Treatment Of Vocal Cord Paralysis Research Articles

Strategies for CO2 Laser Use in Laryngeal Microsurgery: A Systematic Review.

We aim to systematically review the literature addressing perioperative practices for optimal use of the CO2 laser in laryngeal transoral laser microsurgery (TOLMS), with a focus on safety. A systematic review of publications indexed in Medline, Embase, and EBM reviews-Cochrane Central Register of Controlled Trials which evaluated perioperative strategies for the use of CO2 laser in laryngeal TOLMS was conducted. Records obtained from the search strategy were assessed for eligibility in a 2-step process by 2 independent researchers using the Covidence software. Among 2143 identified records, 103 were included in this study. The majority of studies (n = 25) focused on the use of the CO2 laser in oncologic resection, while 20 addressed the treatment of vocal cord paralysis, 16 discussed the treatment of pediatric or congenital pathologies, 11 detailed the management of benign lesions, and 31 studies tackled other surgical indications. Strategies for safe CO2 TOLMS were highly heterogeneous across studies and included preoperative measures (ie, related to the environment, staff preparation, patient protection, and ventilation), intraoperative precautions (ie, protection of nontarget structures, technical considerations, topical and systemic medications), and postoperative strategies (ie, related to airway protection, oral intake, vocal rest, hospitalization duration, drug regimen, and consultant follow-up). The results provided in this study can be used as a framework to guide the creation of laser safety protocols across institutions, guide quality improvement initiatives, the development of simulation training activities, and as a tool to facilitate resident teaching and skill assessment.

Focusing on some problems in diagnosis and treatment of vocal cord paralysis

声带麻痹诊治方面的研究近年来发展迅速，但对其认识尚不够系统、全面。为此，本文就声带麻痹诊断、鉴别诊断、神经损伤再生因素、再生机制及临床表现、手术时机及神经移植方式的选择等方面需注意的问题进行了阐述。.

Ortner's: A Cardiovocal Syndrome

In 1897, Norbert Ortner, an Austrian physician, described three cases of left-sided vocal cord palsy associated with mitral valve stenosis. He postulated that this was due to associated atrial enlargement causing a compressive effect on the left recurrent laryngeal nerve as it coursed under the aortic arch within the mediastinum. More recently, the syndrome, which bears his name – Ortner's syndrome – has come to refer to a vocal cord palsy associated with a number of cardiac and vascular conditions, and has also been referred to as the cardiovocal syndrome. This study presented the case of a 77-year-old male, along with a literature review, who presented with a 2-month history of a vocal hoarseness of unknown cause. Computed tomography of the brain, head, neck, and chest was undertaken to look for a lesion along the distribution of the vagus and recurrent laryngeal nerves. Computed tomography identified a large saccular aneurysm arising from the arch of the aorta, which was the likely cause of his left-sided vocal cord palsy. The patient was referred to a cardiothoracic surgeon at the current hospital for consideration of surgical management. He was also referred on to an otolaryngologist with an interest in voice and expertise in the treatment of vocal cord paralysis in the same vicinity. He underwent a total aortic arch replacement and frozen elephant trunk to treat the arch aneurysm. Postoperatively, his vocal cord palsy was noted to persist and remained unchanged. He ultimately underwent vocal cord medialisation and is being monitored.

Abstract: Efficacy and Outcomes of Fat Grafting Beyond the Breast: A Meta Analysis

INTRODUCTION: As autologous fat transfer (AFT) has become almost ubiquitous in the operating rooms of most aesthetic and reconstructive surgeons, the regenerative nature of grafted adipose tissue is fueling investigations into further applications beyond the usage in the setting of breast reconstruction. Empiric observation has demonstrated that grafted fat may ameliorate adherent scars, aide in the release of contractures, and even accelerate and improve wound healing in radiation damaged skin. As we are only beginning to understand the potential of lipotransfer, it is essential that we properly evaluate our progress. In the setting of its widespread and expanding use, the purpose of our study is to conduct a meta-analysis of “non-breast” fat grafting to elucidate the current measures of success, both from the patient and physician perspective. METHODS: A PubMed/MEDLINE, Web of Science, and Embase search was conducted for all publications from January 1st, 2000 to October 1st, 2017 containing the phrase “autologous fat grafting” and related terms. The initial search yielded a total of 2255. Studies pertaining to AFT other than in the setting of breast reconstruction were individually selected to review. A review of this literature revealed significant heterogeneity of results. Of these studies, only 28 reported quantitative comparative data beyond observational or individual outcomes. No single measure of outcomes could be identified to reliably correlate the results of the various applications, so none were chosen for statistical analysis. RESULTS: A thorough review of the literature demonstrated significant inconsistency in the reporting of measurable outcomes after AFT. Of the publications which presented quantifiable data, similar applications had consistently differing measurements of the same outcome. For example, in the treatment of vocal cord paralysis, one study utilized the Grade, Roughness, Breathiness, Asthenia, Strain (GBRAS) perceptual scale, maximum phonation time (MPT), and Voice Handicap Index (VHI) whereas another described phonation time, jitter, and harmonic-to-noise ratio. In the treatment of neuropathic pain, two studies utilized the Visual Analog Scale (VAS) and Neuropathic Pain Symptom Inventory (NPSI) scales, but a third just simply described the pain or lack thereof. Lastly, in the treatment of scars, one study utilized the Vancouver Scar Scale while another was evaluated using the Patient and Observer Scar Assessment Scale. While these measures are similar in nature, a statistical analysis was impractical unless the raw data could be collected. CONCLUSION: While the aggregate data demonstrates that fat grafting has led to positive outcomes in a multitude of applications beyond breast reconstruction, this meta-analysis serves to underline the growing necessity of a validated measure of outcomes of fat grafting in these disparate settings in order to ensure we continue practicing evidence based medicine.

Endo-extralaryngeal Laterofixation of the Vocal Folds in Patients with Bilateral Vocal Fold Immobility.

Bilateral vocal fold paralysis can result in shortness of breath and severe dyspnea which can be life-threatening. Thirty-five patients with bilateral vocal fold paralysis who underwent endo-extralaryngeal laterofixation according to Lichtenberger were retrospectively analyzed regarding etiology, symptoms, treatment and complications. In 27 patients, laterofixation of the vocal cord alone was performed. Eight patients underwent laterofixation and additional posterior chordectomy of the opposite vocal cord according to Dennis and Kashima. The time of intervention ranged from 1 day to 38 years after the onset of bilateral vocal cord immobility. The intraoperative course was uneventful in all patients. None of the patients had postoperative aspiration. Postoperative voice function was acceptable in all patients. Complications of suture laterofixation were laryngeal edema, formation of fibrin, and malposition of the suture. Laterofixation of the vocal cords according to Lichtenberger is a safe and easy method that can be used as a first-stage treatment of vocal cord paralysis.

Clinical research progress on tissue defect repairing with acellular dermal matrices

Acellular dermal matrix(ADM) is a special biological material that contains only collagen, elastin and other extracellular matrix. ADMs are made by special methods of separating skin epidermis and dermis, and removing Langerhans cells, vascular endothelial cells, fibroblasts cells and major histocompatibility complex (MHC) within the dermis. ADM causes no graft rejection, and provides a good scaffold for tissue reconstruction, angiogenesis and implantation of host cells. The preparation process of ADM includes the separation of epidermis and dermis, decellularization, perforation and freeze-drying. According to the classification method, ADMs can be classified into allogeneic and xenogeneic ADM, patch and injection type ADM, as well as cross-linked and non-crosslinked ADM, which can meet various clinical requirements. ADM is widely used in surgical field, such as treatment of deep burn wounds, breast reconstruction after mastectomy, oral mucosa repair, abdominal wall hernia repair, and treatment of vocal cord paralysis. Due to the characteristics ADM, its application prospect is considerable. The research progress of ADM in recent years was summarized. Key words: Acellular dermal matrix; Preparation; Clinical application

Consensus statement: Using laryngeal electromyography for the diagnosis and treatment of vocal cord paralysis.

The purpose of this study was to develop an evidence-based consensus statement regarding use of laryngeal electromyography (LEMG) for diagnosis and treatment of vocal fold paralysis after recurrent laryngeal neuropathy (RLN). Two questions regarding LEMG were analyzed: (1) Does LEMG predict recovery in patients with acute unilateral or bilateral vocal fold paralysis? (2) Do LEMG findings change clinical management in these individuals? A systematic review was performed using American Academy of Neurology criteria for rating of diagnostic accuracy. Active voluntary motor unit potential recruitment and presence of polyphasic motor unit potentials within the first 6 months after lesion onset predicted recovery. Positive sharp waves and/or fibrillation potentials did not predict outcome. The presence of electrical synkinesis may decrease the likelihood of recovery, based on 1 published study. LEMG altered clinical management by changing the initial diagnosis from RLN in 48% of cases. Cricoarytenoid fixation and superior laryngeal neuropathy were the most common other diagnoses observed. If prognostic information is required in a patient with vocal fold paralysis that is more than 4 weeks and less than 6 months in duration, then LEMG should be performed. LEMG may be performed to clarify treatment decisions for vocal fold immobility that is presumed to be caused by RLN. Muscle Nerve 53: 850-855, 2016.

Pediatric recurrent laryngeal nerve reinnervation: A case series and analysis of post-operative outcomes

ObjectiveTo provide detailed information about recurrent laryngeal nerve (RLN) reinnervation outcomes in children using objective measures. MethodsThe records of three pediatric patients with unilateral vocal cord paralysis that underwent RLN reinnervation were retrospectively reviewed. Fundamental frequency (F0), jitter, shimmer, noise-to-harmonic ratio (NHR), and voice phonation (sustained /s/, /z/, /a/) were measured preoperatively and post-operatively at 13, 9, and 33 months (each time period corresponding to one of the three patients). ResultsMean preoperative and post-operative variables were as follows: shimmer, 9.65±1.02% vs. 4.46±0.71% (p=0.01); NHR, 0.296±0.063 vs. 0.127±0.011 (p=0.04); jitter, 3.57±0.89% vs. 1.46±0.54% (p=0.08); F0, 274.6±35.4Hz vs. 282.2±70.6Hz (p=0.44); maximum phonation time, 7.46±1.40s vs. 9.79±1.84s (p=0.22); /s:z/ ratio, 1.28±0.22 vs.1.07±0.09 (p=0.26). ConclusionsThere was statistically significant improvement in shimmer and NHR. Jitter improvement approached statistical significance. All other variables failed to show significant improvement among this small sample size. RLN reinnervation for pediatric patients is an option for the treatment of vocal cord paralysis. Further studies with larger cohorts are needed to show the full benefits.

Vocal Cord Paralysis After Surgery for Thoracic Aortic Aneurysm

To determine the incidence, etiology, prognosis, and treatment of vocal cord paralysis (VCP) after surgery for thoracic aortic aneurysm (TAA). Retrospective study performed between 1989 and 1995. Academic, tertiary care, referral medical center. Seventy-one TAA patients underwent surgery at the Kameda Medical Center between 1989 and 1995. Sixty-two of 71 patients were examined postoperatively for voice quality. Twenty patients (32%) had hoarseness develop caused by VCP, as confirmed by laryngoscopy. The left recurrent laryngeal nerve had been sacrificed in 1 patient during surgery, but it was preserved in the remaining 19 patients. Unilateral left VCP was noted in 19 patients, and bilateral VCP occurred in 1 patient. The incidence of VCP was higher in those patients who underwent surgery for type I aneurysms (9 of 14 patients, 64%). In 16 of the 19 patients (84%) who received follow-up for > 6 months, vocal cord movement did not return to normal. Surgery to improve voice quality, arytenoid adduction in five patients and intracordal injection in two patients, was performed with success. Our results indicate that surgery for TAA is associated with a relatively high incidence of VCP. VCP occurred despite preservation of the recurrent laryngeal nerve, and the paralysis did not show a spontaneous recovery even 6 months after surgery.

Lack of evoked laryngeal electromyography response in patients with a clinical diagnosis of vocal cord paralysis.

There has been recent debate about whether patients with vocal cord immobility have a neurologic paralysis or whether synkinesis, the misdirection of axons to competing laryngeal muscles, is responsible for the lack of voluntary vocal cord motion. This issue was studied in 15 patients with vocal cord paralysis who underwent laryngeal reinnervation. Evoked electromyography was performed with a surface electrode endotracheal tube. The recurrent laryngeal nerve (RLN) was identified and stimulated with constant current. Of the 15 patients, only 1 produced a compound muscle action potential upon nerve stimulation. The remaining 14 patients had no evoked response during RLN stimulation. A control group of 8 patients with normal vocal cord mobility was studied, and each had a normal evoked electromyography response after RLN stimulation. These results support the assertion that patients who require treatment for vocal cord paralysis do not have synkinesis produced by RLN reinnervation.

Transcutaneous Teflon injection for vocal cord paralysis.

In 1989, I reported a series of 19 cases of unilateral vocal cord paralysis treated by transcutaneous Teflon injection. At that time it was shown that unilateral vocal cord paralysis could be effectively treated in the office in the unanesthetized patient using a transcutaneous route of injection. Since that time, an additional 43 patients have been treated using a similar technique. The initial impression of safety and efficacy has been confirmed in this subsequent series. Several refinements in this technique have simplified its use and improved its reliability. No airway complications have been observed to date and no patients have required hospital admission. Transcutaneous Teflon injection can be considered a useful method for treatment of vocal cord paralysis in selected patients.

Functional Staging for Vocal Cord Paralysis

Phonatory function can be reliably tested after vocal paralysis. After a review of 116 cases, 55 patients underwent objective testing. The clinical history of vocal ability and aspiration were found to be significantly correlated with measurements of phonatory mean flow rate (MFR), maximum phonation time (MPT), and maximum decibel output (SPL). A four-stage classification system, based on clinical and objective measurements, has been formulated. In stage I, measures of vocal parameters approached those of normals with MFR = 155 cc/sec, MPT = 12 sec, and SPL = 92 dB. Patients with stage IV disability have high MFR (480 cc/sec), but low MPTs (less than 3 sec) and low SPL values (76 dB). Factors such as sex, age, weight loss, and the presence of malignancy affect the degree of vocal function deficit. Post-therapy recordings indicated an improvement in vocal function by an increase in MPT and SPL, with a decrease in MFR. Measurements of MFR, PT, and SPL are good objective indicators available to the clinician. Functional staging can be applied to assessment and treatment of vocal cord paralysis.

Extraluminal Arytenoid Reconstruction: Laryngeal Framework Surgery Applied to a Pediatric Problem

Laryngeal framework surgery has proved to be an important alternative in the treatment of vocal cord paralysis in adults. We have modified one of these operations in order to manage debilitating aspiration in a 14-year-old boy. His laryngeal incompetence resulted from a severe neurologic injury and laryngeal scarring from a unilateral arytenoidectomy and multiple Teflon injections. To help him, we studied a series of pediatric larynges and devised an operation that succeeded in rebuilding the bulk of his excised arytenoid cartilage and markedly reducing aspiration.

Nerve Transfer vs Polytef Injection for Vocal Cord Paralysis

Dr Roger Crumley, San Francisco, at the annual meeting of the Triological Society in Palm Beach, Fla, presented an update on his results with nerve transfer in the treatment of vocal cord paralysis. His technique involves anastomosis of the nerve to the sternohyoid muscle to the recurrent laryngeal nerve, distal to the site of injury. Gelfoam injection is performed to provide vocal improvement during the time required for reinnervation. Results were presented for five patients, documented by sonography and, in some cases, videolaryngostroboscopy. The goal of the procedure is not normal movement but resting tone in the vocalis muscle, which permits more normal vibration of the vocal fold. Dr Crumley feels that the results of this procedure are much more reliable than those of polytef (Teflon) injection. Complications of polytef injection that he cited included granuloma formation and migration of the polytef. Dr Crumley states that there are few perfect

The treatment of vocal fold paralysis with injectable collagen: Clinical concerns

<h2>Summary</h2> Over the past several years, the treatment of vocal cord paralysis has been substantially improved by the availability of injectable Teflon. This substance, suspended in glycerin, has provided consistent results in laryngeal rehabilitation due to its tissue tolerance and lack of resorption. Recently, moified bovine collagen has been proposed as an additional substance for use in vocal cord injections to treat vocal fold paralysis. Collagen is currently being used for augmentation of dermatologic scarring, especially on the face. It has undergone clinical trials and has now been approved for clinical use in this setting. Bovine collagen has proven very useful in scar modification. The injections are generally well tolerated and adverse responses do not often occur. Most of the adverse local reactions can be avoided by using a skin test on the forearm 1 month prior to treatment and excluding those patients with positive responses.

The timing of surgical intervention in vocal cord paralysis.

Surgical alteration of the glottis for treatment of vocal cord paralysis is best deferred as long as there is a reasonable chance for spontaneous recovery. Most authors recommend waiting six to 12 months before surgery. However, the literature provides insufficient data to support this concept. This paper presents a group of patients with a thorough analysis of natural history, and other factors considered in planning surgical therapy.

Vocal cord paralysis--1979: etiology and management.

Because of the development of reinnervation surgery, approximately 400 patients have been seen by the author with a referral diagnosis of vocal cord paralysis. Because these patients were being entered into a research protocol to evaluate the efficacy of reinnervation surgery, very careful evaluation and records have been kept. Retrospective analysis of these records has permitted an up-to-date evaluation of the epidemiology, natural history, symptoms, signs and presenting complaints, as well as the status of treatment of vocal cord paralysis at the present time. Since this subject has received only limited treatment in the recent literature, it was felt that such an opportunity to evaluate a large personal experience might be a worthwhile addition to current knowledge of the subject.

Evaluation and treatment of vocal cord paralysis.

AbstractOne hundred eighty‐one patients with unilateral or bilateral vocal cord paralysis unrelated to laryngeal carcinoma or its therapy were studied. The orderly diagnostic profile used to delineate cause of the paralysis includes CBC, VDRL blood sugar profile, latex fixation and serum sampling for toxic heavy metals. The radiologic and endoscopic evaluation is done to completion unless contraindicated, to assess aspiration as well as to observe laryngopharyngeal structures which may cause the paralysis. This evaluative profile defined the etiology of cord paralysis in 80 percent of patients, despite exclusion of viral disease as a cause subsequent to upper respiratory infection. Blunt trauma and previous neck surgery each were responsible for 23 percent of the cases. Fifty‐four patients had bilateral paralysis of which 22 were post thyroidectomy. Surgical repair for cord paralysis was symptomatic, and included 28 successful teflon injected cords. Recurrent laryngeal nerve decompression was successful in four of five operations and arytenoidectomy was performed in 39 patients.