Voice gains following thyroplasty may improve over time

Type I thyroplasty for unilateral vocal fold paralysis restores voice. The purpose of this study was to evaluate measures of voice before thyroplasty, and at 3 months and 1 year after surgery. Of interest was whether vocal improvement in the first weeks after surgery was maintained or even enhanced over time. A total of 40 patients with unilateral paralysis underwent type I thyroplasty with or without arytenoid adduction. Perceptual, acoustic and aerodynamic measures of voice were studied. Perceptual analysis determined that optimal postoperative voice quality evolved over the first year. Acoustic indices of perturbation demonstrated progressive improvement over 12 months, whereas pitch and intensity ranges were increasingly extended. Postoperative glottal flow rates were normalized and phonation times were significantly longer, with benefits maintained over time. All perceptual, aerodynamic and acoustic measures of voice were improved 3 months after thyroplasty, with many measures further improved at 1 year. Such findings provide evidence that voice outcome progressively evolves over the first 12 months after surgery.

Voice outcome following thyroplasty in patients with cancer-related vocal fold paralysis

Medialization laryngoplasty restores voice in patients with unilateral laryngeal paralysis. Of question was whether patients with vocal fold paralysis resulting from cancer or its treatment had as good a post-operative voice result as patients with vocal fold paralysis of benign etiology. The purpose of the present study was to compare post-operative perceptual, acoustic, aerodynamic, and quality of life data in these two patient groups. Twenty-eight patients with vocal fold paralysis secondary to malignancy or its treatment were age and gender-matched with patients with paralysis resulting from benign origin. Pre- and post-operative perceptual judgments of pitch, loudness and quality were rated independently by two speech-language pathologists. A digital audiotape of the patient's voice was analyzed using Soundscope software. Fundamental frequency, conversational intensity and perturbation were evaluated. Glottal flow rates in propositional speech, phonation times and extent of pitch and loudness ranges were also measured. Three quality of life surveys, the Short Form-36 general health survey, the Voice Handicap Index, and the Voice Outcomes Study were administered. Results of voice testing indicated that perceptual, acoustic and aerodynamic data were significantly improved 3 months after thyroplasty in all patients regardless of whether they had a history of cancer. Quality of life data, however, distinguished the two groups. In particular, the general health measure found a significant difference in physical functioning and overall vitality, although satisfaction with improved voice was equally appreciated in both patient groups. Of clinical significance is that though general health may differ, patients with cancer-related laryngeal paralysis can expect to have as good a voice outcome following thyroplasty as patients with paralysis of benign etiology.

Vagal paragangliomas

The management of vagal paragangliomas is extremely challenging. Treatment of these lesions must be tailored individually for each patient. The best treatment modality depends on the patient's age and health and the size and extent of the tumor. This article discusses clinical presentation, multicentric and malignant vagal paragangliomas, evaluation, embolization, surgical management, and special considerations in the management of vagal paragangliomas.

Paraganglioma surgery: complications and treatment

Paragangliomas are vasculature in nature and are surrounded by vital neurovascular structures. The extirpation of these lesions requires careful preoperative evaluation, meticulous surgical technique, and the aid of experienced skull base surgical and rehabilitative teams. When surgery is performed in this way, complications can be minimized, and the function of the upper aerodigestive tract can be protected.

Voice outcome following lateral laryngotomy to remove teflon granuloma

Formation of a Teflon granuloma may lead to progressive dysphonia and airway compromise. Excision of the granuloma by lateral laryngotomy allows preservation of the uninvolved lamina propria. A sternothyroid muscle flap or Silastic implant to medialize the vocal fold restores a straight glottal edge and optimizes voice production. Fifteen patients underwent removal of a Teflon granuloma via a lateral approach. Analysis of data revealed improved acoustic and aerodynamic parameters of voice following surgery. Indices of acoustic perturbation were reduced, and vocal pitch normalized. While the dynamic pitch range was unchanged, the capacity to vary loudness was enhanced. Flow rates in speech, abnormally elevated before surgery, normalized after the procedure, and phonation times were significantly longer. Perceptual and stroboscopic data confirmed that voices were improved, but not normal.

Quality-of-life assessment in patients with unilateral vocal cord paralysis

OBJECTIVE

Our objective was to identify the impact of unilateral vocal cord paralysis (UVCP) on an individual's quality of life both before and after thyroplasty.

STUDY DESIGN AND SETTING

This was a prospective observational outcome study of consecutive patients presenting to a laryngology clinic with UVCP. Participants received The Medical Outcomes Study Short Form 36-Item Health Survey (SF-36), the Voice Handicap Index (VHI), and the Voice Outcome Survey (VOS). Patients underwent medialization laryngoplasty with silastic, with or without arytenoid adduction. Outcome measures were repeated after surgery.

RESULTS

A review of 45 patients at presentation revealed statistically significant reductions in quality of life as measured by each survey. Marked improvements were noted after surgery.

CONCLUSIONS

Our preoperative data support a profile of significant general health-related and voice-related limitations caused by UVCP. Patient perceptions improved significantly after the surgical treatment of glottal insufficiency.

SIGNIFICANCE

The SF-36, VHI, and VOS provide an important complement to traditional endpoints in the analysis of patients with UVCP.

Lateral Skull Base Surgery for Glomus Tumors: Long-Term Control

OBJECTIVE

The age of modern microsurgery has made resection of glomus tumors with extensive skull base involvement possible. Resection of extensive lesions is not without risk of major complication or new cranial nerve deficit. Because glomus tumors are rare and slow growing, data reflecting recurrence risk after resection using modern skull base techniques are lacking. These factors complicate the accurate definition of efficacy of surgical resection and its functional cost. The object of this review is to determine the current incidence of major complications, the surgical cranial nerve deficit, the long-term control rate, and the recurrence risk in patients undergoing surgical resection of glomus jugulare tumors.

STUDY DESIGN

Retrospective case review.

SETTING

Private practice tertiary referral center.

PATIENTS AND INTERVENTIONS

One hundred seventy-six patients with glomus tumors underwent 182 lateral skull base resections between 1972 and 1998.

MAIN OUTCOME MEASURES

Major complications, tumor recurrence, postoperative functional capacity, and factors affecting the incidence of each were assessed.

RESULTS

Complete surgical control was achieved in 85% of cases. There were nine cases of recurrence, for a recurrent rate of 5.5% (9/164). Cerebrospinal fluid leakage occurred in 4.5% of cases with intracranial extension. New deficits for cranial nerves IX, X, XI, and XII occurred in 39%, 25%, 26%, and 21% of cases, respectively. Satisfactory functional recovery was achieved in an overwhelming majority of cases. The mortality rate was 2.7% (5/182).

CONCLUSIONS

Surgical resection of glomus tumors is established as an effective technique with good functional outcomes and long-term control.

Outcomes assessment following treatment of spasmodic dysphonia with botulinum toxin

Spasmodic dysphonia (SD), a disabling focal dystonia involving the laryngeal musculature, is most commonly treated by the intramuscular injection of botulinum toxin (BTX). Although the treatment is well tolerated and generally produces clinical voice improvement, it has never been statistically shown to alter the patient's perception of voice quality or general health. Declining resources for medical care mandate that treatment outcomes be documented. A prospective analysis of the effects of BTX on the patient's perception of voice and general health was undertaken. The Voice Handicap Index (VHI) and Short Form 36 (SF-36) surveys were administered to patients before treatment and 1 month after. Pretreatment and posttreatment scores were analyzed with a Student's t-test. On the VHI, improvements in the patients' perception of their functional, physical, and emotional voice handicap reached statistical significance (p < or = .0005). On the SF-36, patients had statistically significant improvements in mental health (p < or = .03) and social functioning (p < or = .04). Treatment of SD with BTX significantly lessened the patients' perception of dysphonia. In addition, it improved their social functioning and their perception of their mental health. These outcome measures justify the continued treatment of SD with BTX.

Increasing use of the scapula osteocutaneous free flap

OBJECTIVES

To determine the appropriate use of the scapula osteocutaneous free flap (SOFF) and to document donor site morbidity.

STUDY DESIGN

Retrospective review and prospective physical therapy evaluation.

METHODS

A computer database of all free flap procedures performed at a single institution was created. Specific clinical and operative details from cases involving a bone flap were extracted from the database. Rates of usage of the various osteocutaneous flaps were compared over four successive 2-year intervals (1992-1999). A single physical therapist performed a structured evaluation of the donor site.

RESULTS

Overall, 64 bone flap procedures were performed, of which 24 (37.5%) were SOFF procedures. The SOFF utilization has increased from 6.6% to 63.6%, while fibula and iliac crest utilization has fallen significantly. This is in part because of the greater versatility of the SOFF, with the possibility of separate skin paddles and adequate bone length. The mean cutaneous area harvested with the SOFF was 110 cm2 (range, 48-200 cm2) compared with 55.4 cm2 (range, 25-102 cm2) and 77.6 cm2 (range, 50-120 cm2) for the fibula and iliac crest, respectively. Mean bone flap lengths were 8.37, 7.65, and 10.1 cm, respectively, for the SOFF, fibula, and iliac crest. Dual skin paddles were used in 50% of the SOFF procedures versus 2.8% for the fibula flap procedures. There were no significant complications of the donor site in any patient, and there was only one flap failure (4.1%). Related to the SOFF, donor site morbidity was subjectively judged as "mild," for pain, mobility, and strength. There were no complaints of poor appearance of the donor site. Activities of daily living were judged as "not limited" or 'limited a little" in the majority of patients. Objective measurements of range of motion revealed an average reduction of 1 degree to 12 degrees in five different shoulder functions. Elbow and arm ranges of motion were not limited. Strength was minimally reduced in the shoulder, while the arm and forearm showed no reduction in strength.

CONCLUSIONS

The SOFF is a versatile osteocutaneous free flap that can be used for a multitude of reconstructive problems. This and its relative lack of significant donor site morbidity have caused its use to increase significantly.

Sarcoidosis of the pediatric larynx

Sarcoidosis is a chronic granulomatous disease of unknown pathogenesis. Reports of sarcoidosis are much less common in the pediatric literature than in the adult literature. The disease is usually systemic; rarely, however, single organs are affected. Isolated laryngeal involvement is an unusual presentation. We report a well-documented case of isolated laryngeal sarcoidosis in a 14-year-old white boy who presented to our institution with a 6-month history of dysphonia, dyspnea on exertion, and extremely sonorous snoring at night owing to his supraglottic airway disease. To our knowledge, this is only the second case of isolated laryngeal sarcoidosis reported in the pediatric literature. We review the literature and discuss the differential diagnosis, diagnostic evaluation, and treatment with carbon dioxide laser epiglottectomy and intralesional glucocorticoid deposition, which resulted in marked resolution of our patient's symptoms.

Long-standing lateral neck mass as the initial manifestation of well-differentiated thyroid carcinoma

OBJECTIVE

To analyze the presentation, evaluation, and treatment of a subset of patients with well-differentiated thyroid carcinoma who present with a lateral neck mass and no palpable disease in the thyroid gland.

STUDY DESIGN

A retrospective review of all patients undergoing thyroidectomy for malignancy.

METHODS

A database of all thyroidectomies performed for malignancy by the Vanderbilt University Department of Otolaryngology-Head and Neck Surgery from 1992 to 1997 was created. Patients who presented with an isolated neck mass without evidence of palpable disease in the thyroid were selected for the study population.

RESULTS

There were 60 cases of thyroid malignancy, with 14 cases (23.3%) that presented as isolated lateral neck mass. The characteristics of this group (compared with the population of all thyroid malignancies) include younger age at presentation (37.7 +/- 15.2 y vs. 49.8 +/- 15.6 y; Student t test: P = .019) and long-standing presence of symptoms (27.4 +/- 39.6 mo vs. 3.6 +/- 3.9 mo; P = .023). These patients generally presented from a referring facility after having an excisional biopsy, which was 100% accurate. Fine-needle aspiration is becoming more useful and was 66.7% accurate. Histological examination revealed cancer in the thyroid gland in all patients, 11 cases of papillary carcinoma, 2 follicular carcinomas, and one medullary carcinoma The mean size of the primary focus was 10.9 +/- 8.7 mm, with 29% demonstrating bilateral disease and 14% demonstrating multifocal disease in the ipsilateral gland. The neck specimens revealed an average of 5.3 +/- 3.2 metastatic nodes in levels II-IV and 3.9 +/- 4.6 metastatic nodes in the paratracheal region.

CONCLUSION

Based on this patient population, the long-standing lateral neck mass in the young patient should raise the physician's index of suspicion for thyroid carcinoma Fine-needle aspiration should be used in conjunction with judicious excisional biopsy. The bilateral and multifocal nature of otherwise occult primary disease argues for total thyroidectomy in this setting.

Histologic findings of silastic medialization in the canine model

OBJECTIVES

Examine the long-term histological effects of Silastic medialization using a canine model.

STUDY DESIGN

Prospective study evaluating the effects of Silastic medialization in six canine larynges.

METHODS

Two subject groups were evaluated. The first group of four dogs underwent recurrent laryngeal section followed by Silastic medialization on the paralyzed side and placement of a smaller implant on the mobile side. Two of the dogs were sacrificed at 9 months and two at 2 years. The second subject group consisted of two additional dogs who underwent Silastic medialization followed by removal of the implants at 7 months and were sacrificed 18 months later. The larynges were then processed, sectioned in the axial plane, and examined microscopically.

RESULTS

Histological findings of both the mobile and paralyzed sides showed a thin (< 0.5 mm) fibrous capsule surrounding the implant and minimal inflammatory response. Vocal fold mobility was maintained in all cases in which the recurrent laryngeal nerve was left intact. Capsule formation and inflammatory response were similar in all cases.

CONCLUSIONS

Minimal tissue reactivity over a prolonged period of time suggests that long-term results of Silastic medialization remain stable in paralyzed and mobile vocal folds for up to 2 years. Similar tissue response in the subjects in which the Silastic block was removed also suggests that Silastic medialization is a reversible procedure.

Surgical management of thyroid and parathyroid disorders

This article begins with a discussion of thyroid anatomy and physiology and then proceeds with an in-depth study of the area of focus, thyroid and parathyroid disorders, including thyroid nodules and cancer, multinodular goiter, and hyperparathyroidism. Complications of thyroid and parathyroid surgery are discussed.

Management of substernal goiter

OBJECTIVE

To analyze the presentation, evaluation and treatment of patients with large substernal goiters, with emphasis on the radiographic evaluation and the results of treatment.

STUDY DESIGN

A retrospective chart review of 150 patients undergoing thyroidectomy at the Vanderbilt University Department of Otolaryngology-Head and Neck Surgery.

METHODS

Charts of patients undergoing thyroidectomy were reviewed. Those with substernal goiter, defined as a major portion of the goiter within the mediastinum, were included in the study. When available, the radiographic studies were reviewed by a staff neuroradiologist.

RESULTS

Twenty-three patients (15.3%) presented with substernal extension of the goiter. Characteristics of these patients included mean age of 59 years, 78% female, symptoms of compression such as dyspnea, choking, and dysphagia (65%), hoarseness (43%), and previous thyroid surgery (30%). Seventeen percent were asymptomatic. Preoperative radiographs demonstrated tracheal compression (73%), tracheal deviation (77%), esophageal compression (27%), and major vessel displacement (50%). Histology revealed multinodular goiter (16/23, 70%), thyroiditis (3/23, 13%), and malignancy (4/23, 17%). The average size of the resected specimen in greatest dimension was 8.0 cm (range, 3.0-14.0 cm) and weighed 148 g (range, 39-426 g). All were successfully approached through a transcervical incision without the need for sternotomy, and total thyroidectomy was performed in 83% of the cases. No major complications have been documented, and no evidence of tracheomalacia was encountered.

CONCLUSION

Despite the large size of these goiters and the significant involvement of the major mediastinal structures, all were approached through the transcervical incision. Further, despite significant tracheal involvement, there were no cases of tracheomalacia or major complications. For intraoperative planning, the authors advocate the routine use of preoperative computed tomography scanning.

Vagal paraganglioma: a review of 46 patients treated during a 20-year period

BACKGROUND

Vagal paragangliomas (VPs) arise from paraganglia associated with the vagus nerve. Approximately 200 cases have been reported in the medical literature. Because of their rarity, most information regarding these tumors has arisen from case reports and small clinical series.

OBJECTIVE

To detail the clinicopathologic features of 46 patients with VP with an emphasis on the role of a multidisciplinary skull base team in both the successful extirpation and rehabilitation.

DESIGN

Retrospective review of 46 patients with VP managed by a single skull base team.

SETTING

An academic tertiary medical center.

RESULTS

Forty-six patients were treated over a 20-year period (1978-1998). Ten (22%) demonstrated intracranial extension. There was a history of familial paragangliomas in 9 (20%) of the patients. The incidence of multicentric paragangliomas was 78% in patients with familial paragangliomas vs 23% in patients with nonfamilial paragangliomas. Management of this group of 46 patients consisted of surgery (n = 40), radiation therapy (n = 4), and observation (n = 2). The operative approach consisted of a transcervical excision often combined with a transtemporal or lateral skull base approach as dictated by the tumor extent. Postoperative cranial nerve deficits were common, and, as such, aggressive rehabilitation was a vital component in the management of these tumors.

CONCLUSIONS

The management of VP and its associated cranial nerve deficits remains a difficult clinical problem. Options for treatment include surgical resection, radiation therapy, and, in selected cases, observation. Surgical extirpation requires a multidisciplinary skull base team to achieve complete tumor resection. Radiation therapy is reserved for elderly patients and patients at risk for bilateral cranial nerve deficits. Rehabilitation of cranial nerve deficits is an integral part of the management of VP.

Lateral laryngotomy for the removal of Teflon granuloma

Teflon injection has been used for vocal fold medialization following paralysis. Recently, numerous articles have discussed the complications of Teflon injection, including overinjection, airway obstruction. Teflon granuloma, and an abnormal mass effect creating a decreased vibratory character of the true vocal fold. Multiple techniques for Teflon removal have been described. This report details our experience with complete Teflon granuloma removal via a lateral laryngotomy under local anesthesia. Microscopic dissection of the entire granuloma and the paraglottic space was accomplished in all patients. Due to extensive destruction caused by the granuloma, the vocal ligament was resected in 3 patients; it was partially resected and reanastomosed in 1 case, and spared in 6 patients. Laryngeal reconstruction was accomplished with an inferiorly based sternohyoid muscle rotation flap and arytenoid adduction. Effortful speech secondary to pressed vocal quality resolved in all patients. Near-normal to normal vocal quality was obtained in 4 patients, with the average "voice desirability" improving 60% and the effective glottic width increasing 29%. Factors that contributed to a successful outcome included noninvolvement of the vocal ligament and sparing of the mucosal cover.

Delayed regional metastasis from midfacial squamous carcinomas

BACKGROUND

Metastases from mucosal and cutaneous carcinomas can present in a delayed fashion, and this late presentation may confer a different prognosis after conventional treatment.

METHODS

We present a series of patients in which there was a significant time delay between the treatment of a squamous carcinoma of the skin or mucosa of the midface and the detection of regional metastases in 12 of the 13 cases. Primary tumors were located on the lower lip and commissure (n = 3), nasal tip (n = 2), nasal ala (n = 1), columella (n = 1), nasofacial crease (n = 2), maxillary alveolus (n = 3), and mandibular alveolus (n = 1). Metastatic spread manifested by palpable perifacial or submandibular lymph nodes was not evident until greater than 11 months after the treatment of the primary site in 12 of 13 patients (range, 3-45 months). Nine of the patients were clinically staged as N1, whereas there was one each in the N2a, N2b, N2c, and N3 categories. Eleven of the 13 patients were initially seen with palpable disease involving the perifacial nodes within or around the submandibular gland. All patients were treated with neck dissection except one, who refused surgical treatment and underwent a second course of radiotherapy to the cervical region. The nine patients initially seen with clinical stage N1 disease underwent neck dissection with preservation of the sternocleidomastoid, internal jugular vein, and accessory nerve.

RESULTS

Of 10 patients with perifacial node metastases who underwent neck dissection, 8 required sacrifice of the marginal mandibular nerve and overlying platysma to gain adequate margin. Extracapsular spread was present in 11 patients, (8 of 9 who were clinically N1). Postoperative radiotherapy was recommended to all patients with extracapsular spread, although only 7 of the 11 received radiotherapy. There were no regional recurrences after a minimum follow-up of 1 year (range, 12-65 months; mean, 31.4 months). Histologic grade appeared to have no influence on prognosis.

CONCLUSIONS

This cohort demonstrates the ability of midfacial squamous cell carcinoma to manifest regional metastatic disease over a delayed time. This delayed presentation appears to confer a more favorable response to treatment. For midfacial cancers, the perifacial nodes are at greatest risk for metastatic spread. For tumors in this region, primary treatment of the neck is probably not warranted, but careful extended follow-up for the potential of delayed cervical metastasis is prudent.

Laryngotracheal reconstruction in the adult: a ten year experience

The purpose of this study is to retrospectively analyze our experience with airway reconstruction, to outline a new staging system for laryngotracheal (LT) stenosis, and to identify preoperatively those patients likely to fail reconstruction. We reviewed 41 patients who underwent 46 LT reconstructions over the past 10 years. Success was judged by the ability to decannulate patients within 1 year postoperatively. Of our patients, 63% were treated successfully, and an additional 17% had intermediate success. The techniques used for laryngotracheoplasty with augmentation grafting and tracheal resection are reviewed. Major complications, thoracic complications, and wound complications are presented. Each patient was staged by the McCaffrey staging system and Cotton grades. We propose a new staging system based on the extent of the stenosis throughout the glottis, subglottis, and trachea. It is logical and easy to use. Applied to our cases of LT stenosis retrospectively, the new system predicts clinical success (chi2, p = .05). Using contingency tables and chi2 testing for statistical evaluation, we found that diabetics have a significantly higher failure rate (chi2, p = .0002). Further, we identified a group of patients who in addition to the airway stenosis also had comorbid medical conditions that frequently necessitate a tracheostomy. These patients have a significantly higher failure rate (chi2, p = .009). Using this information and applying the staging system prior to reconstruction, we can identify patients likely to fail.

Expression of matrix metalloproteinases and tissue inhibitor of metalloproteinases in head and neck squamous cell carcinoma

Matrix metalloproteinases (MMPs) are a family of proteolytic enzymes implicated in the invasion and metastasis of many cancers. In situ hybridization techniques were used to reveal sites of expression of collagenase (MMP-1), gelatinase 72 kd (MMP-2), gelatinase 92 kd (MMP-9), and tissue inhibitor of metalloproteinase-1 (TIMP-1) in head and neck carcinomas (N = 21). Both TIMP-1 and gelatinase 72 kd were expressed in nearly all tumors, whereas the expression of collagenase and gelatinase 92 kd showed variability. Tumor-associated expression of MMPs was strongest in stromal cells near advancing margins. No differences in expression levels were detected between primary and metastatic sites. This paper reviews the literature and discusses the significance and possible implications of MMPs in head and neck squamous cell carcinoma.

Stretch-induced nerve injury as a cause of paralysis secondary to the anterior cervical approach

The anterior approach to the cervical spine, first described 40 years ago, has become a popular and widely used procedure by spine surgeons to expose the anterior vertebral bodies from C3 to T1. A significant complication of this procedure is transient or permanent ipsilateral recurrent laryngeal nerve paralysis. In a previous review at our institution of patients with hoarseness after an anterior cervical approach, 15 of 16 patients demonstrated right-sided paralysis. The asymmetry in the anatomic courses and lengths of the recurrent laryngeal nerves are proposed to place the right recurrent laryngeal nerve at an increased risk of stretch-related injury during this surgical procedure. We developed a cadaver model to evaluate the in-line stretch on the recurrent laryngeal nerve during the right- and left-sided approaches to the C4 and C7 vertebral bodies. To assess the difference in risk of injury to the two recurrent laryngeal nerves, we performed the anterior approach to the cervical spine in four anatomic positions: the left neck and right neck at the levels of C4 and C7 on 10 fresh human cadavers during the immediate postmortem period. The blades of a Cloward retractor were progressively spread to 2, 3, and 4 cm in the four anatomic positions while the corresponding degrees of ipsilateral recurrent laryngeal nerve stretch resulting from retraction were simultaneously measured. The left recurrent laryngeal nerve had sufficient redundancy in its course within the tracheoesophageal groove in 10 of 10 cadavers such that it exhibited no in situ stretch during the left-sided approach to either the C4 or C7 vertebrae. In contrast, the right recurrent laryngeal nerve has little redundancy in its course and is not protected within the tracheoesophageal groove. The right-sided approach to C7 resulted in an average in situ stretch on the ipsilateral recurrent laryngeal nerve of 12% and 24%, with 3 cm and 4 cm of Cloward retraction, respectively. The right-sided approach to C4 resulted in significant levels of stretch in 3 (30%) of 10 cadavers and no stretch in 7 (70%) of 10 cadavers. The relevance of these data is demonstrated by the review of numerous studies demonstrating the potential for significant neural damage with nerve stretch greater than 12%.

Alternating unilateral botulinum toxin type A (BOTOX) injections for spasmodic dysphonia

Injection of botulinum toxin type A (BOTOX) into both thyroarytenoid muscles is an accepted treatment for spasmodic dysphonia. The authors of this study identified patients who could not tolerate the interval of breathy voice that immediately follows bilateral injections. These patients were offered a protocol in which the injection side was alternated on subsequent treatments. Eighteen patients who received at least two bilateral injections and two unilateral injections were reviewed. Alternating unilateral injections yielded a shorter breathy interval by an average of 12.7 days (P=.0007) and a shorter duration of return of spasmodic symptoms by an average of 26.0 days (P=.0006). Compared with bilateral injections, alternating unilateral injections yielded an average (median) of 3.2 more days of strong voice per day of breathy voice (P=.001). However, unilateral injections had a shorter average interval of strong voice (27.4 days; P=.007), as well as a slightly higher failure rate (4.9% vs. 1.1%). The authors conclude that alternating unilateral botulinum toxin type A injections are useful in patients with spasmodic dysphonia who have difficulty with the breathy voice that follows bilateral injection.

Electrical pacing of the paralyzed human larynx

This study represents the first attempt to electrically pace the paralyzed human larynx. The goal was to determine if electrical stimulation of the posterior cricoarytenoid muscle could produce functional abduction of the vocal fold in pace with inspiration. An external apparatus was used to sense inspiration and reanimate the unilaterally paralyzed larynx of a thyroplasty patient. Stimuli were delivered through a needle electrode to locate and pace the abductor muscle. The magnitude of electrically induced abduction was comparable to spontaneous movement on the normal side. The abduction was appropriately timed with inspiration: this finding demonstrated that this simple pacing system could effectively modulate stimulation with patient respiration.

Long-term follow-up of recurrent laryngeal nerve avulsion for the treatment of spastic dysphonia

Long-term follow-up of 3 to 7 years is reported on 18 patients who had undergone recurrent laryngeal nerve avulsion (RLNA) for the treatment of adductor spastic dysphonia (SD). Data on neural regrowth after previous recurrent laryngeal nerve section (RLNS) are presented in 2 of these 18 patients. We introduced RLNA as a modification of standard RLNS to prevent neural regrowth to the hemiparalyzed larynx and subsequent recurrence of SD. We have treated a total of 22 patients with RLNA, and now report a 3- to 7-year follow-up on 18 of these 22 patients. Resolution of symptoms was determined by routine follow-up assessment, perceptual voice analysis, and patient self-assessment. Sixteen of 18, or 89%, had no recurrence of spasms at 3 years after RLNA as determined at routine follow-up. Two of the 16 later developed spasms after medialization laryngoplasty for treatment of weak voice persistent after the avulsion. This yielded a total of 14 of 18, or 78%, who were unanimously judged by four speech pathologists to have no recurrence of SD at the longer follow-up period of 3 to 7 years. Two of these 4 patients were judged by all four analysts to have frequent, short spasms. The other 2 were judged by two of four analysts to have seldom, short spasms. Three of 18 patients presented with recurrent SD after previous RLNS. At the time of subsequent RLNA, each patient had evidence of neural regrowth at the distal nerve stump as demonstrated by intraoperative electromyography and histologic evaluation of the distal nerve stump. One remained free of SD following RLNA, 1 was free of spasms at 4 years after revision avulsion but developed spasms after medialization laryngoplasty, and the final patient developed spasms 3.75 years after revision RLNA. Medialization laryngoplasty with Silastic silicone rubber was performed in 6 of 18, with correction of postoperative breathiness in all 6, but with recurrence of spasm in 3. Spasms resolved in 1 of these with downsizing of the implant. We conclude that RLNA represents a useful treatment in the management of SD in patients not tolerant of botulinum toxin injections.

Vocal fold paralysis following the anterior approach to the cervical spine

The anterior cervical approach is commonly used for access to the cervical spine. Vocal fold paralysis (VFP), a complication of this approach, is underrepresented in the literature. A review of the database of the Vanderbilt Voice Center revealed 289 patients with VFP, including 16 patients who developed paralysis as a result of an anterior cervical approach. The paralysis was on the right side in all but 1 patient. Compared to patients who developed VFP after thyroidectomy and carotid endarterectomy, patients with VFP after an anterior cervical approach have a higher incidence of aspiration and dysphagia, suggesting the presence of trauma to the superior laryngeal and pharyngeal branches as well as the recurrent branch of the vagus nerve. Two patients had partial return and 1 patient had complete return of vocal fold movement within 10 months. Of the remaining 13 patients, 8 underwent vocal fold medialization with improvement of symptoms. Two patients are 6 and 7 months postinjury and await vocal fold medialization. Two patients are 27 months and 45 months postinjury and are considering vocal fold medialization. The remaining patient was lost to follow-up. An anatomic-geometric analysis of the right and left recurrent laryngeal nerves was performed by using measurements obtained from computed tomography scans of 8 patients with idiopathic unilateral VFP, as well as experience gained through surgical and cadaveric dissections. We conclude 1) the anterior cervical approach may place multiple branches of the vagus nerve at risk; 2) because of anatomic-geometric factors, the right-sided anterior cervical approach may carry a greater risk to the ipsilateral recurrent laryngeal nerve than does the left; and 3) an understanding of the anatomy and geometry presented herein allows relatively safe exposure from either side of the neck.

Reinnervation of the allograft larynx in the rat laryngeal transplant model

The rat model for a vascularized laryngeal allograft is duplicated with significant technical modifications. We report the addition of unilateral host-to-allograft recurrent laryngeal nerve anastomosis to this model. Long-term survival experiments determine the feasibility of reinnervation studies of the allograft larynx with this new mode. A total of 59 transplants have been performed on histocompatible Munich Wistar rats, 36 with attempted unilateral allograft reinnervation. Because of the initially high operative mortality rates, additions and modifications of the original technique resulting in reproducibly enhanced survival are detailed. Factors critical to the functional study of this model with regard to reinnervation are elucidated. Preliminary data on allograft reinnervation are reported as confirmed by videodocumentation of vocal fold mobility, evoked and spontaneous electromyography, and glycogen-depletion studies.

Anatomy of the larynx, trachea, and bronchi

This article reviews the anatomy of the larynx, trachea, and bronchi. It emphasizes the structure of the laryngeal framework, the innervation and blood supply of the larynx and trachea, the anatomic differences between the pediatric and adult larynx and trachea, and the relational anatomy of structures surrounding the trachea and bronchi.

Carotid body tumors: a review of 30 patients with 46 tumors

Minimal morbidity occurs with resection of most carotid body tumors (CBT). With larger tumors significant injury to the cranial nerves has been reported. In order to assess the operative sequelae rate, 30 patients with CBT were reviewed. Sixteen patients either presented with bilateral carotid body tumors or had previously undergone a resection of the contralateral carotid body tumors, for a total carotid body tumor count of 46. Sixteen patients demonstrated a familial pattern while 14 were nonfamilial. Within the familial group, 14 of 16 presented with multiple paragangliomas as compared to 6 of 14 in the nonfamilial group. Tumor size ranged from 0.8 to 12 cm. Vascular replacement occurred in 2 of 20 patients with tumors < 5.0 cm, compared with 5 of 9 with tumors > 5.0 cm. Four patients lost cranial nerves with the resection: superior laryngeal nerve (SLN), 4; cranial nerve X, 1; cranial nerve XII, 1. Ten patients developed baroreceptor failure secondary to bilateral loss of carotid sinus function. First-bite pain occurred in 10 of 25 operative patients. Cranial nerve loss can be minimal with resection of carotid body tumors, however, baroreceptor failure and first-bite pain are postoperative sequelae that are often disregarded in the postoperative period.

Unilateral palatal adhesion for paralysis after high vagal injury

Tumor involvement or sacrifice of the vagus nerve at the level of the jugular foramen is a cause of significant morbidity in skull base surgery. Management of the resulting dysphagia and dysphonia has been significantly improved by the development of vocal cord medialization. However, rehabilitation of palatal paralysis with the resulting velopharyngeal incompetence has not been widely addressed. In an effort to alleviate the symptoms of hypernasality and nasal reflux, unilateral adhesion of the palate to the posterior wall of the nasopharynx is proposed. This report summarizes the operative approach and results in eight patients. Results have been favourable with no significant postoperative complications observed to date.

The diagnosis and treatment of baroreflex failure

BACKGROUND

Baroreflexes originate in the great vessels of the neck and thorax and prevent arterial pressure from rising or falling excessively.

METHODS

This study was undertaken to clarify the cause, clinical spectrum, and therapy of this disorder. We studied 11 patients with baroreflex failure presenting as severe, labile hypertension and hypotension, often with headache, diaphoresis, and emotional instability, and characterized by the failure of exogenous vasoactive substances to alter heart rate. Each underwent hemodynamic monitoring and biochemical, physiologic, and pharmacologic testing.

RESULTS

The patients' maximal systolic blood pressures ranged from 164 to 280 mm Hg, and their minimal systolic pressures ranged from 58 to 96 mm Hg. Plasma norepinephrine and epinephrine concentrations were sometimes many times normal during blood-pressure surges. All the patients had excessive pressor and tachycardia responses to the mental-arithmetic and cold pressor tests and marked hypersensitivity to clonidine. The underlying causes of baroreflex failure included the familial paraganglioma syndrome, neck surgery or radiation therapy for pharyngeal carcinoma, bilateral lesions of the nucleus tractus solitarii, and surgical section of the glossopharyngeal nerves; in two patients the cause was unknown. Therapy with clonidine reduced the frequency of attacks by 81 percent and attenuated the elevated blood pressure and heart rate in the attacks that occurred.

CONCLUSIONS

The syndrome of baroreflex failure should be considered in patients with otherwise unexplained labile hypertension. Clonidine attenuates the pressor and tachycardic surges in baroreflex failure.

Rehabilitation of cranial nerve deficits after neurotologic skull base surgery

Damage to any one of these nerves results in sufficient morbidity to warrant therapy; however, most patients will compensate for isolated loss of function. It is with multiple nerve injuries, as often seen in glomus surgery with the resection of cranial nerves IX, X, and XII that the full efforts of the rehabilitation team are called on. After vocal cord medialization and palatal adhesion, younger healthier patients will eventually resume adequate oral intake. However, the time it requires to return to a reasonably enjoyable diet often extends up to 1 year postoperatively. A few never attain the goal of enjoyable intake and continue to struggle to maintain adequate nutrition. The latter situation is the rule, not the exception, in the elderly population. Our experience over the years has led us to a more conservative treatment of glomus tumors in the elderly debilitated patient.

Thyroplasty in the functional rehabilitation of neurotologic skull base surgery patients

Definitive management of lesions of the lateral cranial base is surgical. Functional outcome is dependent on cranial nerve preservation. In 1988 an effort was made to decrease the incidence of tracheotomy, the duration of hospital stay, and the period prior to unassisted oral intake, by establishing more immediate acquisition of glottic competence through laryngeal rehabilitation. The experience of one author (JLN) in over 40 phonosurgical procedures under local anesthesia is presented. Although tracheotomy provides excellent airway protection, it is accompanied by substantial morbidity. The technique of phonosurgery has dramatically improved recovery and functional outcomes of neurotologic skull base surgery patients, enabling them to realize "cure" rather than "control" of their disease.

Difficulties in endoscopic removal of Teflon granulomas of the vocal fold

The difficulties in treating granulomas resulting from Teflon injection into the vocal fold are underreported in the literature. We have reviewed our experience with nine patients undergoing 27 procedures for Teflon granuloma. Two patients required tracheotomy before undergoing endoscopic granuloma removal because of airway compromise, and a third required urgent tracheotomy following endoscopy. One of the patients requiring elective tracheotomy had a granuloma that extended across the midline to the contralateral arytenoid, causing its fixation. Arytenoidectomy was required for decannulation in this patient. In all but one patient the granuloma nearly completely replaced the thyroarytenoid muscle. This extensive involvement often precludes the adequate excision of the granuloma in a single procedure; however, the microflap technique allows mucosal preservation to facilitate future procedures. In some cases the granuloma destroys large amounts of mucosa, and a microflap cannot be elevated and saved. The difficulties of excision are related to the near-total replacement of the thyroarytenoid muscle by granuloma. This paper will help the otolaryngologist--head and neck surgeon understand this destructive process and the resulting difficulties in surgical rehabilitation.

Silastic medialization and arytenoid adduction: the Vanderbilt experience. A review of 116 phonosurgical procedures

From April 1987 to April 1992, 116 phonosurgical procedures were performed to treat glottal incompetence. The initial numbers of these surgical procedures included the following: 29 primary Silastic medializations, 3 primary Silastic medializations with arytenoid adduction, 53 secondary Silastic medializations, 4 secondary Silastic medializations with arytenoid adduction, and 11 bilateral Silastic medializations. These procedures are useful in treating unilateral true vocal cord paralysis, scarring, bowing, or paresis, as well as bilateral true vocal cord bowing. Of the initial 100 patients, 16 later underwent a revision with either a larger implant's being placed or an arytenoid adduction. Primary Silastic medialization is the placement of an implant under general anesthesia in the same surgical setting in which laryngeal innervation is sacrificed. Secondary Silastic medialization is the placement of an implant under local anesthesia for a preexistent vocal cord malfunction. In either case, overall voice results for unilateral paralysis are very good. Primary Silastic medialization significantly decreases the postoperative rehabilitation period in skull base patients because of the immediate postoperative glottal competence and decreased use of perioperative tracheotomy. Bilateral implants yielded good results in 6 patients with presbylaryngis, but 6 other patients with bowing from other causes experienced only moderate improvement in speech quality. There were no implant extrusions; however, 1 implant was removed secondary to a persistent laryngocutaneous fistula in a patient who had previously undergone laryngeal irradiation. This was the only complication in this series.

Defect reconstruction and cerebrospinal fluid management in neurotologic skull base tumors with intracranial extension

Intracranial extension (ICE) is the spread of tumor into the subarachnoid space through dura or along cranial nerve roots. The single-stage removal of the skull base tumor with its ICE has been confounded by cerebrospinal fluid management and defect reconstruction. The purpose of this report is to review a current protocol for managing the cranial base tumor and its ICE as a unit. The ventricular shunting paper of 1987 is retracted. All tumors were managed at a single stage. Defect reconstruction was size dependent. Ninety-eight neurotologic skull base tumors with ICE were managed from 1971 to 1991. The new protocol was initiated in 1987. Results specific to this group are highlighted. For glomus tumors, cerebrospinal fluid leak rates have been dramatically reduced overall from 14.5% to 4%. The leak rates for nonglomus tumors, overall, have improved slightly. Complications are discussed. The development of this surgical approach protocol improves the functional outcome in patients of surgeons who aspire to disease "cure" rather than "control."

Carotid artery replacement in conjunction with resection of squamous cell carcinoma of the neck: preliminary results

Squamous cell carcinoma can invade the carotid artery. The treatment options then include irradiation, "palliative peeling" of tumor from the artery, and carotid resection with ligation or in-line grafting. Twelve patients with invasion of the carotid artery by cancer had en bloc resection of the artery and tumor. Reconstruction after in-line carotid artery grafting with autogenous vein was completed with a myocutaneous flap. No neurologic events occurred perioperatively or during the follow-up period of 3 to 50 months. Computed tomography and arteriography were unreliable in predicting tumor involvement of the carotid artery. Three patients died during the study--two of unrelated causes, and one of metastases. None of the patients showed evidence of local recurrence from 3 to 50 months. In two of four wound infections the carotid artery graft was exposed. This was successfully treated by a myocutaneous flap. The mean survival for the group was 18 months. Resection and in-line bypass grafting of the carotid artery invaded by cancer can safely be performed in irradiated and potentially infected fields.

Complications of skull base surgery

As skull base resections have increased in complexity and magnitude, so have the complications associated with the procedures. In this paper, we have reviewed the major complications of skull base surgery, including CSF leak, bleeding, stroke, meningitis, cranial nerve deficits and recurrent disease. This report summarizes the factors that lead to these complications, as well as measures to prevent them. We have also discussed our approach to the management of these complications, with particular emphasis on CSF leak and vagal nerve paralysis.

Recurrent laryngeal nerve avulsion for treatment of spastic dysphonia

Treatment of spastic dysphonia by recurrent laryngeal nerve section has resulted in reproducibly good results in the early postoperative period in most patients. However, critical long-term follow-up has shown a high recurrence rate of adductor spasms by the third year after initial nerve section. A patient who developed recurring adductor spasms 1 year after nerve section was reexplored, with identification of neural regrowth into the distal segment of the recurrent laryngeal nerve. The technique of neural avulsion removing the distal nerve up to its insertion into the laryngeal muscles is described. Neural regrowth, which is just one of the possible mechanisms for recurrence of spastic dysphonia, should be prevented by this surgical modification. Twelve patients who have undergone neural avulsion primarily for spastic dysphonia are being followed up without recurrence of symptoms thus far. Although these results appear promising, this short follow-up that averages 1.5 years must be extended to firmly support these concepts.

The lower trapezius flap. Vascular anatomy and surgical technique

The lower trapezius flap was first described in 1980 based on the transverse cervical artery. The older anatomical literature, however, describes the dorsal scapular artery as a major contributor of blood supply to the skin overlying the lower trapezius fibers. To clarify this, 30 dissections of this vascular region were performed. In 15 of 30 dissections, the dorsal scapular artery was dominant and the distal transverse cervical artery arose from the dorsal scapular. In nine of 30 dissections, the transverse cervical artery was dominant and the distal dorsal scapular artery arose from the transverse cervical. In six of 30 dissections, both proximal arteries were of equal caliber with no distal communication. We describe a surgical technique that makes use of the lower trapezius flap with inclusion of the dorsal scapular artery; this technique greatly extends the usefulness of the lower trapezius flap, while decreasing the morbidity caused by division of the upper portion of the trapezius muscle during flap harvest.

Microsurgical anatomy of the lower skullbase--a morphometric analysis

Knowledge of the microsurgical anatomy of the lower skullbase is needed in order to resect tumors involving this region. We have dissected 10 formalin-preserved skullbase specimens and identified the structures that would be encountered during the course of surgery using the lateral approach. A morphometric analysis was performed on the jugular foramen, the hypoglossal canal, the condylar emissary vein, and the foramen magnum. By identifying the relationships of the lower skull base, we hope to minimize the morbidity associated with removing lesions in the region. A representative case is presented and discussed.

Evaluation and treatment of complications of thyroid and parathyroid surgery

The major complications of thyroid and parathyroid surgery include hemorrhage, respiratory obstruction, hyperthyroid storm, hypoparathyroidism, and laryngeal nerve injury. In this article, the incidence, diagnosis, and treatment of various complications are reviewed, with emphasis on hypoparathyroidism and vocal cord paralysis, either bilateral or unilateral. Thyroplastic phonosurgery and carbon dioxide laser arytenoidectomy, two recent surgical additions to the rehabilitation of vocal cord paralysis, are described in depth.

The use of magnetic resonance imaging with high-resolution CT in the evaluation of facial paralysis

Magnetic resonance imaging (MRI) has been widely used in the evaluation of suspected acoustic neuroma, but has not received the same attention with respect to facial paralysis. High-resolution computed tomography (HRCT) has been the radiologic test of choice to evaluate the facial nerve. The necessary HRCT projections, slices, and enhancement techniques to visualize each segment have been outlined. We have developed a radiologic protocol that uses MRI in conjunction with HRCT, applying the strengths of each to evaluate the facial nerve. We have evaluated 15 patients and have found that MRI is the better study to evaluate the brain stem/cerebellopontine angle segment of the facial nerve and better evaluates bone-soft tissue interfaces. HRCT is better in the evaluation of the intratemporal segment of the facial nerve and the assessment of the anatomic perspectives of a lesion within the temporal bone. The results are discussed and case reports illustrate the efficacy of this approach.

The trapezius myocutaneous flap. Dependability and limitations

Many reports of the trapezius myocutaneous flap have centered on a single form of the flap. However, three distinct myocutaneous segments, the superior, the lateral island, and the extended island flaps, can be harvested from the trapezius muscle and its overlying skin. Fifty-five patients underwent reconstruction for head and neck defects using 56 trapezius myocutaneous flaps consisting of 28 superior, 24 lateral island, and four extended island flaps. The four vascular supplies of the trapezius muscle are discussed, with emphasis on the variable nature of the transverse cervical and dorsal scapular arteries. Major complications developed in two of 28 superior, five of 24 lateral island, and one of four extended island flaps. The superior flap, although the most dependable, has the most limited range of application. Both the lateral and extended island flaps have a broader range of clinical application, but their usefulness may be limited by previous neck surgery or occult neoplasm in the neck, as well as by the variable vascular supply. Due to the above limitations, 30% of our attempts to utilize the lateral island flap had to be aborted at the time of surgery and an alternate means of reconstruction used. The trapezius myocutaneous flaps are excellent reconstructive tools for selected defects.