Pourquoi je fais moins d EMG laryngées. Philippe H. Dejonckere

Size: px

Start display at page:

Download "Pourquoi je fais moins d EMG laryngées. Philippe H. Dejonckere"

Alisha Potter
6 years ago
Views:

1 Pourquoi je fais moins d EMG laryngées Philippe H. Dejonckere

4 EMG Technique électrophysiologique qui renseigne sur l activité électrique musculaire (tonus & mouvement) Phonation = mouvement Indication basique : «toute pathologie du mouvement relative au mécanisme phonatoire»

5 Surface / hooked wire / needle Surface : noninvasive > kinesiology Hooked wire Research (limited to superficial muscles; poor specificity) Functional diagnosis (dyskinetic dysphonia) Therapy : Feedback Research (specificity of muscles; multiple channel; correlation with physiological parameters ) Needle electrode Motor neuron disease + neuromuscular junction + myopathies

6 Surface EMG

7 Surface / hooked wire / needle Surface : noninvasive > kinesiology Hooked wire Research (limited to superficial muscles; poor specificity) Functional diagnosis (dyskinetic dysphonia) Therapy : Feedback Research (specificity of muscles; multiple channel; correlation with physiological parameters ) Needle electrode Motor neuron disease + neuromuscular junction + myopathies

15 Surface / hooked wire / needle Surface : noninvasive > kinesiology Hooked wire Research (limited to superficial muscles; poor specificity) Functional diagnosis (dyskinetic dysphonia) Therapy : Feedback Research (specificity of muscles; multiple channel; correlation with physiological parameters ) Needle electrode Motor neuron disease + neuromuscular junction + myopathies

17 EMG laryngée Indication basique : «toute pathologie du mouvement relative au mécanisme phonatoire» Y compris les expertises médico- légales, vu le caractère objectif

22 Indication basique : EMG laryngée «toute pathologie du mouvement relative au mécanisme phonatoire» Y compris les expertises médicolégales, vu le caractère objectif?

23 EMG LEMG

24 Specificities of intrinsic laryngeal muscles Small muscles (Voc : 300 mg; CT : 900 mg) Small MUs (quite low innervation ratio : muscle fibres / nerve fibre), particularly the M. Voc. Possible dual or multiple innervation of the same muscle fibre Shorter MUPs than skeletal muscles Microphonic effect

25 Triple motor endplate in a human thyroarytenoid muscle

28 EMG laryngée Indication basique : «toute pathologie du mouvement relative au mécanisme phonatoire» Y compris les expertises médico- légales, vu le caractère objectif

29 Laryngeal Mobility Disorders 1. Reduced mobility 2. Abnormal movements ( movement disorders )

30 Central Peripheral

31 Reduced mobility (1) 1. Neuromuscular etiology Paresis Paralysis peripheral motorneuron supranuclear neuromuscular junction myopathy peripheral motorneuron neuromuscular junction

32 Reduced mobility (2) 1. Mechanical etiology infiltration ankylosis (?) luxation (?) arthritis / arthrosis

35 Abnormal movements (1) * Bradykinesis usually generalized (M. Parkinson) * Dystonia (spasmodicity) - focal - segmental - multifocal - generalized

37 Spasmodic dysphonia pre treatment

38 Abnormal movements (2) * Tremor - essential - in neurological context Parkinson (rest) cerebellar ataxia (phonation) polyneuropathy * Myoclonus - essential - brainstem (mostly supranuclear)

40 Unilateral Vocal Fold Paralysis / Paresis

41 Bilateral paralysis with (even slight) dyspnoea : : NOLI TANGERE!!!

44 Unilateral Vocal Fold paralysis / paresis

52 !

53 Causes of unilateral VF paralysis/paresis * Congenital (birth trauma?) * Trauma - wounds, blunt traumata - fracture skull base - surgery : skull basis, neck (thyroid!) - internal (cuff intubation tube) (?) * Compression - tumor, lymph node, aneurysma, * Tumor - neurinoma, chemodectoma * Infection : viral mononeuritis (?) * Idiopathic

54 Surgical Causes of Vocal Cord Paralysis

55 Pre-phonatory tuning Rest activity, slightly rhythmic (respiration)

58 > 25 / s

64 Evaluation EMG (general)

65 Discrepancies laryngoscopy - EMG 71 cases of unilateral paresis (laryngoscopy) 58 : EMG partial neurogenic peripheral damage NLI 13 : EMG normal 179 cases of partial neurogenic damage EMG (M. Voc) 119 : laryngoscopic paralysis 58 : laryngoscopic paresis 2 : normal mobility

66 Reasons for discrepancy EMG - Laryngoscopy Anatomical particularities / variants Bilateral innervation of IA Anastomosis NLS NLI Controlateral innervation Mechanical factors Laryngeal torsion / asymmetry Joint fibrosis Paradoxical reinnervation Muscle atrophy / fibrosis

70 Reasons for discrepancy EMG - Laryngoscopy Anatomical particularities / variants Bilateral innervation of IA Anastomosis NLS NLI Controlateral innervation Mechanical factors Laryngeal torsion / asymmetry Joint fibrosis Paradoxical reinnervation Muscle atrophy / fibrosis

72 Reasons for discrepancy EMG - Laryngoscopy Anatomical particularities / variants Bilateral innervation of IA Anastomosis NLS NLI Controlateral innervation Mechanical factors Laryngeal torsion / asymmetry Joint fibrosis Paradoxical reinnervation Muscle atrophy / fibrosis

74 Reasons for discrepancy EMG - Laryngoscopy Anatomical particularities / variants Bilateral innervation of IA Anastomosis NLS NLI Controlateral innervation Mechanical factors Laryngeal torsion / asymmetry Joint fibrosis Paradoxical reinnervation Muscle atrophy / fibrosis

76 SUMMARY Differential diagnosis : peripheral neurogenic damage vs. other etiology (central / mechanical) Partial / total? Presence of collateral regeneration? Reinnervation? Topography?

78 Additional entities Myasthenia Myopathies Spasmodic dysphonia

Autoimmune disorder characterized by Ab against Acetylcholine receptors at the postsynaptic junction Myasthenia Gravis Manifests as: Fluctuating muscle weakness Fatiguability Eye muscle weakness

79 Autoimmune disorder characterized by Ab against Acetylcholine receptors at the postsynaptic junction Myasthenia Gravis Manifests as: Fluctuating muscle weakness Fatiguability Eye muscle weakness NOTES: Eye muscle weakness defines the characteristics of this disease. There are five classes for MG ranging from minimal eye weakness to severe with associated limb abnormalities or bulbar abnormalities affecting the cranial nerves. Of clinical note, a thymoma, if present, should be excised as there is a strong correlation between MG and a thymoma being present.

83 Position of Paralyzed Fold Initially thought to be related to site of injury. RLN versus vagal (RLN + SLN) Paramedian = RLN injury Lateral = RLN + SLN injury Cricothyroid muscle (SLN) was believed to influence the vocal fold position in laryngeal paralysis.

84 Position of Paralyzed Cord 27 Pts with unilateral VF Paralysis underwent FOL and LEMG. VF positions were paramedian in 8 patients, intermediate in 7, and lateral in 11. LEMG, 13 patients had isolated recurrent laryngeal nerve lesions and 13 patients had combined (superior and recurrent laryngeal nerve) lesions. No correlation between the vocal fold position and the status of the cricothyroid muscle.

85 The patient s point of view : Surgical treatment options depend on prognosis? Also age, life expextancy, occupation, compliance to ST, comorbidity, swallowing problems etc

88 Medialization Laryngoplasty

89 Medialization Laryngoplasty

90 Arytenoid Adduction

92 Vocal Fold Injection Short Term Long Term (?)

95 TREATMENT OF BILATERAL VFP

96 Treatment

97 Cordotomy

Re-Innervation Concept that nerve fibers from surrounding areas will re-stimulate the muscles of the Recurrent Laryngeal Nerve Can be achieved surgically as well: Ansa

Whether this is done naturally or surgically, it helps to create stability to the TVF which allows for better contact and voice.

98 Re-Innervation Concept that nerve fibers from surrounding areas will re-stimulate the muscles of the Recurrent Laryngeal Nerve Can be achieved surgically as well: Ansa Cervicalis Phrenic Preganglionic Sympathetic Neurons NOTES: Re-Innervation is beneficial because muscles tend to atrophy unless they maintain innervation. Whether this is done naturally or surgically, it helps to create stability to the TVF which allows for better contact and voice. Reinnervation of the TA muscle restores tension resulting in a more normal mucosal wave. Reinnervation of the PCA and LA muscles stabilizesthe arytenoids and prevents inferior displacement of the vocal process, which may occur in some patients.

of patients undergoing re-innervation Best Measure of Surgical Improvement is MPT NOTES: The amount of time following initial visit/event to surgical time was 15 months.

99 Re-Innervation, cont. Typical Connections: Ansa RLN Hypoglossal RLN Ansa Thyroarytenoid Pedicle 15 months Pre-Surgical observation time Signs of Reinnervation by 4 months post-op Thyroid cancer was the most common cause of patients undergoing re-innervation Best Measure of Surgical Improvement is MPT NOTES: The amount of time following initial visit/event to surgical time was 15 months. In a meta-analysis, most patients were followed around 4 months after surgery. Their improvements were measured by Maximum Phonation Time which was nearly doubled in all studies. Glottic gap was also improved in all studies that reported this finding. While these findings make reinnervation a viable possibility, it is not performed alone with any frequency and not compared to injection thyroplasty or medialization. Most studies reporting on Re-innervation combine this procedure with injection or medialization procedures. Only six studies have demonstrated viable results in humans. There has also been no direct comparison with trials comparing reinnervation with thyroplasty.

100 When all else fails?

101 Biofeedback in swallowing disorders

102 Therapy with semg

103 Conclusion Les atouts de l EMG laryngée : La kinésiologie La recherche en physiologie laryngée Les myopathies et les affections de la jonction neuromusculaire Quelques diagnostics différentiels spécifiques (p. ex. : neurogène vs. mécanique dans un larynx posttraumatique) Le choix du côté à opérer pour une cordotomie (Kashima) : patient trachéotomisé! Contexte de techniques de pointe : pacing, réinnervation, transplantation Bio feedback en déglutologie

104 Indication basique : EMG laryngée «toute pathologie du mouvement relative au mécanisme phonatoire» Y compris les expertises médicolégales, vu le caractère objectif?

105 Merci de votre attention!

106

Superior Laryngeal Nerve Injury: Diagnosis and Management. Presented by: Nyall London October 10, 2014

Superior Laryngeal Nerve Injury: Diagnosis and Management Presented by: Nyall London October 10, 2014 1 Case Presentation 49 year old male s/p right side approach anterior cervical discectomy and fusion