Anatomic direction of entry for botulinum toxin injection to treat the adductor spasmodic dysphonia in Thais

Background: Botulinum toxin injections into the thyroarytenoid (TA) muscle of the larynx is the most popular treatment for adductor spasmodic dysphonia. Injection is usually done by percutaneous transcricothyroid membrane with either electromyography (EMG) or fiberoptic laryngoscopy (FOL) to verify placement of the needle within the TA muscle. This procedure requires a working knowledge of three-dimensional anatomy of the larynx to establish the direction for the accurate placement of the needle. Objective: Find out the appropriate angles and depth of the needle for placement of percutaneous transcricothyroid membrane method of botulintim toxin injection by means of studying the larynges of Thai cadavers. Methods: The descriptive study was performed in 45 Thai freshly thawed cadavers. The angle of the needle from midline sagittal plane, the angle in superior relation to tracheal plane, and the depth from midline cricothyroid (CT) membrane to midlength of TA muscle were measured from the two views of photographs, anteroposterior and lateral. Results: The mean angle of 24.2 +/- 6.76 degrees (mean +/- SD) from the midline sagittal plane in male and 24.9 +/- 7.0 degrees in female were worked out. A mean angle in superior relation to the tracheal plane was 47.7 +/- 7.8 degrees and 51.4 +/- 9.6 degrees in male and female, respectively. The mean depth was 1.7 +/- 0.2 and 1.4 +/- 0.1 cm in male and female, respectively. Conclusion: The mean angles and depth of the needle insertion from the midline of CT membrane to the center of TA muscle in Thai laryngeal specimens were evaluated. These values were different from the studies in Caucasians, but it could provide a direct relationship to the build of the races. This knowledge may help laryngologists do this procedure more accurately with better outcome, especially in hospitals that have no EMG or FOL guide.