society. Eur Arch Otorhinolaryngol 269:2227–2245

    Article  PubMed  Google Scholar 

  28. Maronian NC, Robinson L, Waugh P et al (2004) A new electromyographic definition of laryngeal synkinesis. Ann Otol Rhinol Laryngol 113:877–886

    Article  PubMed  Google Scholar 

  29. Woodson GE, Zwimer P, Murry T, Swenson M (1991) Use of fiberoptic laryngoscopy to assess patients with spasmodic dysphonia. J Voice 5:85–91

    Article  Google Scholar 

  30. Crumley RL (2000) Laryngeal synkinesis revisited. Ann OtolRhinol Laryngol 109:365–371

    Article  CAS  Google Scholar 

  31. Woisard-Bassols V, Alshehri S, Simonetta-Moreau M (2013) The effects of botulinum toxin injections into the cricopharyngeus muscle of patients with cricopharyngeus dysfunction associated with pharyngo-laryngeal weakness. Eur Arch Otorhinolaryngol 270:805–815

    Article  PubMed  Google Scholar 

  32. Ludlow CL (2011) Spasmodic dysphonia: a laryngeal control disorder specific to speech. J Neurosci 31:793–797

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Termsarasab P, Ramdhani RA, Battistella G, Rubien-Thomas E, Choy M, Farwell IM, Velickovic M, Blitzer A, Frucht SJ, Reilly RB, Hutchinson M, Ozelius LJ, Simonyan K (2015) Neural correlates of abnormal sensory discrimination in laryngeal dystonia. Neuroimage Clin 30(10):18–26

    Google Scholar 

  34. Kellman RM, Leopold DA (1982) Paradoxical vocal cord motion: an important cause of stridor. Laryngoscope 92:58–60

    Article  CAS  PubMed  Google Scholar 

  35. Murray DM, Lawler PG (1998) Paradoxical vocal cord movement presenting as severe acute asthma requiring ventilator support. Anaesthesia 53:1006–1011

    Article  CAS  PubMed  Google Scholar 

  36. Soli CG, Smally AJ (2005) Vocal cord dysfunction: an uncommon cause of stridor. J Emerg Med 28:31–33

    Article  PubMed  Google Scholar 

  37. Ranoux D, Gury C, Fondarai J et al (2002) Respective potencies of Botox and Dysport: a double blind, randomised, crossover study in cervical dystonia. J Neurol Neurosurg Psychiatry 72:459–462

    CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Voice and Déglutition Unit, ENT Department, Universitary Hospital of Toulouse, Hôpital Larrey, 31059, Toulouse Cedex 9, France

    Virginie Woisard

  2. Voice and Déglutition Unit, ENT Department, Universitary Hospital of Toulouse and Chongqing Medical University, Chongqing, China

    Xuelai Liu

  3. Neurology Department, ALS and Neuromuscular Disease Reference Center, Universitary Hospital of Toulouse, Toulouse, France

    Marie Christine Arné Bes

  4. Neurosciences Department, Toulouse University Hospital, Toulouse Neuroimaging Center, University of Toulouse, Inserm UPS, Toulouse, France

    Marion Simonetta-Moreau

Authors
  1. Virginie Woisard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Xuelai Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marie Christine Arné Bes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Marion Simonetta-Moreau
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Virginie Woisard.

Ethics declarations

Conflict of interest

Virginie Woisard declares that she has no conflict of interest. Xuelai Liu declares that she has no conflict of interest. Marie Chistine Arné Bes declares that she has no conflict of interest. Marion Simonetta Moreau declares that she has no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Woisard, V., Liu, X., Bes, M.C.A. et al. Botulinum toxin injection in laryngeal dyspnea. Eur Arch Otorhinolaryngol 274, 909–917 (2017). https://doi.org/10.1007/s00405-016-4289-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00405-016-4289-6

Keywords

Search

Navigation