Unilateral Recurrent Nerve Research Articles

Study of movements of individual structures of the larynx during swallowing

Objective: The purpose of this study was to reveal movements of individual structures of the larynx during swallowing. Methods: Subjects were 7 healthy adults, aged 24 to 32 years (average 27 years), who had no organic or functional disease of the pharynx and larynx and 2 adults with unilateral recurrent nerve palsy, aged 49 and 60 years, respectively. We used the Toshiba IIDR system, which is composed of an X-ray TV system and a digital image managing circuit. One-fifth diluted Omnipark 300 was used as contrast medium (lohexol), with 15 cc for each swallow. The mask image for subtraction was designated as the frame before laryngeal elevation during swallowing for subtraction. We obtained the images for observation and analysis after subtracting the mask image from continuously obtained images. These images were captured into a personal computer at 30 frames per s and thereafter frame-by-frame observation and analysis were performed by means of NIH image 1.56. Results: We observed that the vocal folds underwent a series of movements during swallowing. (1) They adduct slowly and do not ascend; (2) then begin to ascend and continue adducting; whereby (3) they abduct for a moment while ascending. (4) Again, they adduct and achieve closure. (5) While maintaining closure, vocal folds elevate further to reach their maximal elevation; and (6) begin to abduct rapidly while maintaining maximal elevation. Finally, (7) they begin to descend and undergo repeated irregular abduction and adduction while descending. In examining the relationship between closure and opening at levels of the vocal fold and false vocal fold, we found that closure at the false vocal fold level precedes that at the vocal fold level and that opening at the vocal fold level precedes that at the level of the false vocal fold. Conclusion: Closure of the false vocal fold level appears important in the protection of the lower respiratory tract during swallowing.

シリコンブロック挿入１８年後の喉頭病理所見

Thyroplasty type I is one of various surgical treatments for glottic insufficiency following unilateral recurrent nerve paralysis. However, the choice of materials for the prosthesis inserted into the thyroid cartilage is controversial with regard to stability and safety. We experienced a case of laryngeal palsy caused by syringomyelobulbia. Thyroplasty type I was performed with a silicone block 18 years ago to prevent aspiration pneumonia, but in accordance with progress of the laryngeal palsy, the patient developed severe pneumonia. We performed a total laryngectomy for the improvement of his dysphagia, and conducted a histopathological study of the larynx with the silicone prosthesis. We found slight fibrinogenesis around the silicone block, however, foreign body giant cells, inflammatory cells, or absorption of silicone were not observed. We tentatively concluded that these findings show the stability and safety of silicone as a prosthesis for thyroplasty type I.

The evaluation and treatment of swallowing disorders

The effects of laryngotracheoesophageal cleft, rheumatoid arthritis, gastroesophageal reflux disease, supracricoid partial laryngectomy with cricohyoidopexy, and postsurgical unilateral recurrent nerve paralysis on swallowing function are examined. Procedures for screening patients for symptoms of s

Prophylactic thyroidectomy in 75 children and adolescents with hereditary medullary thyroid carcinoma: German and Austrian experience.

When mutations of the RETproto-oncogene were found in 1993 to account for hereditary medullary thyroid carcinoma (MTC), surgeons obtained the opportunity to operate on patients prophylactically (i. e., at a clinically asymptomatic stage). Whether this approach is justified, and, if so, when and to which extent surgery should be performed remained to be clarified. A questionnaire was sent to all surgical departments in Germany and Austria. All of the patients who fulfilled the following criteria were enrolled: (1) preoperatively proved RET mutation; (2) age </= 20 years, (3) clinically asymptomatic thyroid C cell disease; and (4) TNM classification pT0-1/pNX/pN0-1/M0. Seventy-five patients were identified, and fifteen mutations were detected in six codons. Two adolescents had unilateral pheochromocytomas as part of the multiple endocrine neoplasia II (MEN-II) syndrome. No hyperparathyroidism was noted. All patients underwent total thyroidectomy, and 57 patients went on to have lymph node dissection. Parathyroid glands were removed in 34 patients and autografted in 11. Histopathology revealed MTC in 46 patients (61%, youngest 4 years); C cell hyperplasia (CCH) only was detected in the other 29 patients. Three patients had lymph node metastases (LNMs) the youngest being age 14 years. Calcitonin levels were not useful for differentiating between CCH and MTC, but in all patients with LNMs at least the stimulated calcitonin levels were assayed. After surgery, five patients (6.7%) sustained permanent hypoparathyroidism, and one patient (1.3%) had a permanent unilateral recurrent nerve palsy. All but three patients (96%) were biochemically cured. In conclusion, prophylactic total thyroidectomy can be performed safely in experienced centers. We recommend prophylactic total thyroidectomy at age 6. Cervicocentral lymph node dissection should be included when calcitonin levels are elevated or if patients are older than 10 years. Bilateral lymph node dissection should be performed if LNMs are suspected or when patients with elevated calcitonin are older than 15 years.

Completion Total Thyroidectomy in Children With Thyroid Cancer Secondary to the Chernobyl Accident

To evaluate the usefulness of submitting children with thyroid cancer secondary to nuclear accidents to a completion total thyroidectomy. A case series consisting of patients living and operated on in Belarus whose parents had asked for a clinical evaluation in a western European center. A tertiary care referral center. The conditions of 47 children from Gomel, Belarus, with differentiated thyroid carcinoma following the nuclear accident at Chernobyl, Ukraine, were evaluated at the University of Pisa, Pisa, Italy. In approximately half of the cases, the treatment in Belarus consisted of a hemithyroidectomy. After a complete evaluation, the decision was made to reoperate on 19 of them by performing a completion total thyroidectomy. The preoperative evaluation revealed that 5 (26%) of the 19 patients who had undergone a hemithyroidectomy had unilateral recurrent nerve palsy and that 2 (10.5%) had hypoparathyroidism. Neck ultrasonography was used for the preoperative localization of thyroid residuals, thyroid nodules, suspicious lymph nodes, and a guided fine-needle aspiration biopsy specimen. The circulating thyroglobulin measurement was obtained before reoperation. An iodine 131 whole-body scan (WBS) was performed and circulating thyroglobulin levels were obtained after completion of the thyroidectomy during withdrawal of levothyroxine sodium therapy. The number of patients with a recurrence of thyroid cancer and lung or lymph node metastases after the completion total thyroidectomy. The results of the histologic examination were positive for papillary thyroid cancer in 6 (28.6%) of 21 patients, 3 with residual cancer in the remaining thyroid lobe and 3 with metastatic lymph node disease. A posttherapy WBS demonstrated lung metastases in 5 (28%) of 18 patients and lymph node metastases in 6 (33%) of 18 patients; the results of a posttherapy WBS were negative for metastases in 7 (39%) of 18 patients. Hypoparathyroidism developed in 4 (21%) of 19 patients who underwent a completion total thyroidectomy; unilateral laryngeal nerve palsy developed in 1 (5.2%) of these 19 patients. Among 22 children who previously underwent total thyroidectomy in Belarus, a diagnostic WBS showed lung metastases in 10 (45%) of the children and lymph node metastases alone in 3 (14%) of the children; the results of a diagnostic WBS were negative for metastases in 9 (41%) of the children. Statistical analysis showed a nonsignificant (P>.05) difference in the prevalence of lung and lymph node metastases in patients who previously underwent total thyroidectomy compared with patients who underwent completion total thyroidectomy. Completion total thyroidectomy allowed for the diagnosis and treatment of recurrent thyroid cancer and lung or lymph node metastases in 61% (11/18) of the patients in whom residual differentiated thyroid carcinoma was not previously recognized.

Unilateral recurrent laryngeal nerve paralysis:The importance of “preoperative” voice therapy

This preliminary retrospective study of 19 female patients and 22 male patients with unilateral recurrent nerve lesions demonstrated the promise of objective measurements in predicting the need for surgery, the efficacy of voice therapy in ameliorating vocal symptoms, and the effects of therapy in conjunction with surgery. Sixty-eight percent (68%) of the female patients and 64% of the male patients did not elect to have surgery. Outcome satisfaction of nonsurgical and surgical patients appeared to be similar. The data from this study support the importance of preoperative therapy for patients with unilateral vocal fold paralysis.

Aerodynamic and temporal disruptions of speech in laryngeal insufficiency.

To describe the effects of laryngeal insufficiency on aerodynamic and temporal aspects of speech breathing and speech production. A survey study with statistical comparisons of patient and normal subject groups. Private and institutional practice. A convenience sample of 23 subjects with laryngeal insufficiency was compared with a volunteer sample of 20 normal-speaking subjects. Patients had frank unilateral recurrent nerve paralysis-paresis or idiopathic laryngeal insufficiency as verified by videostrobolaryngoscopy. Mean airflows, air volumes, and durations for speech inspirations, speech phrases, and non-inspiratory pauses during samples of monologue speech. In comparison with the normal group, the patient group had significantly (P < .01) higher expiratory airflows and volumes during speech and reduced speech phrase durations. In addition, breaths per minute, inspiratory minute volume, and inspiratory airflow were significantly (P < .01) higher for the patient group. An experimental measure of aerodynamic yield for speech increased the statistical separation of the patient and normal groups compared with analyses using simple expiratory airflow measures alone. Insufficient contact of the true vocal folds during speech can affect more than just voice quality. Likely effects include (1) reduced speech phrase duration, (2) increased breaths per minute, (3) increased inspiratory minute volume, and (4) increased inspiratory airflow rate.

Percutaneous Collagen Injection for Postoperative Unilateral Recurrent Nerve Palsy

Percutaneous Collagen Injection for Postoperative Unilateral Recurrent Nerve Palsy

甲状軟骨形成術Ｉ型の一工夫

Isshiki Thyroplasty Type I, a surgical procedure to medialize a paralyzed vocal cord through a window made in the thyroid lamina, has been widely performed to improve hoarseness and misdeglutition in cases of unilateral recurrent nerve paralysis. The medialization of the vocal cord is usually obtained by the insertion of a silicone shim through the window, but the trimming of the silicone is troublesome, and the operation cannot be done without silicone. Thus, we recently devised a new method using a fragment of cartilage instead of silicone. In this method, a vertical portion of the rectangular cartilage removed from the window in the thyroid lamina was inserted between the thyroid cartilage and the endochondrium at the level of the window and was fixed with fibrin glue. This procedure is easy to perform and does not necessitate silicone. Two cases with good results using this method were reported.

Recurrent nerve/ansa cervicalis nerve anastomosis: a treatment alternative in unilateral recurrent nerve paralysis.

Sectioning of the right recurrent nerve was done in 5 mongrel dogs under general anaesthesia. The distal stump was anastomosed with the ansa cervicalis nerve branch to the sternothyroid muscle. Three to 5 months later the vocal cord movements during light and very light anaesthesia were videorecorded. Under light anaesthesia contraction and medial bulging of the reinnervated right vocal cord occurred in 4 of the dogs. Under very light anaesthesia there was also some adduction of the right vocal cord in these 4 dogs. The right recurrent nerve was then sectioned proximally to the anastomosis and stimulated electrically. In all 5 dogs we observed that electrical stimulation produced a strong adduction of the right vocal cord. Histochemistry of the right vocal and posterior cricoarytenoid muscles showed that reinnervation had taken place. The study indicates that in cases of unilateral vocal cord paralysis an anastomosis between the ansa cervalalis and the recurrent nerve will result in improved phonatory function of the affected vocal cord.

Analysis of spasmodic dysphonia by aerodynamic and laryngostroboscopic measurements

Summary Sequential assessment of laryngeal function using laryngostroboscopy and phonatory air flow assessment was carried out in 18 patients with spasmodic dysphonia (SD). Comparison was made between findings in patients before treatment (n = 18), after unilateral recurrent nerve block by lidocaine (n = 6), after bilateral injections of botulinum toxin (Botox) (n = 13), and prior to Botox reinjection (n = 3). Unilateral nerve block resulted in higher mean phonatory airflows than after bilateral Botox injections. Both unilateral nerve block and Botox injections increased fluctuant or alternating flow source (AC); however, unilateral nerve block resulted in more unmodulated airflow leakage. Phonation time on a single breath was longer than with Botox injection. Bilateral Botox injections resulted in better glottal closure, fewer instances of vocal fold level differences, and, better vocal fold vibrations with phase symmetry, as determined by laryngostroboscopy. Partial bilateral denervation using Botox resulted in laryngeal function, which appeared to be intermediate between that of tightly squeezed pretreatment status and a breathy voice with incomplete adduction after unilateral nerve block. Of all treatments assessed, bilateral partial denervation by Botox appeared to be the most physiologic in restoring normal vocal fold vibratory function and airflow.

Funktionelle und elektromyographische Langzeitergebnisse nach primärer mikrochirurgischer Versorgung des N. laryngeus recurrens*

Six patients with unilateral recurrent nerve paralysis underwent phoniatric follow-up after neurolysis or primary microsurgical repair of the recurrent laryngeal nerve. Four patients were controlled by electromyography of the vocal muscle 14 to 80 months post-operatively. In six patients the paralyzed vocal cords were in median to paramedian position with sustained muscle tonus. Phoniatric parameters were found to be close to the average range in healthy persons. EMG findings indicated degenerative neurogenous paralyses in two patients, signs of reinnervation in another. In one case biphasic action potentials could be recorded.

経皮的声帯内注射の治療成績とその影響因子について

The result of transcutaneous intrafold injection and its influencing factors were studied for fifty five procedures in fifty two patients with unilateral recurrent nerve paralysis. Maximum phonation time, mean air flow rate and amplitude perturbation quotient of the voice were normalized or improved after the procedures more than 85%. In general assessment with functional and acoustic examinations, 76% of the procedures showed significant improvement. The paralysis after the thoracic surgery, right vocal fold paralysis and the paralysis complicated with sulcus vocalic tended to have insufficient improvement after injection. The most significant correlation to the result was shown in the degree of vocal fold augmentation immediately after injection. It was depend on the surgeon's technique and the patient's problems such as an anatomical abnormality of the larynx and an insufficient inhibition of the gag reflex.

発声にともなう麻ひ声帯の形状変化に関する画像解析 空気力学的な力の関与について

The development of digital radiography (DR) has made it possible to analyze the contour of the laryngeal soft tissue structures in more detail than the conventional screen-film method. We analyzed the contour of the paralyzed vocal cord during phonation using motion subtraction technique. Forty four patients with unilateral recurrent nerve palsy were examined. The images were obtained by means of frontal tomography of the larynx during quiet inspiration and normal (expiratory) phonation. Tomography during inspiratory phonation was also examined in ten patients who can perform it. The thickness of the slices was 5.0 mm. The authors found that the free margin of the paralyzed vocal cord shifted by the aerodynamic power along the direction of the air flow, i.e. it shifted to the cranial direction during normal phonation and to the caudal during inspiratory phonation. The displacement phenomenon of the paralyzed vocal cord was significantly correlated with the degree of vocal cord atrophy (p less than 0.01). The result would indicate that the aerodynamic power during phonation is one of the factors eliciting the higher position of the paralyzed vocal cord during phonation, in addition to its anatomical displacement due to abduction of the paralyzed arytenoid. This notion should be taken into consideration in selecting the surgical approach for the treatment of unilateral recurrent nerve palsy.

片側反回神経麻ひに対するアテロコラーゲン声帯内注入療法

Seven patients with unilateral recurrent nerve paralysis underwent vocal fold augmentation by intracordal injection of atelocollagen. Injection was done through direct laryngoscopy under general anesthesia. An additional injection was necessary in two cases and was done transcutaneously under local anesthesia. Five patients were followed as long as six months after injection. Four of them received 3. 5% atelocollagen injection and their phonatory function improved dramatically except one patient. The other received 3% atelocollagen injection. But, his vocal fold became again atrophied within a week after injection. Thus 3. 5% atelocollagen should be a choice for vocal fold augmentation. In addition, some physical properties of atelocollagen in the vocal fold was said to be like those of vocal fold itself. Therefore, atelocollagen can be injected into any layer of the vocal fold without specific technical care.

A fundamental study of injectable collagen in vocal rehabilitation

Vocal fold augmentation therapy has been accepted as a choice of treatment for glottic insufficiency due to unilateral recurrent nerve paralysis, vocal fold atrophy and sulcus vocalis. Various injectable materials have so far been investigated and clinically utilized. Although silicone and teflon are materials most widely used currently, our clinical experiences have indicated that they are not totally dependable because of such problems as tissue rection and instability of the volume.Recently, atelocollagen extracted from young calf skin has been reported to be an excellent injectable material and its application to phonosurgery has been described by Ford without investigating its long-termed safety and histocompatibility, and its effect on the vocal fold vibrations after the injection.This lack of investigation on the injection therapy of atelocollagen has prompted the animal experiments to study histological attitude of collagen in the vocal fold and the vocal fold vibration after the injection. The collagen at a concentration of 35, 20 and 10mg/ml were injected into canine vocal folds. The follow up period ranged from 3 days to 9 months after the injection. It was revealed that the most suitable concentration of the collagen for maintenance of the contour of the vocal fold was 35mg/ml, although the volume of the vocal fold tended to decrease very slightly during three days after the injection. Histological studies confirmed no inflammatory reaction in the surrounding tissue after the injection and no migration of collagen during the following-up period. Vibrations of the injected vocal folds during phonation were photographed with an ultra-high speed motion camera and frame-by-frame analyses were done. Mucosal wave-like movements were satisfactority preserved even when the collagen stayed in the submucosal superficial layer of the vocal fold. The result indicates that atelocollagen can be injected into any layers of the vocal fold without specific technical care. Owing to this advantage, use of the atelocollagen will expand indication of augmentation therapy.

Surgical Treatment for Voice Disorder due to Unilateral Recurrent Nerve Palsy

In this paper, various methods of surgical treatment for voice disorder due to unilateral recurrent nerve palsy were briefly reviewed. The author emphasized the necessity of the choice of different approaches depending on the width of the glottal chink; injection or insertion method for the narrow glottal chink (paramedian fixation) and arytenoid adduction for the wide glottal chink (intermediate fixation) and for the difference in the level of the both vocal folds.

Misadventures with injectable polytef (Teflon).

The intracordal injection of polytef (Teflon)-glycerine suspension has proved most effective in relieving dysphonia due to unilateral recurrent nerve paralysis. However, if errors in the technique of injection are committed or if patients are not properly selected, a potentially good result will not be achieved or the voice will be made worse.

Surgery for hoarseness due to unilateral vocal cord paralysis.

I THE MAJORITY of cases of paralytic dysphonia due to the injury of the unilateral recurrent nerve, a spontaneous improvement of voice occurs within several months by a self-compensatory action of the contralateral vocal cord. In some cases, however, hoarseness or aphonia persists for a long time. The chief complaints of the patients are hoarseness and too short phonation per breath. In these cases, the glottal closure is incomplete and glottal sounds are not generated, even after the unaffected vocal cord adducts to maximal extent. In order to obtain serviceable voice, surgical adduction of the paralytic vocal cord to produce effective glottal closure should be considered. Various operations, long known, have been designed for this purpose. There are three principles on which these procedures are based: (1) transposition of the arytenoid cartilage of the paralyzed side (reverse King operation of Morrison1); (2) injection of paraffin, silicone, or Teflon into

INTRACORDAL INJECTION OF SILICONE IN SELECTED DYSPHONIAS.

THE EFFECTIVENESS of intracordally injected Teflon in restoring or improving the voice in a variety of dysphonias, particularly unilateral recurrent nerve paralysis, has been established by Arnold^1-5and corroborated by others.^6,7Specific indications for the use of Teflon are restricted to situations in which dysfunction is permanent. Where there is doubt as to whether cordal function will return, injection of Teflon must be withheld until at least six months have elapsed. Should this rule not be observed and a paralyzed vocal cord spontaneously recover after the injection of Teflon, the voice would be rendered permanently disturbed instead of returning to its normal preparalytic state by virtue of the foreign material within the substance of the cord acting as a benign space-occupying lesion. There is a period of time, therefore, during which the patient with dysphonia from unilateral palsy of uncertain prognosis must endure his disability with no immediate