Vagal Paralysis Research Articles

Palatal adhesion: the treatment of unilateral palatal paralysis after high vagus nerve injury.

Resection of skull base tumors commonly necessitates intraoperative sacrifice of lower cranial nerves at the level of the jugular foramen. Sequelae of unilateral vagus nerve loss include ipsilateral laryngeal paralysis, ipsilateral palatal and pharyngeal paralysis, and velopharyngeal incompetence (VPI) marked by hypernasal speech and nasopharyngeal reflux of liquids during swallowing. Palatal adhesion (PA), a procedure whereby the unilaterally paralyzed palate is attached to the posterior pharyngeal wall, decreases the size of the velopharyngeal port and minimizes the symptoms. This study assessed the outcome of PA in 31 patients with VPI secondary to proximal vagus nerve injury. PA decreased postoperative nasality in 96% of patients. Nasopharyngeal reflux was significantly improved in 83%. Three patients (11%) had minor wound breakdown postoperatively, all of which healed completely with conservative management. PA offers a favorable result with minimal concomitant morbidity and is recommended for patients with VPI secondary to unilateral proximal vagus nerve paralysis.

Radiation-related cranial nerve palsy in patients with nasopharyngeal carcinoma.

Cranial nerve palsy is a rare complication after patients with nasopharyngeal carcinoma (NPC) receive radiotherapy using a technique that delivers 180-200 centigrays (cGy) per day. Cranial neuropathy is of particular clinical interest in terms of making a differential diagnosis, because it is also a common presenting manifestation in patients with NPC. Cranial neuropathy may lead to distressing signs and symptoms in these patients, and their treatment has not been addressed in previous reports. This article presents the authors' experience with radiotherapy-related cranial nerve palsy in patients with NPC. Nineteen patients were diagnosed with radiation-related neuropathy. Patients with recurrent tumors or with a suspicion of persistent or recurrent tumors were excluded. Most patients were treated using 180 cGy or 200 cGy per fraction per day. The total dose was 7000-13,000 cGy to the nasopharynx and 5000-9000 cGy to the neck. Unilateral vocal cord paralysis alone and hearing loss were not included in the analysis. There were 15 male patients and 4 female patients. The latency before palsy occurred was 12-240 months. Single nerve palsy developed in four patients, including two patients with hypoglossal palsy and two patients with recurrent laryngeal palsy. Two patients had three nerve palsies each. The other 13 patients presented with 2 nerve palsies each. Vagus and hypoglossal palsy appeared to be a frequent combination and occurred in 11 patients. Overall, there were 17 patients with hypoglossal palsy (7 bilateral, 8 left-sided, and 2 right-sided), 11 patients with vagus palsy (2 bilateral, 7 left-sided, and 2 right-sided), 6 patients with recurrent laryngeal nerve palsy (5 bilateral), and 2 patients with accessory palsies (all bilateral). Marked neck fibrosis was present in 12 patients. Patients who had vocal cord paralysis suffered from easy choking and hoarseness. Severe respiratory difficulty occurred in two patients who had bilateral vocal cord palsy. Surgical procedures included laryngoplasty, tracheostomy, and gastrostomy. Quality of life improved considerably after patients underwent surgery. Radiotherapy-related cranial nerve palsy may occur in patients with NPC after they receive conventional radiotherapy. Hypoglossal nerve palsy was found the most frequently in this series, followed by vagus nerve palsy and recurrent laryngeal nerve palsy. Neck fibrosis and the course of the three nerves through the neck may be important risk factors for the development of palsy. The diagnosis must be made only after the possibilities of tumor-induced palsy and idiopathic palsy are excluded. Surgery is helpful in improving the quality of life in many patients.

Cervical paragangliomas: diagnosis, management and complications.

Sixteen patients were diagnosed as suffering from cervical paragangliomas. Eleven patients (68.75 per cent) had twelve carotid paragangliomas (CPs), and five patients (31.25 per cent) had six vagal paragangliomas (VP). One CP (8.33 per cent) originated from paraganglia around the common carotid artery (CCA). Three cases of multiple paragangliomas are presented (18.75 per cent). In 80 per cent (4/5) of VP patients there was widening of the carotid bifurcation similar to that seen with CP. This widening occurred whenever the VP was large enough to grown in between the external carotid artery and internal carotid artery (ECA and ICA). Large VPs may displace the vessels either anterolaterally or anteromedially. Knowledge of the direction of the carotid displacement is essential to avoid intra-operative vascular injuries. Colour flow doppler ultrasound (CFD-US) was found to be a good non-invasive method for diagnosis of vascular neck swellings. It enabled the diagnosis of CP with 100 per cent accuracy, but it was not sufficient for diagnosis of high VP. A transcervical approach, cutting the digastric muscle and the styloid process with the attached ligaments and muscles, was sufficient for excision of most VP. However, midline mandibulotomy might be necessary with high VP. Vascular injuries occurred in 12.5 per cent (2/16) of patients. Superior laryngeal nerve and hypoglossal nerve paralysis occurred, respectively, in (2/11) and (1/11) of patients with CP. Vagal paralysis occurred in all patients with VP. Cerebrovascular accident and post-operative death occurred in one patient (6.26 per cent).

Early arytenoid adduction for vagal paralysis after skull base surgery.

To evaluate the efficacy of early arytenoid adduction in the management of vagal paralysis after skull base surgery. Retrospective evaluation at a tertiary care skull base center. Aggressive surgical management of skull base lesions has become increasingly popular owing to advances in surgical technique and intraoperative monitoring. Temporary and permanent lower cranial neuropathies occur frequently, especially after the surgical management of lesions involving the vertebrobasilar system and the jugular foramen. An injury to the proximal vagus nerve is usually associated with dysphonia and swallowing dysfunction. An early arytenoid adduction has been employed in 26 patients with a vagal paralysis after skull base surgery. Most commonly, the neurosurgical patient underwent an arytenoid adduction under general anesthesia on postoperative day 2. Videostroboscopy after arytenoid adduction demonstrated 76% of patients had complete glottic closure. Of those with inadequate glottic closure, all demonstrated a well-medialized posterior glottis with a persistent anterior glottal gap. These patients were easily treated with a secondary type I thyroplasty under local anesthesia with sedation resulting in complete glottic closure. Despite excellent voice outcomes, 66% of these patients had dysphagia requiring enteral feedings for nutritional support. An early arytenoid adduction is an excellent medialization technique that can be performed safely in the early postoperative period under general anesthesia after skull base surgery.

披裂軟骨内転術の成績

Arytenoid adduction surgery was performed on 27 patients with unilateral recurrent laryngeal or vagus nerve palsy, and the results were evaluated. The AC/DC ratio and mean airflow rate were significantly improved (p<0.01) and the improvements persisted for a long follow-up period postoperatively in the majority of patients. The results of phonatory function showed no difference between cases with or without type I thyroplasty or intracordal injection, although there was considerable variability in the AC/DC ratio after surgery. Differences in the level and thickness ratio between the vocal folds were significantly corrected on laryngeal tomography (p<0.01). In patients with combined vagal and hypoglossal nerve palsy, swallowing disturbance is a serious problem. Arytenoid adduction surgery decreased misswallowing and improved the ability to expel an aspirated bolus or sputum in the trachea. Oral feeding became possible in four patients out of seven. These improvements were primarily attributed to increased infraglottic pressure.

Mechanism of glottic closure in a model of unilateral vocal fold palsy.

The effect of extrinsic laryngeal muscles on the position of the paralyzed vocal fold (VF) was analyzed in 13 adult human larynges. Fresh specimens were suspended within a specially constructed frame designed to reproduce the three-dimensional position of the VF, and to allow for simulation of laryngeal muscle action, in five successive experiments resembling: 1) complete vagal paralysis and contralateral adduction, 2) laryngeal elevation added, 3) vocal fold stretching added, 4) contralateral laryngeal tilting added, and 5) ipsilateral cricothyroid muscle activation added. We observed an incremental narrowing of the middle and posterior glottic gaps from 3.9 mm and 6.8 mm respectively in experiment 1 to 1.1 mm and 1.9 mm in experiment 5. Glottic closure in the final experiment was associated with rotation of the glottis to the "paralyzed" side in the axial plane, and contralateral laryngeal tilting in the coronal plane. We show that extrinsic laryngeal muscles can help to close a paralytic gap; crossing of the contralateral VF past the midline was not observed in any of the experiments.

The blood supply of vagus nerve in the human: its implication in carotid endarterectomy, thyroidectomy and carotid arch aneurectomy

The human vagus nerve is supplied by a distinct vagal artery and vein. The artery, which lies on the anterior aspect of the nerve, is reinforced by many small arterioles along its course. These small vessels often lie in the surgical fields in carotid endarterectomy, thyroidectomy and aortic arch aneurectomy. Damage to these vessels may damage the vagus nerve and account for inexplicable cases of vagal palsy following the above surgical procedures.

輪状咽頭筋切断術例の筋組織所見と嚥下病態

Cricopharyngeus muscle specimens obtained during bilateral lateral cricopharyngeal myotomy were examined histopathologically. Ten cases of dysphagic patients with neuro-muscular diseases were subjected to this study. The results were summarized as follows; 1. In three cases, myogenic atrophy was found unilaterally. The histopathological feature was scattered muscular atrophy with slight fibrosis in these cases. 2. Four cases with unilateral nuclear and/or infranuclear vagal paralysis showed a group muscular atrophy and degeneration of muscle fibers ipsilaterally. 3. Four cases clinically presented with a failure of appropriate relaxation of the esophageal inlet. Two of them showed neurogenic muscular atrophy whereas the other two did not show such a histopathological feature. 4. In two cases of Wallenberg's syndrome neurogenic muscular atrophy was found in the cricopharyngeus and thyropharyngeus muscles. 5. There was no positive histopathological findings in the cricopharyngeus muscle of a case with cricopharyngeal dysphagia.

Videostroboscopy of human vocal fold paralysis.

Previous stroboscopic studies of human vocal cord paralysis have been infrequent and have lacked documentation of the site of lesion. In order to study human laryngeal paralysis, the recurrent and superior laryngeal nerves were infiltrated unilaterally with lidocaine hydrochloride in three human volunteers. Vagal paralysis was simulated by combined (superior and recurrent) infiltration in one volunteer. Additionally, 20 patients with untreated laryngeal paralysis were studied from the voice laboratory at UCLA. In addition to videostroboscopic analysis, photoglottography and electroglottography were performed and synchronized with the stroboscopic images. The most significant finding in stroboscopy of the paralyzed larynx was the asymmetry of traveling wave motion. The traveling wave on the normal vocal fold had a faster wave velocity that created a phase difference in the vibration of the two folds. The wave also traversed a greater distance along the vocal fold mucosa on the normal side. No patient or volunteer with untreated laryngeal paralysis had a symmetric traveling wave, either in superior or recurrent laryngeal nerve paralysis. Synchronization with glottography indicated that the differentiated electroglottographic waveform provides useful information about the timing of glottic opening and closure in states of asymmetric laryngeal vibration. Implications for future studies and for the diagnosis of laryngeal paralysis are discussed.

Impending vagus nerve paralysis accelerated to full manifestation following cervical intrathecal neurolysis--case report.

Impending vagus nerve paralysis accelerated to full manifestation following cervical intrathecal neurolysis--case report.

Glomus Vagale Tumors

Eighteen patients with glomus vagale tumors treated by surgical resection are reviewed. Computed tomography and magnetic resonance imaging are diagnostic. Arteriography is used to determine multicentric tumors. The incidence of multicentric tumors in this series was 40%. Adequate surgical exposure is necessary for removal of the tumor without injury to the carotid artery. Vagal paralysis was present in all cases postoperatively and resulted in dysphagia and aspiration. Cricopharyngeal myotomy and Teflon injection aided in rehabilitation of deglutition. Curability with surgery is high, but radiation therapy is recommended in selected patients.

Isolated vagus nerve palsy and vagal mononeuritis.

It is useful to consider vagus nerve palsy as a form of cranial mononeuritis. In contrast with other forms of mononeuritis, the clinicoanatomical features and other aspects of vagal mononeuritis are not well defined. A series of 25 patients with isolated vagal mononeuritis were assessed by clinical and laryngoscopic examination, and laryngeal electromyography was done in all cases. Unilateral recurrent laryngeal nerve palsy was almost twice as common as unilateral superior and recurrent laryngeal nerve palsy and it appeared to have a better prognosis. The majority were on an idiopathic basis, and associated diabetes in two patients raised the possibility of diabetic mononeuritis. Three patients had bilateral palsies; bilateral vagal mononeuritis may represent a separate entity in that it occurs in younger subjects and is associated with upper respiratory tract illness. Partial or complete recovery occurred in about half of the patients.

FUNCTIONAL DISORDERS OF THE PHARYNGO-ESOPHAGEAL JUNCTION: Achalasia and Chalasia

The anatomic, physiologic, and roentgenographic evidence for the presence of a sphincter at the pharyngo-esophageal junction is indisputable. The anatomic group of muscle fibers designed as the cricopharyngeus is probably responsible for a large portion of the sphincteric function, although manometric studies and some anatomic investigations suggest that some of the circular muscle fibers of the upper esophagus may participate in the sphincter mechanism.12 In view of this it is not surprising that the sphincter of the upper esophagus is subject to functional disorders that are similar to those that have been described for the lower esophageal sphincter---namely, achalasia and chalasia. SUMMARY The roentgen aspects of the normal and abnormal behavior of the cricopharyngeal sphincter have been presented, and two specific entities, chalasia and achalasia, have been described. Chalasia, characterized by absence of the normal high resting pressure of the cricopharyngeus, is found only in one disease, myotonic dystrophy, and thus may be a valuable diagnostic sign. Achalasia, failure of inhibition of the normal high resting pressure of the cricopharyngeus during deglutition, may result from any lesion that interferes with the coordinated neuromuscular chain of events that is responsible for normal deglutition. Primary muscle disease, vagal paralysis, and extensive head and neck surgery are among the more common causes. Cricopharyngeal myotomy may be palliative. Cricopharyngeal achalasia may be an important etiologic factor in the pathogenesis of posterior pharyngeal diverticula of the Zenker type.

Electromyographical Studies on the Influence of Autonomic Nervous System on Motility of the Esophagus

The autonomic controls of motility of the esophagus were studied electromyographically. In men and rabbits, the electromyograms of the upper, middle and lower parts of the esophagus were recorded simultaneously by means of bipolar leads with 3 pairs of loop electrodes consisted of circular silber wires attached to a rubber tube.1. Normal patterns of the electromyograms of the esophagus were explained in men and rabbits. Namely, (1) the burst of spike potentials propagated from the upper part to the lower part of the esophagus after a swallow, (2) the rhythmic bursts of spike potentials in the lower part of the esophagus during resting state in rabbits, (3) the burst of spike potentials induced by syringing fluids (5ml) into the esophagus and (4) the burst of spike potentials induced by insufflation of air (10ml) into the esophagus were observed.2. On the experiments of rabbits, the rhythmic bursts of spike potentials in the lower part of the esophagus were increased by the electrical stimulation of the n. vagus and by the administrations of pilocarpin and imidalin, whereas the bursts were decreased by the electrical stimulation of the cervical sympathicus and the administrations of atropine and adrenalin. On the experiments of healthy adults, the spike discharges of the esophagus did not show any marked changes.3. The electromyographic examinations of clinical cases such as a patient after exstripation of the cervical part of the esophagus, a patient with vagus palsy, a patient with cicatricial stenosis of the esophagus and a achalasia patient were performed. In a achalasia patient, after the administration of of mecholyl the appearance of multiple sporadic spike discharges in the middle and lower parts of the esophagus were observed.

Atrophy of laryngeal muscles in vagal paralysis.

The LaryngoscopeVolume 76, Issue 11 p. 1753-1765 Article Atrophy of laryngeal muscles in vagal paralysis.†‡ John A. Kirchner M.D., John A. Kirchner M.D. New Haven, Conn.Search for more papers by this author John A. Kirchner M.D., John A. Kirchner M.D. New Haven, Conn.Search for more papers by this author First published: November 1966 https://doi.org/10.1288/00005537-196611000-00001Citations: 27 † From the Otolaryngology Section, Department of Surgery, Yale University School of Medicine. ‡ Supported by USPHS Grant 5 R01-NB 05465-02 and American Cancer Society Grant T-------267. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume76, Issue11November 1966Pages 1753-1765 RelatedInformation

Digitalis poisoning and its treatment (concluded).

Because digitalis preparations, acetylcholine or vagal stimulation may cause identical electrocardiographic changes in normal persons,113 early efforts were directed toward vagal paralysis with atropine. In fact, some experimental data purported to show that atropine might aid in modifying the myocardial lesions produced by digitalis.69 Clinical results were conflicting. Resnik observed a reversion to regular sinus rhythm from digitalis-induced auricular fibrillation within sixty-eight minutes after a hypodermic injection of 2 mg. of atropine75; Gold and Otto described similar success in interrupting 5 cases of digitalis bigeminy.43 On the other hand, Robinson and Wilson could not modify the toxic effects of . . .

The effect of a single inspiration in lead III and a precordial lead of the human electrocardiogram.

Article1 March 1951THE EFFECT OF A SINGLE INSPIRATION IN LEAD III AND A PRECORDIAL LEAD OF THE HUMAN ELECTROCARDIOGRAMGEORGE L. NORRIS, M.D., EDWARD MASSIE, M.D., F.A.C.P.GEORGE L. NORRIS, M.D.Search for more papers by this author, EDWARD MASSIE, M.D., F.A.C.P.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-34-3-641 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptINTRODUCTIONThat respiration changes the contour of the electrocardiogram has been known since Einthoven, Rotherberger, and Winterberg1studied the shifting electrical axis of the heart and found that sympathetic stimulation or vagal paralysis produced changes similar to those at first thought due solely to the mechanical effects of movement of the diaphragm. Wilson2, 3in 1915 reported three cases in which respiration was associated with auriculoventricular dissociation, and one instance in which a partially inverted T3became upright and exaggerated. The same changes were brought about by pressure over the right vagus, and were eliminated by atropine. He emphasized that...Bibliography1. EinthovenRotherbergerWinterberg ; quoted by Woodruff, L. W.: A clinical study of respiratory variations in the form of the electrocardiogram, Am. Heart J. 8: 412, 1933. CrossrefGoogle Scholar2. Wilson FN: A case in which the vagus influenced the form of the ventricular complex of the electrocardiogram, Arch. Int. Med. 16: 1008, 1915. CrossrefGoogle Scholar3. Wilson FN: Three cases showing changes in the location of the cardiac pacemaker associated with respiration, Arch. Int Med. 16: 86, 1915. CrossrefGoogle Scholar4. CohnRaisbeck AEMJ: An investigation of the relation of the position of the heart to the electrocardiogram, Heart 9: 311, 1922. 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Woodruff LW: A clinical study of respiratory variations in the form of the electrocardiogram, Am. Heart J. 8: 412, 1933. CrossrefGoogle Scholar19. White PD: Heart disease, ed. 3, 1945, The Macmillan Co., New York, pp. 7, 8. Google Scholar20. Scherf D: Alterations in the form of the T waves with changes in the heart rate, Am. Heart J. 28: 333, 1944. CrossrefGoogle Scholar21. LausonBloomfieldCournand HDRAA: The influence of the respiration on the circulation in man, Am. J. Med. 1: 4, 1946. CrossrefGoogle Scholar22. MillerDent JRRF: A new hypothesis of the production of the T wave in the electrocardiogram based on electrokinetic phenomena, J. Lab. and Clin. Med. 28: 168, 1942. Google Scholar23. BestTaylor CHNB: The physiological basis of medical practice, ed. 3, 1943, Williams and Wilkins, Baltimore, pp. 350, 468, 570. Google Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: *Received for publication March 22, 1949.From the Department of Internal Medicine, Washington University School of Medicine, and the Heart Station, Barnes Hospital, St. Louis, Missouri. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byInverted T waves in the precordial electrocardiogram of normal adolescents 1 March 1951Volume 34, Issue 3Page: 641-654KeywordsAtropineElectrocardiographyHeartHospital medicineParalysisRespirationTriiodothyronine ePublished: 1 December 2008 Issue Published: 1 March 1951 PDF downloadLoading ...

REGENERATION OF THE PERIPHERAL VAGUS

1. Recovery of the cardiac fibres of the vagus has been obtained in 12 rabbits, 5 cats, and 1 dog, the vagus nerve having been cut or crushed in the mid‐cervical region.2. In the rabbit, regeneration occurs 3 to 4 months after crushing, and between 1 year 2 months and 2 years 8 months after cutting.3. In the cat, regeneration of the autonomic efferent fibres was obtained 7 months after crushing, and in just over a year (374 days) when the nerve had been cut.4. Regeneration of cardiac vagus fibres was found to have occurred in a dog 10½ years after the right vago‐sympathetic had been cut high in the neck.5. In the same dog, periodic attacks of sickness and a fatal termination, probably due to a relative vagal paralysis, indicated that the cesophageal and gastric vagal fibres had not perfectly regenerated after ten years.6. In the majority of cases, both in cats and rabbits, stimulation below the neuroma gave a more marked inhibition of the heart and consequent fall in blood‐pressure than stimulation above.7. Independent results on heart as regards rate and force on stimulating the peripheral regenerating vagus were observed in a few animals.8. In one cat (No. 4) the peripheral regenerating vagus stimulated central to the neuroma gave a negative result, although stimulation peripherally to the neuroma produced marked inhibition. This apparent instance of peripheral regeneration is discussed in the text and a possible explanation offered.9. In one cat in which no functional regeneration of the central vagus or depressor was observed, but regeneration of at least certain branches of the cervical sympathetic, the thyroid on the operated side was atrophied as compared with the normal side.10. The eye and ear results of sympathetic paralysis disappeared in rabbits during the first few months; in cats during the third year; in one dog, eye and ear differences, lacrimation, and occasional salivation were still noticeable after ten years.11. Regeneration of the recurrent laryngeal fibres of the vagus (rabbits and cats), and functional recovery of the respiratory movements of the paralysed cord, were obtained and confirmed histologically.The expense of this research has been partly defrayed by grants from the Earl of Moray Fund and the Medical Research Council.