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Objectives1. To compare the laryngeal symptoms of Parkinson’s disease (PD) with those of multiple system atrophy (MSA), a Parkinson-plus syndrome (PPS)2. To review the differences in surgical management of upper airway dysfunction in PD versus MSA3. To present a treatment algorithm for management of upper airway disorders in PD and MSA

MethodsCase series of 30 patients (24 with PD, 6 with MSA). Data analyzed included airway manifestations of each disease including clinical and physiological test results and management outcomes.

ResultsVocal cord atrophy causing bowing with mid-cord glottic gap was common in PD patients. One third of PD patients underwent vocal cord augmentation with noticeable improvement in vocal volume and phonation time. Tracheostomy was required in 50% MSA patients for life threatening sleep apnea. Systemic medications and speech therapy were integral components of the management regime.

ConclusionsSurgical management of laryngeal disorders in PD should focus on restoring bulk to atrophic vocal cords to minimize glottic gaps, thus improving vocalizatonefficiency even in the presence of impaired respiratory effort. Conversely, the autonomic dysfunction that characterizes MSA results in upper airway obstruction and thus surgical management focuses primarily on maintaining an adequate airway and frequently necessitates tracheostomy.

Surgical management of airway dysfunction in Parkinson’s Disease compared with Parkinson-plus syndromes

Catherine F. Sinclair MD1, Lowell E. Gurey MD1, Mitchell F. Brin MD2, Celia Stewart PhD3, Andrew Blitzer MD, DDS1

1New York Center for Voice and Swallowing Disorders, St. Luke's Roosevelt Medical Center, New York2Department of Neurology, University of California-Irvine, Irvine, California

3Department of Communicative Sciences and Disorders, New York University

•Speech and laryngeal disability are common in both PD and MSA and can include hypophonia, monopitch, prosodic insufficiency, hypokinetic dysarthria, and discoordinated or paradoxical vocal fold motion.3,4

• Sleep related breathing disorders are more common in MSA, including abnormal sustained EMG activity of limb and respiratory muscles and REM sleep behavior disorder (RBD) in almost all patients.

•Patients with PD may also manifest obstructive sleep breathing disorders and thus sleep studies should be considered in this population as well.5,6

•Poor respiratory support is the primary contributing factor to many of the speech abnormalities in PD

•Up to 75% of carefully selected patients with vocal cord (VC) bowing and relatively preserved pulmonary function will benefit from VC augmentation•Preoperative patient selection is important and performance of PFTs is essential to evaluate respiratory reserve•Patients with significant reductions in volume of air presented to the larynx during speaking are unlikely to benefit from vocal fold augmentation surgery and augmentation may in fact worsen respiratory effort

• In contrast for patients with a Parkinson plus syndrome, bowed vocal cords are rare

• the primary surgical intervention is tracheostomy to overcome severe airway obstruction.

•Retrospective case series of 30 patients (6 MSA, 24 PD) with clinical evidence of vocal or breathing abnormalities

•All patients underwent a functional laryngeal examination with fiberoptic direct laryngoscopy with or without pulmonary function testing (PFT) and evaluation for sleep apnea in the sleep laboratory.

Outcome measures

•Patient demographics

•Upper airway disease manifestations

•Management specifics including surgical and non-surgical interventions

•Primary outcome of surgical intervention hypophonia improvement

•An algorithm for management of upper airway disorders in PD versus MSA vas constructed

•Appropriate surgical management of dysphonia for PD versus MSA patients is different and requires that surgeons have knowledge of the main airway issues related to these two disease processes.

• Sleep studies are essential when evaluating patients with MSA as tracheostomy is the most common surgical intervention

•PFTs for PD patients in combination with laryngoscopy will assist in selecting those who may benefit from vocal fold augmentation.

Introduction•Parkinsonism is characterized by any combination of:

•Resting tremor;•Rigidity;•Bradykinesia; and•Loss of postural reflexes1,2

•Idiopathic parkinsonism (i.e. Parkinson’s Disease, PD) is a progressive multi-factorial neurodegenerative disease

•Parkinson-plus syndromes (e.g. multiple system atrophy, MSA) are characterized by parkinsonism in combination with:

•Pyramidal dysfunction;•Cerebellar ataxia;•Lower motor neuropathy•Autonomic nervous system abnormalities

•Laryngeal manifestations common in PD and MSA

•No prior studies have compared these diseases to determine whether laryngeal symptoms and subsequent airway management strategies differ.

•Aims of the current study were:• to analyze laryngeal symptoms, clinical examination findings and management outcomes for a series of patients with PD or MSA• to derive an algorithm for the surgical management of laryngeal and upper airway dysfunction in PD versus MSA.

INTRODUCTION

METHODS AND MATERIALS

1.Brin MF, Blitzer A, Velickovic M. Movement Disorders of the Larynx. In: Blitzer A, Brin MF, Ramig LO, eds. Neurologic Disorders of the Larynx. New York:Thieme 2009:160-95.2. Fahn S. Parkinsons’s disease and other basal ganglion disorders. In: Asbury AK, McKhann GM, McDonald WI, eds. Diseases of the NervousSystem: Clinical Neurobiology, Philadelphia: Ardmore Medical Books; 1986:1217-1228.3. Hanson DG, Gerratt BR, Ward PH. Cinegraphic Observations of Laryngeal Function in Parkinson’s Disease”. Laryngoscope 1984;94:348-53.4. Aronson AE, Brown JR, Litin EM, Pearson JS. Spastic Dysphonia. II. Comparison with Essential (voice) Tremor and other Neurologic and Psychogenic Dysphonias. J Speech Hearing Dis 1968;33:219-31.5. Maria B, Sophia S, Michalis M, et al. Sleep breathing disorders in patients with idiopathic Parkinson's disease. Respir Physiol 2003;97(10):1151-7.6. Schaller S, Anderer P, Dorffner G, et al. Autonomic Dysfunction in PD During Sleep. Movt Dis 2012;27(3):454.

CONCLUSIONS

DISCUSSIONRESULTS

REFERENCES

Figure 1a. Larynx during phonation pre-injection

Figure 1b. Larynx during phonation post-injection

ABSTRACT

Andrew Blitzer, MD DDSNew York Center for Voice and Swallowing Disorders, Head and Neck Surgical Group, New YorkEmail: ab1136@aol.com Phone: 212 262 4444

CONTACT

HEAD & NECKSurgical Group

•3 MSA patients (50.0%) required tracheostomy for airway obstruction secondary to severe OSA

•No MSA patient received vocal cord augmentation surgery due to airway concerns

•All PD patient’s with bowed vocal cords and normal PFT (n=8) underwent vocal cord injection augmentation

•6 patients (75.0%) had improved vocal loudness >50% of baseline postoperatively (Figure 1a,b)

•Sleep study and PFT results are shown in Table 2