Laryngeal function in postpolio patients

Increased cerebral integrity metrics in poliomyelitis survivors: putative adaptation to longstanding lower motor neuron degeneration

BACKGROUND

Post-polio syndrome (PPS) has been traditionally considered a slowly progressive condition that affects poliomyelitis survivors decades after their initial infection. Cerebral changes in poliomyelitis survivors are poorly characterised and the few existing studies are strikingly conflicting.

OBJECTIVE

The overarching aim of this study is the comprehensive characterisation of cerebral grey and white matter alterations in poliomyelitis survivors with reference to healthy- and disease-controls using quantitative imaging metrics.

METHODS

Thirty-six poliomyelitis survivors, 88 patients with ALS and 117 healthy individuals were recruited in a prospective, single-centre neuroimaging study using uniform MRI acquisition parameters. All participants underwent standardised clinical assessments, T1-weighted structural and diffusion tensor imaging. Whole-brain and region-of-interest morphometric analyses were undertaken to evaluate patterns of grey matter changes. Tract-based spatial statistics were performed to evaluate diffusivity alterations in a study-specific whiter matter skeleton.

RESULTS

In contrast to healthy controls, poliomyelitis survivors exhibited increased grey matter partial volumes in the brainstem, cerebellum and occipital lobe, accompanied by increased FA in the corticospinal tracts, cerebellum, bilateral mesial temporal lobes and inferior frontal tracts. Polio survivors exhibited increased integrity metrics in the same anatomical regions where ALS patients showed degenerative changes.

CONCLUSIONS

Our findings indicate considerable cortical and white matter reorganisation in poliomyelitis survivors which may be interpreted as compensatory, adaptive change in response to severe lower motor neuron injury in infancy.

Post-polio Syndrome: More Than Just a Lower Motor Neuron Disease

Post-polio syndrome (PPS) is a neurological condition that affects polio survivors decades after their initial infection. Despite its high prevalence, the etiology of PPS remains elusive, mechanisms of progression are poorly understood, and the condition is notoriously under-researched. While motor dysfunction is a hallmark feature of the condition, generalized fatigue, sleep disturbance, decreased endurance, neuropsychological deficits, sensory symptoms, and chronic pain are also often reported and have considerable quality of life implications in PPS. The non-motor aspects of PPS are particularly challenging to evaluate, quantify, and treat. Generalized fatigue is one of the most distressing symptoms of PPS and is likely to be multifactorial due to weight-gain, respiratory compromise, poor sleep, and polypharmacy. No validated diagnostic, monitoring, or prognostic markers have been developed in PPS to date and the mainstay of therapy centers on symptomatic relief and individualized rehabilitation strategies such as energy conservation and muscle strengthening exercise regimes. Despite a number of large clinical trials in PPS, no effective disease-modifying pharmacological treatments are currently available.

Management of unilateral true vocal cord paralysis in children

PURPOSE OF REVIEW

Historically, information gained from the treatment of unilateral true vocal cord paralysis (UVCP) in adults was the same used to treat children. Today, there is a growing body of literature aimed specifically at the treatment of this condition in children. It is an area of growing interest as UVCP can significantly impact a child's quality of life.

RECENT FINDINGS

Children with UVCP may present with stridor, dysphonia, aspiration, feeding difficulties, or a combination of these symptoms. Diagnosis relies on laryngoscopy, but other adjuncts such as ultrasound and laryngeal electromyography may also be helpful in making the diagnosis and forming a treatment plan. In many instances, there is effective compensation by the contralateral vocal fold, making surgical intervention unnecessary. Children who cannot compensate for a unilateral defect may suffer from significant dysphonia that can affect their quality of life because their ability to be understood may be diminished. In these patients, treatment in the form of medialization or reinnervation of the affected recurrent laryngeal nerve may be warranted.

SUMMARY

UVCP is a well recognized problem in pediatric patients with disordered voice and feeding problems. Some patients will spontaneously recover their laryngeal function. For those who do not, a variety of reliable techniques are available for rehabilitative treatment. Improved diagnostics and a growing understanding of prognosis can help guide therapy decisions along with the goals and desires of the patient and his or her family.

Dysphagia and dysphonia among persons with post-polio syndrome - a challenge in neurorehabilitation

OBJECTIVE

To study the occurrence of dysphagia and dysphonia in persons with post-polio syndrome admitted into the centre for neurological rehabilitation in Finland.

MATERIALS AND METHODS

Fifty-one persons with post-polio syndrome who were rehabilitated at Käpylä Rehabilitation Centre, Helsinki, Finland, in 2003-2004 were interviewed on problems with swallowing and voice production. Pulmonary function testing and grip strength measurement were performed. A clinical assessment of oral motor and laryngeal functions was carried out for those who reported daily problems with voice production or swallowing.

RESULTS

Fifteen persons (29.4%) reported daily problems with swallowing or voice production. In the clinical assessment, the most commonly observed deficits in swallowing included decreased pharyngeal transit (n = 13) and the food catching in the throat (n = 4). The disturbance of co-ordination of breathing and voice production was seen in 12 persons. There were no significant differences in any of the potential predictors between the groups.

CONCLUSIONS

Professionals need to be aware of the routine evaluation of dysphagia and dysphonia in patients with post-polio syndrome.

Update on current and emerging treatment options for post-polio syndrome

Post-polio syndrome (PPS) refers to the clinical deterioration experienced by many polio survivors several decades after their acute illness. The symptoms are new muscle weakness, decreased muscle endurance, fatigue, muscle pain, joint pain, cold intolerance, and this typical clinical entity is reported from different parts of the world. The pathophysiology behind PPS is not fully understood, but a combination of distal degeneration of enlarged motor units caused by increased metabolic demands and the normal aging process, in addition to inflammatory mechanisms, are thought to be involved. There is no diagnostic test for PPS, and the diagnosis is based on a proper clinical workup where all other possible explanations for the new symptoms are ruled out. The basic principle of management of PPS lies in physical activity, individually tailored training programs, and lifestyle modification. Muscle weakness and muscle pain may be helped with specific training programs, in which training in warm water seems to be particularly helpful. Properly fitted orthoses can improve the biomechanical movement pattern and be energy-saving. Fatigue can be relieved with lifestyle changes, assistive devices, and training programs. Respiratory insufficiency can be controlled with noninvasive respiratory aids including biphasic positive pressure ventilators. Pharmacologic agents like prednisone, amantadine, pyridostigmine, and coenzyme Q10 are of no benefit in PPS. Intravenous immunoglobulin (IVIG) has been tried in three studies, all having positive results. IVIG could probably be a therapeutic alternative, but the potential benefit is modest, and some important questions are still unanswered, in particular to which patients this treatment is useful, the dose, and the therapeutic interval.

EFNS guideline on diagnosis and management of post-polio syndrome. Report of an EFNS task force

Post-polio syndrome (PPS) is characterized by new or increased muscular weakness, atrophy, muscle pain and fatigue several years after acute polio. The aim of the article is to prepare diagnostic criteria for PPS, and to evaluate the existing evidence for therapeutic interventions. The Medline, EMBASE and ISI databases were searched. Consensus in the group was reached after discussion by e-mail. We recommend Halstead's definition of PPS from 1991 as diagnostic criteria. Supervised, aerobic muscular training, both isokinetic and isometric, is a safe and effective way to prevent further decline for patients with moderate weakness (Level B). Muscular training can also improve muscular fatigue, muscle weakness and pain. Training in a warm climate and non-swimming water exercises are particularly useful (Level B). Respiratory muscle training can improve pulmonary function. Recognition of respiratory impairment and early introduction of non-invasive ventilatory aids prevent or delay further respiratory decline and the need for invasive respiratory aid (Level C). Group training, regular follow-up and patient education are useful for the patients' mental status and well-being. Weight loss, adjustment and introduction of properly fitted assistive devices should be considered (good practice points). A small number of controlled studies of potential-specific treatments for PPS have been completed, but no definitive therapeutic effect has been reported for the agents evaluated (pyridostigmine, corticosteroids, amantadine). Future randomized trials should particularly address the treatment of pain, which is commonly reported by PPS patients. There is also a need for studies evaluating the long-term effects of muscular training.

Postpolio syndrome: a challenge to the health-care system

The practical eradication of poliomyelitis in industrialized countries marks one of the most important achievements of world health policy. Yet, disability induced by polio not only continues to exist among survivors with paralytic sequelae, but may also be further accentuated in a considerable number of affected subjects by the development of postpolio syndrome (PPS). PPS aggravates the motor sequelae already present in such subjects and reduces their functional capacity to the point where it affects their activities of daily living and worsens their quality of life. Inasmuch as development of PPS questions the concept of poliomyelitis as a static disease it poses a challenge not only to health professionals but also to policy-makers tasked with providing the necessary health-care measures and appropriate resources. This study sought to review research on this syndrome and to draw up some recommendations that might prove useful to the health authorities for decision-making purposes.

Laryngeal manifestations of postpoliomyelitis syndrome

Postpoliomyelitis syndrome (PPS) is a disease that may occur in survivors of acute poliomyelitis several decades after their initial infection. It can present as dysphonia, with vocal weakness and fatigue. Swallowing, respiratory, and other laryngopharyngeal symptoms may be manifestations of the disease or they may represent worsening of previously stable and compensated deficits. Three cases of laryngeal changes in PPS with videostroboscopic and laryngeal electromyography findings highlight the features of this disorder. We review possible etiologies of laryngeal PPS, diagnostic criteria, and treatment, as well as the current literature.

Posterior glottic stenosis and bilateral vocal fold immobility: diagnosis and treatment

Posterior glottic stenosis and bilateral vocal fold immobility cause obstruction of the airway at the glottis. Presentation of this problem may vary according to the cause. Full evaluation of the status of the larynx is crucial with regard to the mobility of the arytenoid cartilage and innervation of the laryngeal musculature. There are many techniques for surgically treating this condition, each with advantages and disadvantages. The surgeon should be familiar with a variety of these procedures and be able to adapt to each patient's situation.

New laryngeal muscle weakness in post-polio syndrome

The authors describe the clinical presentations of post-polio laryngeal muscle weakness in three patients with prior polio infection who presented with new complaints including slowly progressive dyspnea, dysphagia, and/or hoarseness. Evaluations by laryngeal videostroboscopy and electromyography revealed vocal cord abductor and/or adductor weakness, recurrent posterior glottic web in one case, and, in the two patients who agreed to electromyography, evidence of prior denervation and reinnervation in laryngeal muscles. Treatment was directed at attempting to maintain an airway and optimize vocal quality. One patient benefitted from tracheostomy, one benefitted from vocal cord medialization, and one benefitted from resection of interarytenoid scarring. The authors conclude that diagnosis of laryngeal post-polio syndrome is facilitated by laryngeal electromyography. Interventions directed at maintaining an appropriate airway and optimizing vocal quality may be helpful.