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ABSTRACT: We established an animal model of recurrent laryngeal nerve reinnervation with persistent vocal fold immobility following recurrent laryngeal nerve injury.
In 36 rats, the left recurrent laryngeal nerve was transected and the stumps were abutted in a silicone tube with a 1-mm interspace, facilitating regeneration. The mobility of the vocal folds was examined endoscopically 5, 10, and 15 weeks later. Electromyography of the thyroarytenoid muscle was performed. Reinnervation was assessed by means of a quantitative immunohistologic evaluation with anti-neurofilament antibody in the nerve both proximal and distal to the silicone tube. The atrophy of the thyroarytenoid muscle was assessed histologically.
We observed that all animals had a fixed left vocal fold throughout the study. The average neurofilament expression in the nerve both distal and proximal to the silicone tube, the muscle area, and the amplitude of the compound muscle action potential recorded from the thyroarytenoid muscle on the treated side increased significantly (p < 0.05) over time, demonstrating regeneration through the silicone tube.
Recurrent laryngeal nerve regeneration through a silicone tube produced reinnervation without vocal fold mobility in rats. The efficacy of new laryngeal reinnervation treatments can be assessed with this model.
The Annals of otology, rhinology, and laryngology 01/2013; 122(1):49-53. · 1.05 Impact Factor
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ABSTRACT: Abstract Conclusions: Three different types of glottal configuration in unilaterally paralyzed larynx were proposed by utilizing three-dimensional computed tomographic (3DCT) images. This new classification might facilitate understanding of the behavior of the affected vocal fold in terms of vocal function. Objectives: To develop a classification of glottal configuration in unilateral vocal fold paralysis (UVFP) based on the thickness and location of the vocal folds utilizing 3DCT and to compare each type of configuration with vocal function. Methods: Thirty-seven consecutive patients with UVFP underwent CT during phonation and inhalation. 3D endoscopic and coronal images on two occasions were produced. Maximum phonation time and mean airflow rate were also measured. Results: Three types of glottal configuration were proposed. The thickness of the affected vocal fold during phonation was equal to or slightly thinner than the healthy fold in 10 patients (type A). The affected fold of the remaining 27 was thin during phonation; they were further classified into types B and C. In type B, the affected fold remained thin during phonation and inhalation (n = 12). Type C was allocated to those showing one or two paradoxical movements of the affected fold (n = 15). Those with type A showed significantly better vocal function.
Acta oto-laryngologica 11/2012; · 0.98 Impact Factor
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ABSTRACT: OBJECTIVES/HYPOTHESIS: To evaluate the impact of nimodipineon reinnervation of the long-term denervated rat thyroarytenoid (TA) muscle following nerve-muscle pedicle flap (NMP) implantation. STUDY DESIGN: Quantitative histologic and physiologic assessments. METHODS: Using 120 Wistar rats, we performed NMP implantation at different times after transection of the left recurrent laryngeal nerve (RLN). Sixty animals received nimodipine treatment (NIMO [+] group), and the remaining 60 animals received no nimodipine treatment (NIMO [-] group). As a control, an additional 28 animals were subjected only to transection of the left RLN (DNV group). Subgroups were assigned based on the period after RLN transection (0 [immediate], 8, 16, and 32 weeks). In the DNV group, we assessed histologically the muscle area, axons, neuromuscular junctions (NMJs), and myosin heavy chains (MyHC) type IIA and IIB in the TA muscle. In the NIMO (-) and NIMO (+) groups, histologic assessments and evoked electromyography were performed on the TA muscle at 10 weeks post-NMP implantation. RESULTS: In 8-week interval subgroups, the muscle fiber area and the number of NMJs in the NIMO (+) group were significantly greater than in the NIMO (-) group (P < 0.05, each). In the 0-week and 32-week interval subgroups, the muscle fiber subtype changed significantly, from IIA to IIB (P < 0.01 and P < 0.05, respectively); and, at all time-points the muscle fiber area, number of NMJs, and action potentials in the TA muscle tended to be greater in the NIMO (+) group than in the NIMO (-) group. CONCLUSIONS: Nimodipine expedited the effects of NMP implantation on reinnervation of the long-term denervated TA muscle. Laryngoscope, 2012.
The Laryngoscope 09/2012; · 1.75 Impact Factor
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ABSTRACT: Arytenoid adduction (AA) as surgical treatment for unilateral vocal fold paralysis (UVFP) is associated with higher morbidity from airway complications due to postoperative laryngeal edema compared with other laryngeal framework surgeries. The aim of this study was to evaluate postoperative laryngeal edema after AA using a new videolaryngoscopic (VL) scoring assessment.
Prospective case series.
Nineteen patients with UVFP (14 males and five females; mean age, 56 years) who were treated with AA alone or combined with ansa cervicalis (AA/AC) nerve anastomosis or nerve-muscle pedicle (AA/NMP) flap implantation were evaluated. Laryngeal edema was assessed by VL scoring for 10 days postoperatively. Degree of edema was scored in three subsites: the membranous vocal fold, arytenoid mound, and pyriform sinus on the operated side. Statistical significance was defined as P < .05.
No patient experienced postoperative airway compromise. Interexaminer reliability was generally high (Spearman r > 0.75). The mean degree of edema increased steadily from postoperative day (POD) 1 to 3, peaking on POD 3 at all subsites. It then declined significantly from POD 3 to 7 (P < .05) and gradually through POD 10. The maximum degree of edema, maximum edema time, and operative time were not correlated significantly at any subsite. Maximum edema time and surgery type (AA vs. AA/AC or AA/NMP) were not correlated at any subsite.
Inter-rater reliability for the proposed VL scoring was significant at all subsites. The VL findings suggest that AA alone or AA combined with reinnervation showed maximum laryngeal edema on POD 3 but added no significant morbidity.
The Laryngoscope 03/2012; 122(5):1104-8. · 1.75 Impact Factor
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ABSTRACT: X-linked agammaglobulinemia (XLA) is caused by a mutation in the Bruton tyrosine kinase, leading to an arrest in B cell development. Consequently, patients with XLA show significant decreases in gammaglobulin. Here, we describe a child with postmeningitic deafness and XLA who underwent a cochlear implantation. His psychomotor development had been normal and his congenital immunodeficiency was noticed only postoperatively. Immunoglobulin replacement treatment was started, but he still suffered repeated infections. Eventually, his cochlear implant was removed. A preoperative check of immunological status might be advisable in postmeningitic patients undergoing cochlear implantation to reduce the risk of postoperative infectious complications.
Auris, nasus, larynx 02/2012; 39(6):638-40. · 0.58 Impact Factor
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ABSTRACT: To evaluate the long-term efficacy of arytenoid adduction (AA) combined with ansa cervicalis-recurrent laryngeal nerve anastomosis (ACN-RLN) in the treatment of unilateral vocal fold paralysis.
Retrospective review of clinical records.
Institutional practice.
Nine patients with severe paralytic dysphonia with large glottal gap were included. Voice outcome was followed up over 24 months postoperatively. One patient did not attend the 24-month evaluation.
All patients underwent AA + ACN-RLN. The ansa cervicalis nerve to the sternohyoid muscle was used as the donor nerve.
Maximum phonation time (MPT), pitch range, harmonics-to-noise ratio (HNR), and perceptual voice quality were evaluated preoperatively and postoperatively at 1 to 3 months, 6 to 8 months, 12 to 14 months, and 24 months.
All parameters improved significantly after surgery and continued to improve over the 24-month period. The MPT continued to improve over time (P = .01, P = .006, and P = .001 when comparing the 1- to 3-month evaluation with the 6- to 8-month, 12- to 14-month, and 24-month evaluations, respectively). Also, pitch range and HNR showed significant, steady improvement over the 24-month duration of the study. Perceptual voice quality markedly improved at 24 months compared with the 1- to 3-month, 6- to 8-month, and 12- to 14-month follow-ups (P = .004, P = .005, and P = .02, respectively, for grade overall, and P = .004, P = .008, and P = .02, respectively, for breathiness grade).
Treatment with AA + ACN-RLN provides near-normal vocal function in the 24-month follow-up. Therefore, this method could be a successful surgical treatment for severe paralytic dysphonia.
Archives of otolaryngology--head & neck surgery 01/2012; 138(1):60-5. · 1.92 Impact Factor
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ABSTRACT: Our objective was to evaluate the efficacy of modified nerve-muscle pedicle (NMP) flap transfer combined with arytenoid adduction (AA) (AA + modified NMP) for treatment of unilateral vocal fold paralysis. The patterns of voice outcome assessed using phonatory function tests and auditory perceptual judgments were followed-up for 2 years.
Prospective study.
Thirteen subjects among those presented with paralytic dysphonia between March 2002 and December 2008 were treated with AA + modified NMP. The voice outcomes (six objective and two subjective voice parameters) were evaluated preoperatively and in four different time points postoperatively over 2-years duration.
All voice parameters showed initial postoperative improvement. Moreover, five parameters showed significant continuous improvement over the 2-year follow-up (maximum phonation time, pitch range, shimmer, and grade overall and breathiness of the grade-roughness-breathiness-asthenia-strain scale (GRBAS), whereas two parameters revealed continuous improvement over the first 12 to 14 months after surgery (mean flow rate and harmonics-to-noise ratio).
AA + modified NMP improves both short- and long-term voice outcomes in unilateral vocal fold paralysis patients. Therefore, AA + modified NMP is an effective surgical combination for the treatment of severe paralytic dysphonia.
The Laryngoscope 05/2011; 121(5):1018-22. · 1.75 Impact Factor
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Otolaryngology Head and Neck Surgery 04/2011; 145(5):874-5. · 1.72 Impact Factor
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ABSTRACT: To overcome the demerits of conventional postoperative aural packing, we developed a useful protocol for postoperative stenting of the external auditory canal after middle ear surgery which enables transcanal drainage and simultaneously allows for visual inspection and treatment of the canal, as necessary.
Twenty-four surgeries, 21 patients underwent tympanoplasty with a postaural incision. At the end of all surgical procedures, the external auditory canal was packed with a 0.3mm thickness rolled, tapered silastic sheet (RTSS) with antibiotic ointment applied to one surface. The inserted RTSSs were removed at 5-10 days postoperatively. We assessed the efficacy and the reliability of the RTSS.
In 23 ear surgeries on 20 patients, we achieved successful postoperative ear packing utilizing our RTSS. With these patients, the tympanic membrane and the external auditory meatus were able to be observed immediately after the completion of the stenting during the surgery and the removal of the gauze over the operated ear at Day 1 to Day 3 postoperatively. During 4 surgeries with ventilation tube insertion to the tympanic membrane, there was secretion through the inserted ventilation tube which was easy to suction. In one surgery, on one patient, additional packing materials were utilized once only during a sandwich graft myringoplasty. No patients showed any harmful effects during the postoperative period.
The useful and reliable RTSS, with antibiotic ointment applied to one surface, has several positive advantages that the conventional packing methods do not.
Auris, nasus, larynx 12/2010; 37(6):680-4. · 0.58 Impact Factor
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ABSTRACT: To describe a new technique of nerve-muscle pedicle (NMP) flap implantation combined with arytenoid adduction (AA) to treat dysphonia due to unilateral vocal fold paralysis and to examine postoperative vocal function.
Retrospective review of clinical records.
Tertiary academic center.
Twenty-two consecutive patients underwent NMP flap implantation with AA and were followed up short term over a period of 1 to 6 months (mean, 2.9 months) and long term over a period of 7 to 36 months (mean, 21.4 months).
An NMP flap was made using an ansa cervicalis branch and a piece of the sternohyoid muscle. A window was opened in the thyroid ala at the level of the vocal fold. Then, AA was performed and the NMP flap was securely implanted onto the thyroarytenoid muscle through the window under microscopic guidance.
The maximum phonation time, mean airflow rate, pitch range, and acoustic parameters (jitter, shimmer, and harmonics to noise ratio) were evaluated before surgery and twice after surgery.
All parameters improved significantly after surgery (P < .01). The measurements for maximum phonation time, mean airflow rate, and harmonics to noise ratio were within normal ranges after surgery. Furthermore, the maximum phonation time and jitter were significantly improved after long-term follow-up compared with early postoperative measurements (P < .01 and P < .05, respectively).
Precise harvest of an NMP flap and its placement directly onto the thyroarytenoid muscle combined with AA provided excellent vocal function. The NMP method may have played a certain role in the improvement of postoperative vocal function, although further study with electromyographic examination is required to clarify the innervation status of the thyroarytenoid muscle.
Archives of otolaryngology--head & neck surgery 10/2010; 136(10):965-9. · 1.92 Impact Factor
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ABSTRACT: Type II thyroplasty, or laryngeal framework surgery, is based on the hypothesis that the effect of adductor spasmodic dysphonia (AdSD) on the voice is due to excessively tight closure of the glottis, hampering phonation. Most of the previous, partially effective treatments have aimed to relieve this tight closure, including recurrent laryngeal nerve section or avulsion, extirpation of the adductor muscle, and botulinum toxin injection, which is currently the most popular. The aim of this study was to assess the effects of type II thyroplasty on aerodynamic and acoustic findings in patients with AdSD.
Case series.
University hospital.
Ten patients with AdSD underwent type II thyroplasty between August 2006 and December 2008. Aerodynamic and acoustic analyses were performed prior to and six months after surgery. Mean flow rates (MFRs) and voice efficiency were evaluated with a phonation analyzer. Jitter, shimmer, the harmonics-to-noise ratio (HNR), standard deviation of the fundamental frequency (SDF0), and degree of voice breaks (DVB) were measured from each subject's longest sustained phonation sample of the vowel /a/.
Voice efficiency improved significantly after surgery. No significant difference was found in the MFRs between before and after surgery. Jitter, shimmer, HNR, SDF0, and DVB improved significantly after surgery.
Treatment of AdSD with type II thyroplasty significantly improved aerodynamic and acoustic findings. The results of this study suggest that type II thyroplasty provides relief from voice strangulation in patients with AdSD.
Otolaryngology Head and Neck Surgery 04/2010; 142(4):540-6. · 1.72 Impact Factor
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ABSTRACT: Unilateral vocal fold paralysis (UVFP) is one of the most serious problems in conducting surgery for thyroid cancer. Different treatments are available for the management of UVFP including intracordal injection, type I thyroplasty, arytenoid adduction, and laryngeal reinnervations. The effects of immediate recurrent laryngeal nerve (RLN) reconstruction during thyroid cancer surgery with or without UVFP before the surgery were evaluated with videostroboscopic, aerodynamic, and perceptual analyses. All subjects experienced postoperative improvements in voice quality. Particularly, aerodynamic analysis showed that the values for all patients entered normal ranges in both patients with and without UVFP before surgery. Immediate RLN reconstruction has the potential to restore a normal or near-normal voice by returning thyroarytenoid muscle tone and bulk seen with vocal fold denervation. Immediate RLN reconstruction is an efficient and effective approach to the management of RLN resection during surgery for thyroid cancer.
Journal of Oncology 01/2010; 2010:846235.
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ABSTRACT: The factors responsible for the observed failures can be broken into two major groups: (1) a wrong indication and (2) an inadequate technique to achieve relief from an excessively tight glottal closure. The use of a titanium bridge in place of a silicone shim was found to be essential. Type II thyroplasty can relieve the symptoms of adductor spasmodic dysphonia (AdSD) when implemented with a modern technique using titanium bridges.
To identify the factor or factors that necessitated revision surgery in type II thyroplasty for AdSD, detailed analytical examinations were made of individual cases with unsatisfactory outcomes.
A retrospective analysis of a case series with follow-up periods of 2-5 years.
Ninety AdSD patients underwent type II thyroplasty. The results in one patient were limited because a pathological mechanism other than AdSD was also involved. One patient, a singer, who wanted a more intense voice for singing was dissatisfied with the results. In three patients, the material used for fixation was inadequate. In two other patients, the method of application of the fixative material was found to be insufficient as it did not include both the upper and lower sides.
Acta oto-laryngologica 11/2009; 129(11):1287-93. · 0.98 Impact Factor
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ABSTRACT: Use of the titanium bridge, both at the top and bottom corners of the incised thyroid cartilage, is essential for success. Most importantly, these procedures should be done with minimal damage to the tissues involved, using fine instruments.
Type II thyroplasty that aims at lateralization of the vocal folds for spasmodic dysphonia is a type of surgery that requires utmost surgical caution, because of the extremely delicate site for surgical intervention, critically sensitive adjustment, and difficult procedures to maintain the incised cartilages in a correct position.
By means of a postoperative questionnaire and examinations, analyses were made of the relation in each case between the detailed surgical records and the outcomes in terms of subjective complaints, vocal features, and laryngeal as well as aerodynamic findings.
It was found that surgical failures or unsatisfactory results arise most frequently from certain clear mechanical faults. The critical procedures that most affected the results included: (1) incision and separation of the thyroid cartilage at the midline; (2) adjustment of separation width for optimal voice; (3) cartilage-perichondrium separation for holding an appropriate titanium bridge; and (4) installation and fixation of titanium bridges.
Acta oto-laryngologica 07/2009; 130(2):275-80. · 0.98 Impact Factor
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ABSTRACT: A certain degree of subclinical extrathoracic airway compromise may ensue after thyroplastic surgery, although none of the patients reported the presence of dyspneic symptoms in their normal daily lives.
To determine the effects of thyroplastic surgery on respiratory function and compare them with the improvement of vocal function.
The study included 53 patients; 7 had type I thyroplasty (type I), 9 had arytenoid adduction (AA), 10 had AA with type I, and 27 had AA with neuromuscular pedicle flap implantation (NMP). Phonatory and respiratory functions were measured preoperatively and postoperatively. The presence of dyspnea during daily activities was determined postoperatively.
The difference between the pre- and postoperative values was statistically significant in five comparisons. Forced expiratory volume in 1 s/forced expiratory volume (FEV(1%)) in the AA with type I group, FEV(1)/peak expiratory flow rate (PEFR) in the AA group, and PEFR in the three groups (type I, AA, and AA with NMP). Forty-six patients associated with AA were combined for statistical analysis. The differences were statistically significant for FEV(1%), PEFR, and FEV(1)/PEFR. Changes in maximum phonation time (MPT) were found to have a significant correlation with changes in FEV(1)/PEFR. All the patients denied episodes of dyspnea during their normal daily activities.
Acta oto-laryngologica 06/2009; 130(1):132-7. · 0.98 Impact Factor
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ABSTRACT: Nerve-muscle pedicle (NMP) implantation was effective in the recovery from atrophic changes in long-term denervated thyroarytenoid (TA) muscle. Re-innervation occurred via the transferred nerve. However, the effectiveness of the NMP method may decline with increasing duration of denervation.
To evaluate the effects of NMP implantation on long-term denervated rat TA muscle.
Wistar rats (n=105) were divided into two groups in which the left recurrent laryngeal nerve (RLN) was transected without (DNV group) or with (NMP group) subsequent NMP implantation, and subgroups of each group were formed depending on the period after RLN transection (immediate to 48 weeks). In the DNV subgroups, we histologically assessed the area of muscle and the number of neuromuscular junctions. In the NMP subgroups, we performed electromyographic, videolaryngoscopic, and histologic assessments. The muscle area and muscle action potentials were evaluated by comparing the treated and untreated sides. The ratio of the number of nerve terminals to that of acetylcholine receptors was also assessed.
The TA muscle area was significantly larger in most of the NMP subgroups compared with the DNV subgroups. Muscle action potentials were present in all NMP animals. All histologic and physiologic assessments revealed degradation as the denervation period in the five NMP subgroups.
Acta oto-laryngologica 01/2009; 129(12):1486-92. · 0.98 Impact Factor
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ABSTRACT: To determine the incidence of black spots after resolution of laryngeal granuloma (LG), to compare the disease duration from the beginning of treatment to resolution between patients with and without black spots, and to assess the histologic findings of LG in resected or biopsied specimens.
Retrospective.
Forty-six patients with LG on the cartilaginous portion of the vocal fold were included. Their clinical records were reviewed. Histologic specimens were re-examined.
Causes of LG were postintubation in 10 patients, unilateral vocal fold immobility in 1, Candida infection in 1, and were not specified in 34 (either hyperfunctional vocal abuse, laryngopharyngeal regurgitation, or both). Of the 10 patients with postintubation LG, 9 resolved; of the 33 patients with LG from other causes, 21 resolved. Of the 28 resolved patients, 12 developed a black spot at the previous lesion site. Of the 18 patients whose LG resolved without surgical intervention, 11 developed a black spot at the previous lesion site, and the remaining 7 patients did not develop any black spots. The treatment period until LG resolution was significantly longer among patients with a black spot than those without a spot (P = .0372). Histologic examination revealed the presence of hemosiderin accumulation accompanied by infiltration of lymphocytes and macrophages in 8 of the 16 patients who had their LGs resected or biopsied.
Accumulation of hemosiderin in the subepithelial layer, together with little blood flow and dense connective tissue in the cartilaginous portion of the vocal fold, are important factors contributing to the persistence of LG.
The Laryngoscope 06/2008; 118(5):932-7. · 1.75 Impact Factor
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ABSTRACT: To assess the effectiveness of type II thyroplasty with a titanium bridge in adductor spasmodic dysphonia (AdSD).
Retrospective chart review, patient response to a questionnaire on the ease of phonation and voice quality, and pre- and postoperative fiberoptic laryngoscope findings.
Forty-one patients who underwent type II thyroplasty with a titanium bridge between December 2002 and December 2005 who have been followed for at least 12 months postoperatively.
Six patients were male, and 35 were female. The voice was recorded before and at least 6 months after surgery. Initially, 97.6%, 61%, and 48.8% of the patients had a strangulated, interrupted, or tremulous voice, respectively. The mean ratings of strangulation, interruption, and tremor were calculated. The respective mean pre- and postoperative scores were 1.51 and 0.46 for strangulation, 0.76 and 0.05 for interruption, and 0.65 and 0.048 for tremor. In the postoperative questionnaire, 70% of the patients judged their voice as excellent and the remaining patients as improved to good or fair.
Type II thyroplasty is a highly effective therapy for AdSD. The voice in AdSD may roughly be classified into strangulated, tremulous, and interrupted types. The outcome measures justify the continued treatment of AdSD with type II thyroplasty.
The Laryngoscope 01/2008; 117(12):2255-9. · 1.75 Impact Factor
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ABSTRACT: The objective of this prospective study was to assess the long-term effects of immediate reconstruction of the recurrent laryngeal nerve (RLN) during thyroid cancer extirpation on postoperative phonatory function.
The subjects were 22 patients with advanced thyroid cancer who underwent resection of the primary lesion and involved RLN. RLN paralysis was seen in 12 patients preoperatively and involvement of the RLN was noted intraoperatively in 10. Immediate reconstruction of the RLN was performed on eight patients using the great auricular nerve and one underwent direct anastomosis of the RLN stumps (group I). Nine patients opted not to have phonosurgical procedures (group II). The remaining four had arytenoid adduction immediately after cancer extirpation (group III). Phonatory function (stroboscopy, maximum phonation time [MPT], mean airflow rate [MFR], harmonics-to-noise ratio [HNR], jitter, and shimmer) was followed for at least 9 months.
Minimal or no glottal gap during phonation was observed in six patients in group I, whereas the patients in group II had a large gap along the entire fold. HNR, MPT, and MFR were significantly better in group I (17.7 +/- 3.6 dB, 15.1 +/- 6.3 s, and 100 +/- 32 mL/s, respectively) than in group II (12.1 +/- 2.9 dB, 5.4 +/- 3.1 s, and 430 +/- 207 mL/s, respectively). Patients in group III had a gap of varying degrees along the membranous fold. Although HNR, shimmer, and MPT in group III were comparable to group I, the other parameters were less favorable than in group I.
Immediate RLN reconstruction at the time of thyroid cancer extirpation can provide excellent postoperative phonatory function.
The Laryngoscope 10/2006; 116(9):1657-61. · 1.75 Impact Factor
