Glottal Incompetence Research Articles

Cricopharyngeal myotomy and arytenoid adduction in the management of combined laryngeal and pharyngeal paralysis.

Aspiration caused by unilateral combined laryngeal and pharyngeal paralysis is a serious clinical problem. This article reviews the abnormal physiology, which includes glottal incompetence, impaired pharyngeal propulsion, and sensory loss, and reports the results of surgical treatment of, 13 patients who had significant dysphagia and aspiration caused by unilateral laryngeal and pharyngeal paralysis. In eight patients the cause was surgical resection or trauma of the tenth cranial nerve, with concomitant twelfth nerve injury in four. Four patients had central lesions. One patient had a surgical tenth cranial nerve injury as well as a stroke. Thyroplasty, alone in two patients, and combined with cricopharyngeal myotomy in a third, improved voice, but not swallowing. In all patients treated by arytenoid adduction plus cricopharyngeal myotomy, aspiration was eliminated, and patients gained weight. Six of these patients had been dependent on enteral tube feedings. The results support the safety and efficacy of simultaneous arytenoid adduction and cricopharyngeal myotomy for dysphagia caused by combined laryngeal and pharyngeal paralysis.

Cricopharyngeal myotomy and arytenoid adduction in the management of combined laryngeal and pharyngeal paralysis

Aspiration caused by unilateral combined laryngeal and pharyngeal paralysis is a serious clinical problem. This article reviews the abnormal physiology, which includes glottal incompetence, impaired pharyngeal propulsion, and sensory loss, and reports the results of surgical treatment of, 13 patients who had significant dysphagia and aspiration caused by unilateral laryngeal and pharyngeal paralysis. In eight patients the cause was surgical resection or trauma of the tenth cranial nerve, with concomitant twelfth nerve injury in four. Four patIents had central lesions. One patient had a surgical tenth cranial nerve injury as well as a stroke. Thyroplasty, alone in two patients, and combined with cricopharyngeal myotomy in a third, improved voice, but not swallowing. In all patients treated by arytenoid adduction plus cricopharyngeal myotomy, aspirationwas eliminated, and patients gained weight. Six of these patients had been dependent on enteral tube feedings. The results support the safety and efficacy of simultaneous arytenoid adduction and cricopharyngeal myotomy for dysphagia caused by combined laryngeal and pharyngeal paralysis. (Otolaryngol Head Neck Surg 1997;116:339-43.)

A comparison of type I thyroplasty and arytenoid adduction

Glottal incompetence is a common laryngeal disorder causing impaired swallowing and phonation. The resultant voice has been characterized as weak and breathy with a restricted pitch range. Currently, medialization thyroplasty and arytenoid adduction are two of the surgical treatments for patients with glottal incompetence. However, few studies have evaluated the changes in objective measures of speech with type I thyroplasty and arytenoid adduction. In this study, 59 patients with glottal incompetence underwent either type I thyroplasty or arytenoid adduction. Acoustic (jitter, shimmer, and harmonics-to-noise ratio) and aerodynamic (airflow, subglottic pressure, and glottal resistance) measures were obtained both pre- and postoperatively. No significant differences were found among acoustic or aerodynamic measures for operation type. However, a significant pre/postsurgery effect was observed for translaryngeal airflow. In addition, no significant differences were found among the measures for patients with traditional compared with nontraditional operative indications. Patients who developed glottal insufficiency due to previous laryngeal surgery (e.g., vocal fold stripping) demonstrated no statistically significant improvement in acoustic or aerodynamic measures following thyroplasty or arytenoid adduction.

Laryngeal complications after type 1 thyroplasty.

Type I thyroplasty has become a primary surgical choice for voice restoration in patients with glottal incompetence. This study examines factors associated with laryngeal complications after type I thyroplasty. Ten laryngoscopic variables were analyzed from preoperative, intraoperative, and postoperative videolaryngoscopies of 51 patients undergoing 58 medialization procedures. Ten patient and operative variables were examined by medical record review. Major complications were defined as wound hemorrhage, airway obstruction, or prosthesis extrusion. Minor complications were defined as vocal fold hematoma without airway obstruction or prosthesis movement. The major complication rate was 8.6%, and the minor complication rate was 29%. No delayed hemorrhage or airway obstruction occurred. Prosthesis extrusion occurred in five (8.6%) patients 1 week to 5 months after surgery. Extrusion was associated with suboptimal prosthesis placement in 80% of cases. Two patients retained excellent glottal closure despite extrusion. Vocal fold hematoma was identified in 14 (24%) cases and resolved within 1 week. Prosthesis movement occurred in three (5%) patients 1 week to 6 months after surgery and resulted in poor glottal closure. All patients with prosthesis extrusion or movement were female. Type I thyroplasty remains a safe outpatient procedure with few major complications. Prosthesis extrusion was associated with suboptimal prosthesis placement and may or may not result in poor glottal closure. Minor vocal fold hematomas were relatively frequent, resolved rapidly, and were not associated with airway obstruction. Female patients may be more prone to complications because of their small laryngeal size.

Intensive voice treatment in parkinson disease: Laryngostroboscopic findings

As part of ongoing research to investigate and document the efficacy of intensive voice therapy to improve functional communication in patients with idiopathic Parkinson disease, 45 patients were enrolled in a controlled, randomized, prospective study. Pre- to posttreatment comparisons are presented here on 22 of those patients who underwent laryngeal imaging examination. Of the 22 patients, 13 patients received intensive therapy aimed at increasing vocal and respiratory effort (VR), whereas nine received intensive therapy aimed at increasing respiratory effort (R) only. All patients had a pretreatment evaluation that included two (but sometimes only one) voice recordings and an otolaryngologic examination with laryngostroboscopy. At the completion of 4 weeks of therapy (16 sessions), two voice recordings were made, and laryngostroboscopy was again performed. The pre- and posttherapy videolaryngostroboscopy tapes were then randomized and rated by four judges. Raters' findings were then compared with vocal intensity measured before and after therapy. The VR therapy group showed improvements on laryngostroboscopic variables: less glottal incompetence and no significant change in supraglottal hyperfunction after therapy. No differences were observed in the R-only group. The mean intensity increase in the VR therapy group was 12.5 dB, compared with a decrease of 1.9 dB in the R-only group. These findings suggest that in patients with Parkinson disease, intensive therapy focusing on phonatory effort improves adduction of the vocal folds as assessed by laryngostroboscopy. Differences in laryngeal function in these patients observed with fiberoptic laryngoscopy and rigid telescopic laryngoscopy are discussed.

Laryngeal complications after type I thyroplasty

Type I thyroplasty has become a primary surgical choice for voice restoration in patients with glottal incompetence. This study examines factors associated with laryngeal complications after type I thyroplasty. Ten laryngoscopic variables were analyzed from preoperative, intraoperative, and postoperative videolaryngoscopies of 51 patients undergoing 58 medialization procedures. Ten patient and operative variables were examined by medical record review. Major complications were defined as wound hemorrhage, airway obstruction, or prosthesis extrusion. Minor complications were defined as vocal fold hematoma without airway obstruction or prosthesis movement. The major complication rate was 8.6%, and the minor complication rate was 29%. No delayed hemorrhage or airway obstruction occurred. Prosthesis extrusion occurred in five (8.6%) patients 1 week to 5 months after surgery. Extrusion was associated with suboptimal prosthesis placement in 80% of cases. Two patients retained excellent glottal closure despite extrusion. Vocal fold hematoma was identified in 14 (24%) cases and resolved within 1 week. Prosthesis movement occurred in three (5%) patients 1 week to 6 months after surgery and resulted in poor glottal closure. All patients with prosthesis extrusion or movement were female. Type I thyroplasty remains a safe outpatient procedure with few major complications. Prosthesis extrusion was associated with suboptimal prosthesis placement and may or may not result in poor glottal closure. Minor vocal fold hematomas were relatively frequent, resolved rapidly, and were not associated with airway obstruction. Female patients may be more prone to complications because of their small laryngeal size. (OTOLARYNGOL HEAD NECK SURG 1995;113:671-3.)

Autologous collagen vocal fold injection: A preliminary clinical study

This preliminary study reports the first use of injectable autologous collagen for vocal fold augmentation. In previous studies, the authors showed cross-linked bovine collagen to be effective in more than 150 patients with glottic incompetence, particularly those with focal defects or scarred or atrophic vocal folds. However, concerns about possible adverse immunologic responses to the bovine material have limited its use. The authors studied eight patients with difficult vocal fold pathology, including sulcus vocalis, atrophy, and scarring secondary to trauma and cordectomy. Skin was harvested under local anesthesia, processed into a naturally cross-linked injectable form (Autologen), and injected using indirect laryngoscopy. Voice production was evaluated prior to the injection and at intervals after the injection, using subjective, perceptual, aerodynamic, acoustic, and videostroboscopic assessments. The results indicate that autologous collagen is comparable to injectable bovine collagen in the management of several difficult glottic insufficiency problems and that the likelihood of a hypersensitivity response is negligible. Unlike bovine collagen preparations, Autologen does not require breakdown of the natural collagen molecule, so it is anticipated that this material will be better tolerated and more stable over time.

Medialization Laryngoplasty and Arytenoid Adduction

Educational objectives: To analyze the causes of glottal incompetence, including vocal cord paralysis, paresis, and senile bowing, and to perform surgery to correct the incompetency, including Silastic medialization, arytenoid adduction, and reinnervation.

Surgery for glottal incompetence

Surgery for glottal incompetence

Pushing exercise program to correct glottal incompetence

A voice therapy program using pushing exercises to correct glottal incompetence is described. The program utilizes various types of instrumentation to determine whether or not a given patient is likely to benefit from the treatment. The program also provides feedback of target voices. Three cases with incomplete glottal closure and subsequent vocal dysphonia characterized by an asthenic breathy quality are used to illustrate the program. Details of the program, termination criteria, and problems and precautions learned from treating 29 patients over a 3-year period are presented.

Silastic Medialization and Arytenoid Adduction: The Vanderbilt Experience

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.

気管食道科と縦隔 縦隔疾患とさ声

It is well known that hoarse voice can be produced during the course of any laryngeal lesion. One possible cause is recurrent nerve paralysis due to various pathological conditions. Among various etiologies, our clinical statistics indicate that the incidence of hoarseness due to mediastinal pathology is 2.6%. As for treatment, glottal incompetence should be corrected and various methods have been proposed for this purpose. From our experience, arytenoid rotation and intracordal injection give the best results. However indication for each technique should be considered carefully.

声門閉鎖に関する実験的研究

The glottic incompetence caused by recurrent laryngeal paralysis results in not only voice problem but also occasional aspiration. Injections of silicon or collagen have been effectively used to improve the voice of paralysis cases. A transcutaneous intrafold injection technique in which the needle is inserted into the vocal fold through the thyroid lamina under fiberoptic monitoring has been employed in our clinic. There have been few reports on the effect of intrafold injection upon aspiration. In the present study, we measured the glottic closing pressure during swallowing in 12 normal cats and 19 cats with recurrent laryngeal nerve paralysis. In paralytic animals, measurements were conducted before and after silicon injection. A micro-tip catheter pressure transducer (Model PC-330, Micro-Tip, Miller Co. Ltd.) was employed. The results indicate that silicon injection can increase the glottic closing pressure up to the level enough to avoid aspiration.

Effects of Lateral Manual Compression upon Glottic Incompetence: Objective Evaluations

Forceful manual compression of the thyroid and cricoid cartilages modifies the position, shape, and tension of the vocal folds. This is the basis of the four laryngeal manual compression tests, adjunctive examinations used as a means of preoperative assessment of patients for medialization laryngoplasty, ie, Isshiki thyroplasty types I and IV and arytenoid adduction. The laryngeal manual compression tests are simple to perform and noninvasive. Each of the four examinations yields valuable information on the effects on the voice of changes in vocal cord characteristics produced by manual compression. In this report, one of the four tests, lateral manual compression, is evaluated objectively with well-attested methods of videostroboscopic, aerodynamic, and acoustic analysis. The technique of performing lateral manual compression is described, and advantages and disadvantages are noted and compared in 10 patients. Preliminary findings in 4 patients in this group indicate that medialization laryngoplasty should be considered when test results are conclusive of effective glottic closure. Data derived in this preliminary study will be augmented as patients are added to the series.

Airway complications in the head injured.

Fifty head-injured patients who had tracheostomy were followed during rehabilitation by video fiberoptic laryngoscopy examination. Complications of aspiration (23/50), airway stenosis (13/50), and phonation dysfunction (16/24) were followed. Spontaneous resolution of aspiration may require a prolonged course. A majority of patients (37/50) had improvement and could be decannulated. Prognostic factors correlated to eventual decannulation included age, level on the Glasgow Coma Outcome Scale, and type of head injury. Those with poor neurologic improvement and glottic incompetence (13/50) are poor candidates for decannulation. Significant airway stenosis can involve both laryngeal and tracheal sites. Neurologic dysfunction may complicate the decannulation process after airway anatomy has been restored by surgery. Dysphonia resulting from intubation, peripheral laryngeal and nerve injury, or central laryngeal movement dysfunction are common. Preventive maintenance with ongoing evaluation can avoid airway crises such as aspiration pneumonia, hemoptysis, and innominate artery.

Cricoid collapse. A new technique for management of glottic incompetence.

A new procedure corrects glottic incompetence in patients following extended horizontal partial laryngectomy. The procedure consists of making vertical, cartilaginous cuts to collapse one half of the cricoid cartilage to a fixed midline position. In selected patients, this procedure has been demonstrated to permit decannulation where conventional methods have failed.

Vocal Fold Furrows. A 10-Year Review of 240 Patients

A retrospective review of 240 patients with vocal fold furrows seen at the Department of Otolaryngology, Kurume University Hospital over the 10-year period from 1971 to 1980 was completed. Of the 240 patients, 173 were male and 67 were female. In 195 patients, the furrows were the major pathology causing hoarseness; in 29, the furrows were associated with other major laryngeal diseases; and, in 16, there were no voice problems. We call the first group "sulcus vocalis" in this paper. The onset of voice problems in the cases of sulcus vocalis was at the age of 40 years or older in most case, at young childhood in some, and at adolescence in some cases. Typical findings of sulcus vocalis consisted of bilateral furrows on the vocal fold edges extending over the entire length of the membranous portion, bowed vocal fold edges, glottic incompetence during phonation and excessive ventricular fold adduction. No effective treatments have been established.

Correction of posterior glottic incompetence following horizontal partial laryngectomy.

Posterior glottic insufficiency following horizontal partial laryngectomy results in persistent aspiration. A new method of correction of this occurrence is described. The procedure is an extralaryngeal approach. A tracheotomy is not required. The procedure was successful in 4 of 6 patients.

Gelfoam paste injection for vocal cord paralysis: temporary rehabilitation of glottic incompetence.

Vocal cord paralysis frequently results in open glottic incompetence with aspiration, an ineffective cough, and poor voice production. Glottic competence can be restored temporarily be injecting the true vocal cord with Gelfoam paste. This clinical use of Gelfoam for temporary rehabilitation is indicated in : 1) situations in which paralysis may be temporary, 2) patients for whom an open operative procedure must be delayed, and 3) circumstances in which it is desirable to determine the effect of vocal cord injection prior to placement of nonabsorbable material. The injection of Gelfoam paste results in minimal tissue reaction. Absorption is gradual over a period of six to ten weeks, allowing time for some glottic compensation. The injection may be repeated without adverse effects until the paralysis resolves or intervention of a permanent nature is indicated.

Replacement of the arytenoid following vertical hemilaryngectomy.

A considerable body of literature advocates and defines treatment of vocal cord cancer with posterior extension by hemilaryngectomy. The present study was carried out to determine the feasibility of using a newly devised pedicle flap, composed of thyroid cartilage and inferior constrictor muscle, to replace the ablated arytenoid cartilage. Animal investigation revealed satisfactory viability of the pedicle flap in canines, and in humans, five patients with T2 glottic carcinoma demonstrated excellent postoperative deglutition and return of voice. The results of the study indicate that this surgical technique merits consideration for its use in minimizing protracted glottic incompetence following hemilaryngectomy. The thyroid cartilage-inferior constrictor muscle pedicle flap may also prove useful as partial cricoid replacement in selected cases of subglottic extension and in cricoid reconstruction following trauma.