Question of the Week - August 2022

 

August 10th, 2022

A 41-year-old female presents to clinic with complaints of a “strangled” voice and breathiness when speaking for the past 8 months. She says she has noticed that her voice sometimes breaks in the middle of her sentences, specifically when she starts words with vowels, such as “we eat eggs every day.” She initially tried voice therapy, with no improvement in voice symptoms.

Which of the following treatments is the best option for management of her condition?

A. Surgical denervation-reinnervation of recurrent laryngeal nerve
B. Continued voice therapy
C. Direct injection of botulinum toxin
D. None of the above

  • Quiz Answer: C (Direct injection of botulinum toxin)

    Explanation: This patient exhibits adductor spasmodic dysphonia, a focal dysphonia affecting the adductor laryngeal muscles during speech. It is rare, but it most commonly presents in middle age, around the 4th decade. In these patients, the vocal fold adductor muscles spasm, closing the vocal folds too tightly and cutting off the voice on words beginning with vowels or on vowels in the middle of words. Voice therapy is typically attempted first, as it is noninvasive. However, its efficacy is limited, and direct injection of botulinum toxin (BT) into the laryngeal muscles has been shown to be more effective. BT injection reduces tight glottic closure, and it is typically repeated after every 3 months. Surgical denervation-reinnervation of the recurrent laryngeal nerve has been shown to benefit patients, but this is generally done after attempting BT injections.

    Reference:

    Hyodo M, Asano K, Nagao A, et al. Botulinum Toxin Therapy: A Series of Clinical Studies on Patients with Spasmodic Dysphonia in Japan. Toxins (Basel). 2021;13(12):840. Published 2021 Nov 25. doi:10.3390/toxins13120840.

    Ludlow CL. Spasmodic dysphonia: a laryngeal control disorder specific to speech. J Neurosci. 2011;31(3):793-797. doi:10.1523/JNEUROSCI.2758-10.2011

August 24th, 2022

A 65-year-old man with a history of chronic rhinosinusitis with nasal polyposis (CRSwNP) and asthma presents to the clinic complaining of recurrent nasal obstruction, facial pain, and loss of smell despite ongoing treatment with oral corticosteroids. Over the last 10 years, he has taken oral steroids and antibiotics every 2-3 months in addition to 7 functional endoscopic sinus surgeries for recalcitrant CRSwNP. After exhausting the standard treatment options with minimal improvement, he is prescribed Dupilimab. This monoclonal antibody reduces type 2 inflammation by blocking the action of which inflammatory mediator(s):

A. IL-33
B. IL-5
C. IL-4 and IL-13
D. IgE

  • Quiz Answer: C (IL-4 and IL-13)

    Explanation: Biologic therapies are an emerging treatment option for patients with poorly controlled CRS. Drugs targeting type 2 inflammatory mediators such as IL-5, IL-33, IgE and TSLP have all been developed. However, Dupilimab is the only biologic FDA approved for the treatment of poorly controlled CRSwNP. Dupilumab targets IL-4a, a shared receptor subunit between IL-4 and IL-13. Mepolizumab (anti-IL-5 monoclonal antibody), Omalizumab (anti-IgE), and Etokimab (anti-IL-33) are not currently FDA approved for the treatment of CRSwNP.

    Reference: Laidlaw TM, Buchheit KM. Biologics in chronic rhinosinusitis with nasal polyposis. Ann Allergy Asthma Immunol. 2020;124(4):326-332.