Transverse Cordotomy with Thyroarytenoid Myectomy for Bilateral Vocal Fold Immobility

We propose a modification of the transverse cordotomy procedure which improves the predictable airway outcome and allows for better voice. Laryngoscope, 134:2790-2792, 2024.

Virtual reality cricothyrotomy - a case-control study on gamification in emergency education

BACKGROUND

Cricothyrotomy is an invasive and rare emergency intervention to secure the airway in a "cannot intubate, cannot ventilate" situation. This leads to lack of routine. Cricothyrotomy is performed only hesitantly. Therefore, we aim to improve teaching by including a virtual reality (VR) cricothyrotomy as a learning tool.

METHODS

We programmed the VR cricothyrotomy in the C# programming language on the open-source Unity platform. We could include 149 students that we randomly assigned to either a study group (VR cricothyrotomy) or control group (educational video). We asked the study group to subjectively rate the VR cricothyrotomy. To evaluate our intervention (VR cricothyrotomy) we took the time participants needed to perform a cricothyrotomy on a plastic model of a trachea and evaluated the correct procedural steps.

RESULTS

The majority of students that performed the VR simulation agreed that they improved in speed (81%) and procedural steps (92%). All participants completed the cricothyrotomy in 47s ± 16s and reached a total score of 8.7 ± 0.7 of 9 possible points. We saw no significant difference in time needed to perform a cricothyrotomy between study and control group (p > 0.05). However, the total score of correct procedural steps was significantly higher in the study group than in the control group (p < 0.05).

CONCLUSIONS

Virtual reality is an innovative learning tool to improve teaching of emergency procedures. The VR cricothyrotomy subjectively and objectively improved correct procedural steps. Digitized education fills an educational gap between pure haptic experience and theoretical knowledge. This is of great value when focusing on extension of factual knowledge.

TRIAL REGISTRATION

DRKS00031736, registered on the 20th April 2023.

Neurectomy and Myomectomy for Treatment of Spasmodic Dysphonia

Spasmodic dysphonia (SD) is a debilitating neurological disorder affecting the muscles of voice production. Sudden involuntary movements of the vocal folds lead to phonatory breaks and to forced, strained, and strangled voice quality in adductor SD, or breathy breaks in abductor SD. There is currently no cure for spasmodic dysphonia, and the gold standard for treatment is the injection of botulinum toxin in small amounts to the intrinsic laryngeal musculature.1 However, botulinum treatment requires periodic reinjection, produces vocal instability immediately after injection, lacks uniform results among patients, and patients can develop antibodies to botulinum toxin. Long-term or permanent symptom relief would be ideal. We present four patients with adductor and one patient with abductor spasmodic dysphonia who underwent neurectomy and myomectomy for treatment. The mean age was 64 years (age range 45-83). The mean duration of adductor spasmodic dysphonia was 11.8 years. The duration of abductor spasmodic was 4 years. All patients had previously been treated with voice therapy and botulinum toxin A. The mean duration of follow up was 1.7 years. Four patients had subjective and objective improvement after surgery. One patient had subjective improvement.

Intraoperative cricothyroid muscle electromyography may contribute to the monitorization of the external branch of the superior laryngeal nerve during thyroidectomy

Background

In thyroid surgery, both the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN) should be preserved for maintaining the vocal cord functions. We aimed to evaluate whether EMG of the CTM applied after the superior pole dissection provided additional informative data to the IONM via ETT or not, regarding the EBSLN function.

Methods

The prospectively collected data of the patients, who have undergone thyroidectomy with the use of IONM for the exploration of both the RLN and EBSLN between October 2016 and March 2017, were evaluated retrospectively. Patients over 18 years of age with primary thyroid surgery for malignant or benign thyroid disease, and whom were applied CTM EMG with a needle electrode after the completion of thyroidectomy were included in the study. In the study, each neck side was evaluated as a separate entity considering the EBSLN at risk.

Results

The data of 41 patients (32 female, 9 male) (mean age, 46.7 + 9.1; range, 22-71) were evaluated. Sixty seven EBSLNs out of 26 bilateral and 15 unilateral interventions were evaluated. With EBSLN stimulation after the superior pole dissection, positive glottic EMG waveforms via ETT were obtained in 45 (67.2%) out of 67, and the mean glottic amplitude value was 261 + 191 μV (min-max: 116-1086 μV). Positive EMG responses via the CTM EMG were achieved from all of the 67 EBSLNs (100%) with stimulation using a monopolar probe at the most cranial portion above the area of divided superior pole vessels. The mean value of CTM amplitudes via CTM EMG obtained with EBSLN stimulation was 5268 + 3916 μV (min-max:1215 -19726 μV). With EBSLN stimulation, the mean CTM EMG amplitude was detected significantly higher than the mean vocal cord amplitude (p<0.0001). The CTM EMG provided more objective quantifiable data regarding the EBSLN function (100% vs 67,2%, p<0.001).

Conclusion

In addition to the IONM via ETT, intraoperative post-dissection CTM EMG via needle electrode is a safe, simple and applicable method that may provide significant additional informative data to IONM with ETT by obtaining and recording objective quantitative data related to the EBSLN function.

Comparison of Botulinum Toxin Injections and Type 2 Thyroplasty for Adductor Spasmodic Dysphonia

OBJECTIVES

Injection of botulinum toxin type A (BTX) into intrinsic laryngeal muscles is the current gold standard therapy for adductor spasmodic dysphonia (AdSD). However, a surgical procedure could potentially offer more stable and long-lasting voice quality to AdSD patients. Here, we report the long-term results of type 2 thyroplasty (TP2) with TITANBRIDGE® (Nobelpharma, Tokyo, Japan) compared with those of BTX injections.

METHODS

In total, 73 AdSD patients visited our hospital between August 2018 and February 2022. Patients were provided the option of BTX injections or TP2. They were assessed via the Voice Handicap Index (VHI)-10 before treatments and at scheduled clinical follow-ups at 2, 4, 8, and 12 weeks for BTX and at 4, 12, 26, and 52 weeks for TP2.

RESULTS

Overall, 52 patients selected the BTX injection and had a pre-injection mean VHI-10 score of 27.3 ± 8.8. Following injections, the scores significantly improved to 21.0 ± 11.1, 18.6 ± 11.5, and 19.4 ± 11.7 at 2, 4, and 8 weeks, respectively. There were no significant differences between the pre-injection scores and the 12-week scores (21.5 ± 10.7). Alternately, 32 patients opted to be treated with TP2 and had a pre-treatment mean VHI-10 score of 27.7. All patients reported an improvement in their symptoms. Additionally, the mean VHI-10 score significantly improved to 9.9 ± 7.4 at 52 weeks following treatment. There was a significant difference between the two treatment groups at 12 weeks. Some patients received both treatments.

CONCLUSION

These preliminary results provide important insights into the value of TP2 as a potential permanent treatment for AdSD patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3443-3448, 2023.

Surgeons With Five or More Actual Cricothyrotomies Perform Significantly Better on a Virtual Reality Simulator

BACKGROUND

Discriminating performance of learners with varying experience is essential to developing and validating a surgical simulator. For rare and emergent procedures such as cricothyrotomy (CCT), the criteria to establish such groups are unclear. This study is to investigate the impact of surgeons' actual CCT experience on their virtual reality simulator performance and to determine the minimum number of actual CCTs that significantly discriminates simulator scores. Our hypothesis is that surgeons who performed more actual CCT cases would perform better on a virtual reality CCT simulator.

METHODS

47 clinicians were recruited to participate in this study at the 2018 annual conference of the Society of American Gastrointestinal and Endoscopic Surgeons. We established groups based on three different experience thresholds, that is, the minimal number of CCT cases performed (1, 5, and 10), and compared simulator performance between these groups.

RESULTS

Participants who had performed more clinical cases manifested higher mean scores in completing CCT simulation tasks, and those reporting at least 5 actual CCTs had significantly higher (P = 0.014) simulator scores than those who had performed fewer cases. Another interesting finding was that classifying participants based on experience level, that is, attendings, fellows, and residents, did not yield statistically significant differences in skills related to CCT.

CONCLUSIONS

The simulator was sensitive to prior experience at a threshold of 5 actual CCTs performed.

Bilateral vocal fold immobility: Clinical findings of ten cases and suggested treatment options

OBJECTIVE

To present the clinical findings of 10 cases of bilateral vocal fold immobility (adducted type) and suggest potential treatment options.

METHODS

This retrospective study included 10 patients who underwent tracheostomy for restricted airway due to bilateral vocal fold immobility of the adducted type during the period from 2007 to 2017. All 10 patients underwent unilateral laterofixation surgery with or without additional arytenoidectomy using a CO₂ laser. The effect of laterofixation surgery for decannulation was evaluated. Statistical analysis was performed to assess the effects of laterofixation based on the results of preoperative and intraoperative examinations including endoscopic examinations, electromyography, and the intraoperative traction-mobility test.

RESULTS

Initial laterofixation surgery for decannulation was effective in 6 cases. In the 4 cases that exhibited laterofixation failure, additional endoscopic subtotal arytenoidectomy was performed. Statistical analysis of the effects of laterofixation revealed that, in cases with bilateral preserved muscle tone, unilateral simple laterofixation surgery was unable to achieve a significantly effective glottal airway. Additional subtotal arytenoidectomy was also ineffective in a case with bilateral ankylosis.

CONCLUSION

Based on the clinical findings in these 10 cases of bilateral vocal fold immobility of the adducted type, treatment options are suggested and a severity classification system of bilateral vocal fold immobility is proposed that focuses mainly on electromyography results for assessment of dynamic restenosis and traction-mobility test results for assessment of static restenosis. Validation of the classification system is needed in a larger cohort of cases of bilateral vocal fold immobility.

Impact of cardiopulmonary resuscitation on a cannot intubate, cannot oxygenate condition: a randomised crossover simulation research study of the interaction between two algorithms

OBJECTIVES

During a 'cannot intubate, cannot oxygenate' situation, asphyxia can lead to cardiac arrest. In this stressful situation, two complex algorithms facilitate decision-making to save a patient's life: difficult airway management and cardiopulmonary resuscitation. However, the extent to which competition between the two algorithms causes conflicts in the execution of pivotal treatment remains unknown. Due to the rare incidence of this situation and the very low feasibility of such an evaluation in clinical reality, we decided to perform a randomised crossover simulation research study. We propose that even experienced healthcare providers delay cricothyrotomy, a lifesaving approach, due to concurrent cardiopulmonary resuscitation in a 'cannot intubate, cannot oxygenate' situation.

DESIGN

Due to the rare incidence and dynamics of such a situation, we conducted a randomised crossover simulation research study.

SETTING

We collected data in our institutional simulation centre between November 2016 and November 2017.

PARTICIPANTS

We included 40 experienced staff anaesthesiologists at our tertiary university hospital centre.

INTERVENTION

The participants treated two simulated patients, both requiring cricothyrotomy: one patient required cardiopulmonary resuscitation due to asphyxia, and one patient did not require cardiopulmonary resuscitation. Cardiopulmonary resuscitation was the intervention. Participants were evaluated by video records.

PRIMARY OUTCOME MEASURES

The difference in 'time to ventilation through cricothyrotomy' between the two situations was the primary outcome measure.

RESULTS

The results of 40 participants were analysed. No carry-over effects were detected in the crossover design. During cardiopulmonary resuscitation, the median time to ventilation was 22 s (IQR 3-40.5) longer than that without cardiopulmonary resuscitation (p=0.028), including the decision-making time.

CONCLUSION

Cricothyrotomy, which is the most crucial treatment for cardiac arrest in a 'cannot intubate, cannot oxygenate' situation, was delayed by concurrent cardiopulmonary resuscitation. If cardiopulmonary resuscitation delays cricothyrotomy, it should be interrupted to first focus on cricothyrotomy.

Olfactory Ecto-Mesenchymal Stem Cells in Laryngeal Nerve Regeneration in Rats

Selective intralaryngeal reinnervation has been shown to be effective in experimental models. This consists of independently reinnerving the adductor and abductor of laryngeal muscles of the larynx, in order to prevent any misalignment of the axonal regrowth, improve the functional recovery and tend toward reduction of synkinesis. The surgical technique remains complex. Current research focuses on simplifying and improving this technique. Olfactory ectomesenchymal stem cells (OEMSC) represent an interesting candidate for cell therapy and could be obtained from olfactory mucosa. Recent reports suggest a neuroregenerative potential in various animal models of central and peripheral nervous systems injuries. The aim of this study was dual: to develop a simple surgical model of selective reinnervation applicable in humans and to evaluate the relevance of OEMSC-based cell therapy for improving axonal guidance. Eight Fisher syngeneic rats were used to carry out the OEMSCs culture. Thirty-four Fisher syngeneic rats were operated on, divided into three groups depending on the transplanting. For all the rats, we have performed a side to end anastomosis of the vagal nerve with the inferior laryngeal nerve by interposition of a nerve graft from the left femoral nerve. Then, the first group didn't have any injection, the second group has an injection of thrombin and the third group has an injection of one million EOMSCs. Three months after surgery, laryngeal muscle activity was evaluated by videolaryngoscopy and electromyography recordings. In order to illustrate the quality of axonal regrowth, a fluorescent tracer was injected into the right posterior crico-arytenoid muscle (PCA) to reveal the cellular bodies of the motoneurons responsible for reinnervation of the PCA in the central nervous system. In our study, no improvement was found during the videolaryngological functional evaluation or with regard to the electrical activity of the PCA muscle. The cells colabelled in retrograde tracing were numerous in all groups, reflecting abnormal axonal regeneration. The interposition of a nerve graft, as side to end anastomosis between the vagus nerve and the inferior laryngeal nerve, filled with OEMSCs, does not provide better reinnervation of a hemilarynx.

A high-fidelity simulator for needle cricothyroidotomy training is not associated with increased proficiency compared with conventional simulators: A randomized controlled study

BACKGROUND

A high-fidelity task simulator for cricothyroidotomy was created using data from a 3-dimensional (3D) computed tomography scan using a 3D printer. We hypothesized that this high-fidelity cricothyroidotomy simulator results in increased proficiency for needle cricothyroidotomy compared with conventional simulators.

METHODS

Cricothyroidotomy-naive residents were recruited and randomly assigned to 2 groups, including simulation training with a conventional simulator (Group C) and with a high-fidelity simulator (Group 3D). After simulation training, participants performed cricothyroidotomy using an ex vivo porcine larynx fitted with an endoscope to record the procedure. The primary outcomes were success rate and procedure time. The secondary outcome was a subjective measure of the similarity of the simulator to the porcine larynx.

RESULTS

Fifty-two residents participated in the study (Group C: n = 27, Group 3D: n = 25). There was no significant difference in the success rate or procedure time between the 2 groups (success rate: P = .24, procedure time: P = .34). There was no significant difference in the similarity of the simulators to the porcine larynx (P = .81).

CONCLUSION

We developed a high-fidelity simulator for cricothyroidotomy from 3D computed tomography data using a 3D printer. This anatomically high-fidelity simulator did not have any advantages compared with conventional dry simulators.

[Analysis of phonosurgical methods of treatment in spasmodic dysphonia]

Spasmodic dysphonia (SD) is rather a rare voice disorder. It is most often seen in woman aged 40-50. The disease is caused by deep emotional and neurological disorders of extrapyramidal system. Two main clinical forms of SD are distinguished: about 90% of cases - adductor spasmodic dysphonia and abductor spasmodic dysphonia roughly 10%. Conservative therapy does not always yield sufficient effects. Botulinum toxin - type A injections into the thyroarytenoid muscle are also used in therapy. Though results are temporary and reversible. Among phonosurgical methods thyroplasty type II according to Isshiki and tyroarytenoid muscle myectomy (TAM) should be also mentioned among phonosurgical methods. The aim of the work is to evaluate results of conservative and phonosurgical treatment of SD. Spasmodic dysphonia markedly restricts communication process of patients and public relations both social and occupational.

Cadaver-based training is superior to simulation training for cricothyrotomy and tube thoracostomy

Emergency medicine (EM) training mandates that residents be able to competently perform low-frequency critical procedures upon graduation. Simulation is the main method of training in addition to clinical patient care. Access to cadaver-based training is limited due to cost and availability. The relative fidelity and perceived value of cadaver-based simulation training is unknown. This pilot study sought to describe the relative value of cadaver training compared to simulation for cricothyrotomy and tube thoracostomy. To perform a pilot study to assess whether there is a significant difference in fidelity and educational experience of cadaver-based training compared to simulation training. To understand how important this difference is in training residents in low-frequency procedures. Twenty-two senior EM residents (PGY3 and 4) who had completed standard simulation training on cricothyrotomy and tube thoracostomy participated in a formalin-fixed cadaver training program. Participants were surveyed on the relative fidelity of the training using a 100 point visual analogue scale (VAS) with 100 defined as equal to performing the procedure on a real patient. Respondents were also asked to estimate how much the cadaveric training improved the comfort level with performing the procedures on a scale between 0 and 100 %. Open-response feedback was also collected. The response rate was 100 % (22/22). The average fidelity of the cadaver versus simulation training was 79.9 ± 7.0 vs. 34.7 ± 13.4 for cricothyrotomy (p < 0.0001) and 86 ± 8.6 vs. 38.4 ± 19.3 for tube thoracostomy (p < 0.0001). Improvement in comfort levels performing procedures after the cadaveric training was rated as 78.5 ± 13.3 for tube thoracostomy and 78.7 ± 14.3 for cricothyrotomy. All respondents felt this difference in fidelity to be important for procedural training with 21/22 respondents specifically citing the importance of superior landmark and tissue fidelity compared to simulation training. Cadaver-based training provides superior landmark and tissue fidelity compared to simulation training and may be a valuable addition to EM residency training for certain low-frequency procedures.

Supracricoid Hemilaryngopharyngectomy in Patients with Invasive Squamous Cell Carcinoma of the Pyriform Sinus

On the basis of a retrospective review of an inception cohort of 135 patients, with an isolated, previously untreated, moderately differentiated to well-differentiated invasive squamous cell carcinoma of the pyriform sinus and a minimum of 3 years of follow-up, consecutively managed with a supracricoid hemilaryngopharyngectomy (SCHLP) at a single tertiary referral care center and locally controlled, the authors review in detail the surgical technique, highlight the potential technical pitfalls, and document the complications and long-term functional outcome. The overall postoperative mortality rate was 3.7%. The overall mortality rate directly related to the SCHLP was 1.5%. A significant surgical complication directly related to SCHLP completion was noted in 9.6% of cases. The mean lengths of time to removal of the tracheotomy and feeding tubes were 9 and 19 days, respectively. The mean duration of hospitalization was 25 days. Normal swallowing without aspiration by the first postoperative month was noted in 64.6% of patients. Temporary grade 1–2 aspiration and grade 3 aspiration were noted in 26.9% and 8.5% of patients, respectively. Overall, in our series, successful oral alimentation without gastrostomy or completion total laryngectomy was achieved in 91.9% of patients by the first postoperative year, and the incidences of permanent gastrostomy, completion total laryngectomy, and aspiration-related death were 0.7%, 1.5%, and 0.7%, respectively. A significant late complication related to the use of postoperative radiotherapy was noted in 26.5% of cases. From a functional point of view, such results suggest that SCHLP should be integrated among the various conservation treatment options available to patients with selected invasive squamous cell carcinoma of the pyriform sinus.

Comparison of the Glottic Closure Reflex in Traditional “Open” versus Endoscopic Laser Supraglottic Laryngectomy

Objectives:

Cancer of the supraglottic larynx may be surgically treated with either traditional “open” supraglottic laryngectomy (OSL) or endoscopic laser supraglottic laryngectomy (ELSL). Pharyngeal dysphagia is a well-documented consequence of traditional OSL from which near-normal swallowing characteristically recovers 14 to 40 days after surgery. Conversely, ELSL results in the resumption of serviceable swallowing within 2 to 7 days after surgery.

Methods:

A prospective assessment of the glottic closure reflex in 6 consecutive patients who had ELSL was performed by fiberoptic endoscopic evaluation of swallowing with sensory testing.

Results:

All 6 patients with ELSL demonstrated an intact glottic closure reflex both before surgery and 48 to 72 hours after surgery. In contrast, 7 of 8 historical control patients who had OSL demonstrated a persistent absence of the glottic closure reflex 3 weeks to 12 years later.

Conclusions:

Although a number of clinical factors influence swallowing recovery, one important factor separating our patient groups was the preservation of the glottic closure reflex in patients who underwent endoscopic laser resection. Because the loss of the glottic closure response persists for years after traditional OSL, it is concluded that the sensory field deficit caused by superior laryngeal nerve section is largely not recoverable; however, compensatory mechanisms remain important in serviceable recovery, even if delayed after operation. Indeed, preservation of the glottic closure response appears to enhance swallowing recovery when equivalent compensatory mechanisms are used.

Transoral Approach to Laser Thyroarytenoid Myoneurectomy for Treatment of Adductor Spasmodic Dysphonia: Short-Term Results

Objectives:

The surgical technique for the resection of the recurrent laryngeal nerve for adductor spasmodic dysphonia (ASD) has high late failure rates. During the past decade, botulinum toxin has emerged as the treatment of choice for ASD. Although effective, it also has significant disadvantages, including a temporary effect and an unpredictable dose-response relationship. In this study we investigated the effectiveness of a new transoral approach to laser thyroarytenoid myoneurectomy for treatment of ASD.

Methods:

Fourteen patients with ASD underwent transoral laser myoneurectomy of bilateral thyroarytenoid muscles. Under general anesthesia, an operating microscope and a carbon dioxide laser were used to perform myectomy of the mid-posterior belly of bilateral thyroarytenoid muscles together with neurectomy of the terminal nerve fibers among the deep muscle bundles. Care was taken not to damage the vocalis ligaments, arytenoid cartilages, and lateral cricoarytenoid muscles. Preoperative and postoperative videolaryngostroboscopy and vocal assessments were studied.

Results:

The 13 patients who completed more than 6 months follow-up were enrolled in this study. Moderate and marked vocal improvement was achieved in 92% of the patients (12 of 13) after laser surgery during an average follow-up period of 17 months (range, 6 to 31 months). No vocal fold atrophy or paralysis was observed in any patient. None of the patients had a recurrence during the follow-up period.

Conclusions:

Transoral laser myoneurectomy of bilateral thyroarytenoid muscles is a relatively simple, effective, and valuable technique for the treatment of ASD. The durability of outcome achieved with this procedure is encouraging.

Complex intubation, cricothyrotomy and tracheotomy

Complex intubation, cricothyrotomy and tracheotomy. Successful management of a difficult airway begins with recognizing the potential problem. When the patient cannot breathe spontaneously, oxygenation and ventilation should start first with bag-valve ventilation, with or without an airway adjunct such as a Mayo cannula, followed by an orotrache4l intubation attempt, performed by an experienced emergency doctor. If orotracheal intubation fails, a quick decision must be made regarding surgical options. In a "cannot intubate, cannot ventilate" situation, a surgical cricothyrotomy should be considered. When orotracheal intubation is impossible, but bag-valve or laryngeal mask ventilation is possible, an urgent surgical tracheostomy should be performed. In the long run, patients in need of longterm artificial ventilation will need a percutaneous or open tracheostomy. This review provides an update of all aspects of immediate and long-term airway management.

Surgical cricothyrotomies in prehospital care. Surgical airway placement is indicated when you cannot intubate or ventilate

Managing the airway does not mean intubation, it means managing the airway. Allowing a patient to breathe on their own with appropriate positioning, bag-valve ventilation and blind insertion devices are all airway management options. The surgical cricothyrotomy is a rare and life-saving procedure when managing patients who are in a "can't intubate, can't ventilate" situation. These patients will die without aggressive and rapid intervention. While not all surgical cricothyrotomies provide a definitive airway, the needle cricothyrotomy is an ineffective means for ventilation and its use is discouraged. Understand the techniques used in your program and that are within your scope of practice as an EMS provider. Provide your patient the best opportunity for survival by knowing your program's surgical airway procedure thoroughly, and practice it regularly.

[Role of ultrasound in airway management]

Recent advancement in ultrasound technology allows us to visualize detailed structures around the airway. One of the important roles of the airway ultrasound is to identify cricothyroid membrane where the emergent invasive access should be performed. Now we can assess the risk of difficult cricothyroidotomy before anesthesia of which the new ASA difficult airway guideline suggests. Airway ultrasound can also be used to confirm correct position of the tracheal tube and laryngeal mask, difficult laryngoscopy prediction in obese patients, assessing vocal cord function, prediction of the post extubation stridor, and so on. We also introduce perioperative evaluation of the airway via sonography (PEAS) protocol in this review.

Application of pitch range evaluation subsequent to arytenoid adduction and thyroplasty

OBJECTIVE

The purpose of this study was to figure out the application of pitch range (PR) evaluation subsequent to arytenoid adduction (AA) combined with type 1 thyroplasty (TP1) in unilateral vocal fold paralysis (UVFP).

STUDY DESIGN

Retrospective review of clinical records.

METHODS

Subjects were 50 patients with UVFP for whom PR and maximum phonation time (MPT) could be evaluated before and 1 year after AA + TP1. Subjects were divided into two groups based on preoperative PR (pre-PR) (group 1: ≤1 semitone (ST); group 2: ≥2 ST). Correlations among pre-PR and post-PR, MPT, and age were assessed. We also evaluated PRs in subjects with PR deterioration and PRs by causative diseases.

RESULTS

PR was significantly extended from a median of 17.0-22.0 ST in all subjects. Pre-PR was correlated with post-PR. Post-PR correlated with post-MPT in group 2 but not in group 1. There was no correlation between post-PR and age or causative diseases. The mean change in PR among subjects with PR deterioration (28.0%, 14/50) was -3.6 ST. Pre-PR and the improvement of post-PR were negatively correlated in group 2.

CONCLUSION

PR evaluation can be useful for predicting post-PR. The effects of age and causative diseases were small compared with other factors, such as pre-PR width and surgical effects. The successful surgery may improve both PR and MPT. However, several cases showed obvious discrepancy of those postoperative improvements. It will be necessary to assess this discrepancy, particularly in subjects with postoperative voice insufficiency.

Reinnervation of bilateral posterior cricoarytenoid muscles using the left phrenic nerve in patients with bilateral vocal fold paralysis

Objective

To evaluate the feasibility, effectiveness, and safety of reinnervation of the bilateral posterior cricoarytenoid (PCA) muscles using the left phrenic nerve in patients with bilateral vocal fold paralysis.

Methods

Forty-four patients with bilateral vocal fold paralysis who underwent reinnervation of the bilateral PCA muscles using the left phrenic nerve were enrolled in this study. Videostroboscopy, perceptual evaluation, acoustic analysis, maximum phonation time, pulmonary function testing, and laryngeal electromyography were performed preoperatively and postoperatively. Patients were followed-up for at least 1 year after surgery.

Results

Videostroboscopy showed that within 1 year after reinnervation, abductive movement could be observed in the left vocal folds of 87% of patients and the right vocal folds of 72% of patients. Abductive excursion on the left side was significantly larger than that on the right side (P < 0.05); most of the vocal function parameters were improved postoperatively compared with the preoperative parameters, albeit without a significant difference (P > 0.05). No patients developed immediate dyspnea after surgery, and the pulmonary function parameters recovered to normal reference value levels within 1 year. Postoperative laryngeal electromyography confirmed successful reinnervation of the bilateral PCA muscles. Eighty-seven percent of patients in this series were decannulated and did not show obvious dyspnea after physical activity. Those who were decannulated after subsequent arytenoidectomy were not included in calculating the success rate of decannulation.

Conclusions

Reinnervation of the bilateral PCA muscles using the left phrenic nerve can restore inspiratory vocal fold abduction to a physiologically satisfactory extent while preserving phonatory function at the preoperative level without evident morbidity.

[Mediafixation of the vocal cord through the external approach in the patients presenting with unilateral laryngeal paralysis]

The objective of the present work was to develop a method for the modification of the vocal cord during the treatment of the patients presenting with unilateral laryngeal paralysis taking into consideration individual peculiarities of stereotopometric characteristics of the larynx in the subjects of different gender, neck structure, and body constitution. The earlier proposed method of laryngostereotopometry was employed in this study. The following body features were measured prior to surgery: the total length, acromial diameter, chest circumference, neck length and circumference; the degree of the fissure of glottis closure was measured by transnasal fibrolaryngoscopy. The transplant was cut out of the quadrangular cartilage of the nasal septum in the form of a prism having the base shaped as an isosceles triangle with the base equal to the width of the fissure of glottis; the vertical and horizontal sizes of the transplant were calculated from the formulas of multiple linear regression analysis. The autotransplant was introduced through the "window" in the plate of the shield-like cartilage between its internal perichondrium and the thyroarytenoid muscle of the arytenoid cartilage of the paralysed vocal cord in the horizontal direction in front of the site of attachment of the vocal cord of arytenoids cartilage up to the projection of the anterior commissure with fixation to the shield-like cartilage by a ligature.

Analysis of pitch range after arytenoid adduction by fenestration approach combined with type I thyroplasty for unilateral vocal fold paralysis

OBJECTIVE

The purpose of this study was to determine the postoperative pitch range acquired in cases of unilateral vocal fold paralysis, as well as factors affecting outcomes.

SUBJECTS AND METHODS

We analyzed 39 cases of unilateral vocal fold paralysis for which surgery was performed between January 2006 and January 2009 and for which pitch ranges and the items listed below were measured preoperatively and 1 year postoperatively. Arytenoid adduction (AA) and type I thyroplasty were performed simultaneously in all cases regardless of preoperative severity. AA was performed by the fenestration approach as previously reported. In this procedure, the cricoarytenoid and cricothyroid joints are not released. Correlations between pitch range acquired postoperatively and the following items were examined: (1) pre- and postoperative maximum phonation time (MPT), (2) pre- and postoperative mean airflow rate (MFR), and (3) preoperative pitch range. Furthermore, patients were surveyed regarding their ability to sing after surgery, and the pitch range cutoff value dividing ability and inability to sing was calculated.

RESULTS

Pitch range increased significantly from 3±4.47 halftones (mean ± standard deviation) preoperatively to 17.5±5.80 halftones postoperatively. Preoperative MPT, MFR, and pitch range did not correlate with postoperative pitch range. Postoperatively, only MPT correlated with the width of postoperative pitch range. Twenty-three of 39 subjects (59%) responded that they were able to sing, and the pitch range cutoff value dividing the two groups was 22 halftones.

CONCLUSION

AA and type I thyroplasty significantly expanded postoperative pitch range. There was no correlation between preoperative severity and width of pitch range acquired postoperatively.

Nerve-muscle pedicle implantation in the denervated thyroarytenoid muscle of aged rats

CONCLUSION

Nerve-muscle pedicle (NMP) implantation was effective in the recovery of atrophic changes in the denervated thyroarytenoid (TA) muscle in aged rats.

OBJECTIVES

To evaluate the effects of NMP implantation on the denervated TA muscle in aged rats.

METHODS

Wistar rats aged 20 months and 8 weeks were respectively divided into two groups in which the left recurrent laryngeal nerve (RLN) was transected without (aged/young DNV group) or with (aged/young NMP group) NMP implantation. The aged DNV and NMP groups were further divided into two subgroups, based on the period after RLN transection (10 or 20 weeks). In the DNV groups, we assessed the area of muscle and the number of neuromuscular junctions (NMJs) histologically. In the NMP groups, we performed electromyography and histological assessments. For electromyography, we stimulated the transferred nerve and evaluated the muscle action potentials (MAPs) of the TA muscle.

RESULTS

The muscle areas in the aged NMP groups were significantly larger than those in the aged DNV groups. More NMJs were found in aged NMP groups compared with aged DNV groups. MAPs were seen in all NMP animals. No significant differences were observed between the aged and young NMP groups in histological and physiological assessments.

Cricothyroid approximation for voice and swallowing rehabilitation of high vagal paralysis secondary to skull base neoplasms

This study documents the speech and swallowing outcomes of isolated ipsilateral cricothyroid approximation (aka tensioning thyroplasty; Type IV thyroplasty) for the treatment of high vagal paralysis (combined superior laryngeal nerve and recurrent laryngeal nerve paralysis). This is a pilot study of five cases with high vagal paralysis consequent to skull base neoplasms. Unilateral cricothyroid tensioning sutures were used. In all cases, vocal fold tensioning and vertical realignment of lax vocal folds were achieved. A partial, but acceptable medialization of vocal cord position was achieved. In all cases, aspiration was minimized and normal swallow function was restored by 6 weeks. The voice outcome was excellent in four cases and acceptable in one. Cricothyroid approximation restores vocal fold tension; in addition, it restores vertical vocal fold position and partially restores horizontal vocal fold position. Good voice and swallowing outcomes have been achieved. The procedure is quick, safe, and convenient when combined with a skull-base excision procedure. Further evaluation is merited.

Functional electrical stimulation of the left recurrent laryngeal nerve using a vagus nerve stimulator in a normal horse

The aim of this study was to assess the feasibility of implanting an existing vagus nerve stimulating (VNS) electrode around the recurrent laryngeal nerve. The stimulus response characteristics required to achieve abduction of the ipsilateral arytenoid by the VNS electrode in the normal horse could then be determined. The electrode was wound around the left recurrent laryngeal nerve at the cervical level and connected to a pulse generator. Stimulus response characteristics were obtained by measuring stimulated arytenoid displacement endoscopically in the standing, non-sedated horse. A full and sustained abduction of the arytenoid was obtained with a stimulation frequency of 25 Hz and intensity of 1 mA with a pulse width of 250 μs.

[Case of obstructive sleep apnea possibly having led to postoperative appearance of generalized convulsion]

Adverse surgical outcomes appear to be more frequent in patients with known obstructive sleep apnea (OSA). However, OSA patients may present for surgery without a prior diagnosis. A 37-year-old man underwent craniotomy for surgical direct neck clipping of the right ruptured internal carotid aneurysm. His intraoperative and early postoperative courses were uneventful. At night, about 48 hr after surgery, he developed sudden generalized tonic-clonic convulsion and temporary depressed consciousness resulting in marked hypercapnea (Pa(CO2)>100 mmHg). His respiration was transiently supported by PSV mode via LMA. He soon got well without neurologic deficits. At night, about 74 hr postoperatively, a generalized convulsion was again observed with hypercapnea. Aside from the respiratory support, percutaneous cricothyroidotomy was performed using Minitrach II system for his airway control, leading to no further recurrence of seizure. He was suspected to have unrecognized OSA due to such characteristic findings of sleep apnea as obesity (BMI>30) and witnessed apneas by his family. Postoperative rapid eye movement (REM) sleep rebound has been suggested to contribute to two consecutive night appearance of seizure. Clinical suspicion for OSA should be required preoperatively and perioperative heightened awareness is recommended.

Nerve-muscle pedicle implantation facilitates re-innervation of long-term denervated thyroarytenoid muscle in rats

CONCLUSIONS

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.

OBJECTIVES

To evaluate the effects of NMP implantation on long-term denervated rat TA muscle.

MATERIALS AND METHODS

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.

RESULTS

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.

Rescue ventilation: resolving a "cannot mask ventilate, cannot intubate" situation during exchange of a Combitube for a definitive airway

Our anesthesia care team was called to care for a patient who was admitted to the emergency department with the esophageal-tracheal double-lumen airway device (Combitube, Tyco Healthcare, Nellcor, Pleasanton, California) in place, which needed to be exchanged for a definitive airway because the patient required an extended period of mechanical ventilation. Several techniques were attempted to exchange the esophageal-tracheal Combitube (ETC) without success. First, we attempted direct laryngoscopy with the ETC in place after deflation of the No. 1 proximal cuff and sweeping the ETC to the left. We were prepared to use bougie-assisted intubation but could not identify any airway anatomy. After removal of the ETC, we unsuccessfully attempted ventilation/intubation with a laryngeal mask airway (LMA Fastrach, LMA North America, San Diego, California). Our third attempt was insertion of another laryngeal mask airway (LMA Unique, LMA North America) with marginal ventilation, but we again experienced unsuccessful intubation using a fiberscope. The ETC was reinserted after each intubation attempt because mask ventilation was impossible. Before proceeding with cricothyrotomy, we repeated direct laryngoscopy but without the ETC in place. We identified the tip of the epiglottis, which allowed for bougie-assisted intubation. This obviated the need for emergency cricothyrotomy.

Developing technical expertise in emergency medicine--the role of simulation in procedural skill acquisition

Developing technical expertise in medical procedures is an integral component of emergency medicine (EM) practice and training. This article is the work of an expert panel composed of members from the Society for Academic Emergency Medicine (SAEM) Interest Group, the SAEM Technology in Medical Education Committee, and opinions derived from the May 2008 Academic Emergency Medicine Consensus Conference, "The Science of Simulation in Healthcare." The writing group reviewed the simulation literature on procedures germane to EM training, virtual reality training, and instructional learning theory as it pertains to skill acquisition and procedural skills decay. The authors discuss the role of simulation in teaching technical expertise, identify training conditions that lead to effective learning, and provide recommendations for future foci of research.

Anatomical and surgical considerations of the external branch of the superior laryngeal nerve: a systematic review

The anatomical course of the external branch of the superior laryngeal nerve (EBSLN) is variable, and a consistent approach to its preservation during thyroid surgery is needed to reduce risk of post-operative voice impairment. Despite agreement that careful dissection in the region of the superior thyroid pole is required, there is no accepted 'best' approach, nor any universal acknowledgement that location of the EBSLN is actually necessary. The popular cernea classification of EBSLN has limitations, including its decreased reliability with increased thyroid size and its irrelevance in cases of 'buried' variants. * Recent work has identified factors such as ethnicity and stature in the prevalence of EBSLN variants. Consistent approaches to the post-operative detection of EBSLN injury are needed to build an accurate picture of the incidence of surgical nerve injury. Then a standardised approach to EBSLN preservation may emerge.

Effect of neurotrophin-3 on reinnervation of the larynx using the phrenic nerve transfer technique

Current techniques for reinnervation of the larynx following recurrent laryngeal nerve (RLN) injury are limited by synkinesis, which prevents functional recovery. Treatment with neurotrophins (NT) may enhance nerve regeneration and encourage more accurate reinnervation. This study presents the results of using the phrenic nerve transfer method, combined with NT-3 treatment, to selectively reinnervate the posterior cricoarytenoid (PCA) abductor muscle in a pig nerve injury model. RLN transection altered the phenotype and morphology of laryngeal muscles. In both the PCA and thyroarytenoid (TA) adductor muscle, fast type myosin heavy chain (MyHC) protein was decreased while slow type MyHC was increased. These changes were accompanied with a significant reduction in muscle fibre diameter. Following nerve repair there was a progressive normalization of MyHC phenotype and increased muscle fibre diameter in the PCA but not the TA muscle. This correlated with enhanced abductor function indicating the phrenic nerve accurately reinnervated the PCA muscle. Treatment with NT-3 significantly enhanced phrenic nerve regeneration but led to only a small increase in the number of reinnervated PCA muscle fibres and minimal effect on abductor muscle phenotype and morphology. Therefore, work exploring other growth factors, either alone or in combination with NT-3, is required.

Impact in vocal quality in partial myectomy and neurectomy endoscopic of thyroarytenoid muscle in patients with adductor spasmodic dysphonia

Impact in vocal quality in partial myectomy and neurectomy endoscopic of thyroarytenoid muscle in patients with adductor spasmodic dysphonia the adductor spasmodic dysphonia is a severe vocal disorder characterized by muscle laryngeal spasms during speech, producing phonatory breaks, forced, strained and strangled voice. Its symptoms come from involuntary and intermittent contractions of thyroarytenoid muscle during speech, which causes vocal fold strain, pressed one against another and increased glottic resistance. Aim: report the results in the impact in vocal quality in neurectomy of the thyroarytenoid branch of the inferior laryngeal nerve by endoscopic route associated with partial myectomy of the thyroarytenoid muscle with co2 laser. Material and method: the surgery was done in 07 patients (06 females and 01 male), aged 22 to 75, with adductor spasmodic dysphonia. They were submitted to vhi (voice handicap index) before and after surgery. Results and conclusions: the vocal improvement was obtained in all studied patients, deterioration in vocal quality after surgery was not noticed. There was evident difference in the vhi before and after surgery. This surgical thecnique proved to be efficient and innovative in the treatment of adductor spasmodic dysphonia.

[Effects and use of the suture direction mimicking only the force action of the lateral cricoarytenoid muscle in arytenoid adduction combined with thyroplasty type I]

Isshiki's arytenoid adduction combined with thyroplasty type I is a useful procedure for correcting the membranous vocal fold atrophy and the height difference between the two vocal folds, particularly in patients with a large posterior glottal chink and atrophy. Conventional arytenoid adduction (Isshiki's arytenoid adduction) is designed to place a suture through the muscular process of the arytenoid attached anteriorly to the thyroid ala, stimulating the function of the thyroarytenoid muscle and lateral cricoarytenoid muscle. Combining with thyroplasty type I, the suture direction of conventional arytenoid adduction prevented inserting implant material into the pocket of the thyroid cartilage window. In contrast to conventional arytenoid adduction, the suture direction in our approach is anchored anteroinferiorly, mimicking only the action of the lateral cricoarytenoid muscle (the major adductor of the larynx). It is used the thyroid cartilage window in thyroplasty type I to determine the direction of the lateral cricoarytenoid muscle. After approaching the muscular process based on Isshiki's arytenoid adduction, two nylon sutures are tied across the muscular process or the lateral cricoarytenoid muscle nearby the muscular process. The cricoarytenoid joint is not dislocated. One of the sutures was anchored to the inferior rear corner of the thyroid cartilage window to be used with thyroplasty type I and the other was anchored to the rear lower margin of the thyroid lamina. Gore-tex medialization thyroplasty is done after tying the sutures on the thyroid ala. Subjects were 30 unilateral paralytic dysphonia. Maximum phonation of all patients improved significantly after surgery. The preoperative and postoperative mean maximum phonation times were 6.0 and 17.9 seconds. No major complications occurred in this study. Our approach effectively combined arytenoid adduction and thyroplasty type I for patients with severe insufficient glottic closure.

Subtotal laryngectomy with tracheohyoidopexy: a possible alternative to total laryngectomy

OBJECTIVE

The objective of this study was to describe a new subtotal laryngectomy technique that foresees two variations: 1) tracheohyoidopexy (THIP + A or A-A)-subtotal removal of the larynx maintaining one or two cricoarytenoid units and subsequent tracheohyoidopexy; and 2) tracheohyoidoepiglottopexy (THIEP + A or A-A)-resection guarantees preservation of the suprahyoid epiglottis maintaining one or two cricoarytenoid units and further suspension of the tracheal stump at the epiglottis and hyoid bone.

METHODS

The technique is described, step by step, extending laryngeal resection beyond the limits adopted for supracricoid subtotal laryngectomy (SSL). Unlike SSL, tracheohyoidopexy allows glottic tumors with subglottic extension (T2-T3) to be treated, not only laryngeal tumors with invasion of one cricoarytenoid joint (T3), but also locally advanced laryngeal tumors with anterior extension through the thyroid cartilage (T4).

RESULTS

A total of 30 operations have been performed: 22 THIEP and eight THIP. In one case, total laryngectomy was necessary 16 days postoperatively as a result of a large pharyngostoma. One month after the operation, all patients were able to tolerate a soft diet. Tracheostomy was removed within 43 postoperative days only in 26 cases. Phonatory results are comparable to those obtained with supracricoid laryngectomy. No definite oncologic conclusions can be drawn, at present, as a result of the short follow-up period.

CONCLUSIONS

Tracheohyoidopexy is a supracricoid laryngectomy extended toward the cricoid, which, like total laryngectomy, focuses on radical resection of T and N. Functional results are similar to those obtained with SSL; it is mandatory to maintain one functioning cricoarytenoid unit and a wide pyriform sinus.

[Two cases of laryngoplasty performed under a general anesthesia applied using a laryngeal mask for the treatment of unilateral vocal cord paralysis]

In general, laryngoplasty for unilateral vocal cord paralysis is performed under local anesthesia because the patient's voice must be heard and the movement of the vocal cords visualized during the endoscopic procedure to ensure good results. We encountered two cases who could not endure a long operation under local anesthesia and the insertion of an endoscope because of their age and gag reflex. We thus performed a combined lateral cricoarytenoid muscle pull (LCA-pull) and a type I thyroplasty under general anesthesia applied using a laryngeal mask. Although the patients could not phonate during the operation, the laryngeal mask allowed the vocal cords to be observed. Both patients achieved in maximal phonation time over 13 seconds, and the postoperative mean flow rates improved to under 110 mL/s. The postoperative period perturbation quotient and amplitude perturbation quotient also improved to within the normal limits.

Management of pediatric airway granular cell tumor: role of laryngotracheal reconstruction

OBJECTIVE

To discuss the role of laryngotracheal reconstruction (LTR) in granular cell tumor (GCT) and to highlight the importance and seriousness of GCT in pediatric airway cases.

METHODS

A historical literature review was performed and a GCT case from the University of Miami Pediatric Otolaryngology Clinic is presented to highlight the role of LTR in the treatment of GCT.

RESULTS

A case of a GCT of the laryngotracheal airway is reported and the management is discussed. Histological discussion and a review of the literature are included regarding GCT. This case is the third reported in the English literature of two synchronous GCT lesions of the upper airway repaired with a laryngotracheal reconstruction.

CONCLUSIONS

In the authors' experience once conservative management consisting of endoscopic debulking has failed the treatment of choice for GCTs of the pediatric airway that are unresectable is a single stage laryngotracheal reconstruction with negative frozen section pathology to assure total wide local excision.

Three-dimensional laryngeal model for planning of laryngeal framework surgery

CONCLUSION

The three-dimensional prototype model was useful for planning of laryngeal framework surgery.

OBJECTIVE

To discuss the usefulness of a three-dimensional laryngeal model for laryngeal framework surgery.

MATERIALS AND METHODS

A three-dimensional laryngeal model was created based on the postoperative helical computed tomography (CT) data of the larynx (case 1) which underwent lateral cricoarytenoid muscle (LCA) pull surgery. LCA pull surgery is a kind of arytenoid adduction for unilateral vocal cord paralysis. A three-dimensional model of case 1 larynx was prototyped using a selective laser sintering method. In case 1, the patient's voice did not improve after LCA pull surgery. The three-dimensional model revealed that the original surgical procedure was not appropriate to obtain optimal arytenoid adduction. According to the analysis of this three-dimensional model, we changed the surgical approach and performed this new refined LCA pull surgery on another patient with unilateral vocal cord paralysis (case 2).

RESULTS

We were able to pull LCA precisely in case 2. Three-dimensional CT of case 2 after refined LCA pull surgery allowed the correct pulling of LCA and complete adduction of arytenoid. The postoperative voice improved remarkably.

Treatment of adductor-type spasmodic dysphonia by surgical myectomy: a preliminary report

OBJECTIVES

Despite the belief that it represents a central neurologic dysfunctional process, adductor-type spasmodic dysphonia without tremor is usually effectively treated by injection of botulinum toxin A; however, in most cases such injections must be repeated every few months. A promising new surgical procedure is herein reported.

METHODS

Under local anesthesia with intravenous sedation, a large laryngoplasty window is created, and under direct vision with intraoperative voice monitoring, fibers from the thyroarytenoid and lateral cricoarytenoid muscles are removed until breathiness occurs. The two sides are staged; that is, one side is done at a time, with surgery on the second side being performed 3 to 6 months after that on the first side, if needed.

RESULTS

This was a retrospective, unblinded study of 5 patients who underwent myectomy of the thyroarytenoid and lateral cricoarytenoid muscles. The preliminary results show improved voice fluency in all patients at 5 to 19 months of follow-up. There was no period of prolonged breathiness or dysphagia in any of the patients, and there were no surgical complications.

CONCLUSIONS

Myectomy of the thyroarytenoid and lateral cricoarytenoid muscles is a promising new surgical treatment for adductor-type spasmodic dysphonia that may effectively mimic "permanent" botulinum toxin injections.

[Combination of direct pull of lateral cricoarytenoid muscle and thyroplasty type I for severe unilateral vocal cord paralysis]

Techniques and the outcome of our approach that combined two operations, a direct pull of the lateral cricoarytenoid muscle (LCA-Pull) and Isshiki's thyroplasty type I are reported. LCA-Pull is very simple and allows natural adduction of arytenoid by pulling LCA. The subjects were five patients whose maximal phonation time (MPT) were under 5 seconds. All patients achieved MPT over 13 seconds. Mean flow rates (MFR) varied from 340ml/s to over 1000 ml/s before the operation. In all patients, the post operative MFR improved to under 150 ml/s. Sometimes severe unilateral vocal cord paralysis requires both arytenoid adduction and medialization thyroplasty to obtain good voice. Combination of LCA-Pull and thyroplasty type I is very effective for severe case, and could be done in the same operating field by creating an additional window in the thyroid ala.

Direct pull of lateral cricoarytenoid muscle for unilateral vocal cord paralysis

CONCLUSION

Lateral cricoarytenoid muscle-pull surgery (LCA pull) is a safe and effective method for the treatment of unilateral vocal cord paralysis.

OBJECTIVE

To evaluate the results of an improved method of LCA pull for unilateral vocal cord paralysis.

MATERIAL AND METHODS

Thirteen patients with unilateral vocal cord paralysis underwent LCA pull between April 2003 and January 2004. A small window was made in the posterior lower part of the thyroid cartilage and 2-3 mm in a cranial direction to the lower edge of the thyroid cartilage. The inner perichondrium was carefully removed to expose the LCA muscle. A 4-0 nylon suture placed through the LCA muscle was pulled to adduct the arytenoid and was tied to the anterior lower part of the thyroid cartilage. All cases were treated by LCA pull alone. In all cases, the maximum phonation time was measured and an auditory evaluation was performed using the grade, roughness, breathiness, asthenia and strain scale. The airflow rate was measured in five cases.

RESULTS

Vocal improvement was obtained in 11/13 cases (85%). One of the unimproved cases had cricoarytenoid joint ankylosis. No complications were observed.

Perichondrial flap to prevent chondritis and cartilage necrosis in salvage vertical partial laryngectomy for recurrent glottic carcinoma after irradiation: a new procedure

CONCLUSION

We conclude that our new closure method using the posterior- and inferior-based perichondrial flap may diminish the chance of development of chondritis in salvage vertical partial laryngectomized patients with recurrent glottic cancer.

OBJECTIVE

Post-radiation laryngeal chondritis with resultant cartilage necrosis is one of the most dreaded complications of radiotherapy treatment of glottic carcinoma. In the case of salvage vertical partial laryngectomy, the risk of its development may be increased. We introduce a new posterior- and inferior-based perichondrial flap procedure to prevent postoperative chondritis after salvage vertical partial laryngectomy.

MATERIAL AND METHODS

The perichondrium is incised along the midline and upper border of the thyroid cartilage, but not along the inferior border, unlike the conventional method. Then, the posterior- and inferior-based perichondrial flap, along with the cricothyroid muscle fascia, is elevated from the midline. For closure of the pharyngeal lumen, the outer perichondrium of the lesion side is sutured to the inner perichondrium of the contralateral side to protect the larynx from pharyngeal secretion. The utility of this procedure is reviewed retrospectively in 10 patients with locally persistent or recurrent squamous cell carcinoma of the vocal cord after failed laryngeal radiation therapy between 1994 and 2001.

RESULTS

None of our patients developed chondritis postoperatively. The interval between the operation and removal of the tracheostomy tube ranged from 8 to 23 days (mean 12 days). Patients were able to swallow without aspiration within 7-22 days of the operation (mean 10 days). Discharge from hospital was possible after a mean recovery period of 11 postoperative days.