Vocal Cord Immobility Research Articles

P073: Bilateral Vocal Cord Immobility: Treatment Outcomes

P073: Bilateral Vocal Cord Immobility: Treatment Outcomes

Vocal cord fixation caused by an impacted fish bone in hypopharynx: report of a rare case

We report a rare case of vocal cord fixation caused by a fish bone in the hypopharynx. The patient was a 72-year-old woman. She presented with hoarseness that had appeared suddenly while eating baked fish. The diagnosis was suggested by a clinical history and confirmed by a computed tomography scan. The fish bone was removed via microlaryngoscopic operation under general anesthesia. The restoration of her vocal cord mobility required a few months. Vocal cord fixation is an extremely rare complication of a pharyngeal foreign body. In all of the few cases reported previously, the fixation was caused by mechanical obstruction of vocal cord movement or by recurrent nerve palsy secondary to inflammation. Our case is not typical of mechanical or inflammatory fixation. It is possible that the recurrent nerve was damaged directly by the fish bone.

Acromegaly presented as a cause of laryngeal dyspnea

Acromegalic patients can develop obstructive sleep apnea syndrome or upper airflow obstruction. The development of dyspnea is unusual and the fixation of both vocal cords is exceptional. We report the case of a patient with bilateral vocal cord paralysis. Fiberoptic laryngoscopy and computed tomography (CT) of the neck showed a supra-glottic stenosis due to a swelling of the soft tissue. A tracheostomy was first performed. Thereafter, micro-laryngoscopy using laser vaporisation of the supra-glottic soft tissue was attempted but failed to remove the tracheostomy canula. Finally, blood tests and cerebral MRI revealed an acromegaly. The patient underwent a trans-sphenoidal resection of the pituitary adenoma. Fifteen months later, fiberoptic laryngoscopy showed bilateral restoration of vocal cord mobility and the tracheostomy canula was successfully removed after 18 months. Vocal cord fixation is probably due to hypopharyngeal and laryngeal soft tissue swelling and can be reversible after successful treatment of the adenoma.

高圧酸素療法が有効であった放射線治療後の喉頭壊死例

Laryngeal necrosis is a rare complication of radiotherapy for early-staged laryngeal or hypopharyngeal cancer. However, when it occurs, there is no definitive treatment and laryngectomy is frequently required. Here we present a case of advanced laryngeal necrosis (grade 4, Chandler classification) treated with hyperbaric oxygen (HBO) therapy.A 60-year-old woman received radiotherapy with 64.8Gy for early-staged hypopharyngeal cancer in combination with three courses of cisplatin (40mg/body/week). She developed pharyngeal pain and progressive dyspnea because of laryngeal edema 3 months after the completion of radiotherapy, and received an emergent tracheostomy. In order to differentiate radiation injury from cancer recurrence, biopsies were obtained under direct laryngoscopy and showed intense necrosis without malignancy. Since laryngeal radionecrosis was presumed, the patient received HBO therapy at 2 atmospheres absolute (ATA) with 100% O2 for 2 hours per session. After 20 HBO treatments, laryngeal edema improved and her clinical symptoms including pharyngeal pain, swallowing pain and dysphagia, were ameliorated significantly. However, decannulation has not been achieved because of bilateral vocal cord fixation. We considered that HBO therapy was effective in the present case and that HBO therapy should be recommended as a therapeutic option whenever laryngeal necrosis occurs and there is a chance to save the larynx.

Changes in the Cricoarytenoid Joint Induced by Intubation in Neonates

To characterize the histopathologic characteristics of the cricoarytenoid joint (CAJ) as a means to understand the mechanisms of vocal cord fixation in children after prolonged intubation. Histologic analysis of laryngeal specimens obtained from infants who had died secondary to various causes and who had been intubated from 1 to 30 days. Histopathologic characteristics of CAJ. Laryngeal specimens from infants who had been intubated for prolonged periods of time demonstrated evidence of hemorrhage, infection, inflammation, and fibrosis within the CAJ. Furthermore, a statistical correlation was found between the length of intubation and the presence of these histologic abnormalities. To our knowledge, this is the first study to demonstrate histologic changes in the CAJ in laryngeal specimens of children who have been intubated for prolonged periods of time. Such histological changes in the CAJ could explain the mechanism of vocal cord immobility in children after intubation.

Vagal nerve stimulator implantation: An otolaryngologist’s perspective

This study was conducted to compare an otolaryngologist's experience with a cohort of epilepsy patients implanted with a vagal nerve stimulator (VNS) to previously published data. Demographics, preoperative seizure frequency, medications, and complications were retrospectively collected from patients implanted by the senior author. Postoperative medications and seizure frequency were obtained from referring neurologists. Seventeen patients were implanted over a 24-month period. Average age was 28.3 years. Patients presented with petit mal (n = 3), tonic-clonic (n = 6), complex partial (n = 5), and grand mal (n = 8) seizures. Mean follow-up postimplantation was 13.5 months. Most patients had at least a 50% reduction of seizure frequency, with 3 patients being seizure free. There were no postoperative infections. One patient had left vocal cord immobility. The most common side effect was voice disturbance during device activation. Otolaryngologists are well equipped to perform VNS implantation and to diagnose and treat possible laryngeal side effects. C-4.

Aggravation of Laryngeal Rheumatoid Arthritis After Use of a Laryngeal Mask Airway

We report a case of aggravation of laryngeal rheumatoid arthritis (RA) after the use of a laryngeal mask airway (LMA). The patient was a 55-year-old woman with severe RA who underwent wrist arthrodesis under general anesthesia using a size 3 LMA. A few days after the operation, she reported hoarseness. Inflammation of the arytenoid region and vocal cord immobility were observed by fiberoptic nasolaryngoscopy. Vocal function returned to normal by postoperative day 42 in response to prednisolone therapy. In this case, stridor was misdiagnosed preoperatively, and postoperative symptoms and local findings were probably caused by aggravation of laryngeal RA resulting from substantial compression of the arytenoid region by the LMA. For patients with RA referred for surgery, a careful search for cricoarytenoid arthritis is essential, particularly in those with laryngeal stridor, because it may be aggravated after general anesthesia.

Our results in surgical treatment of laryngotracheal stenosis, ten years experience

There are numerous techniques for the treatment of laryngotracheal stenosis. The aim of this paper was to present surgical techniques and results of treatment of laryngeal and laryngotracheal stenosis in a ten-year period by retrospective analysis. Medical records of 34 patients (17 male and 17 female) surgically treated for laryngeal or laryngotracheal stenosis between 1995 and 2004 were analyzed. 19 (55.9%) patients had previous surgical procedures, whereas fifteen patients (44.1%) were diagnosed and treated for the first time. 5 patients had a glottic-subglottic stenosis, 11 patients had a subglottic stenosis, 16 patients had subglottic-tracheal stenosis and 2 patients had a glottic-subglottic-tracheal stenosis. 21 patients had normal vocal cord motion, 8 patients showed unilateral vocal cord fixation, and 5 had bilateral vocal cord fixation. Laryngotracheoplasty with anterior-posterior costal cartilage graft was performed in 24 patients, while single stage segmental laryngotracheal resection of the stenotic part was performed in 8 patients. One patient was operated in direct laryngomicroscopy and one with dilatation of the stenotic segment with T tube insertion. The most common complication was the development of granulation due to use of the Montgomery T-tube which was removed in direct laryngomicroscopy. Except for one patient, 33 (97%) patients were decannulated. There was no perioperative mortality. Although laryngotracheoplasty with anterior-posterior costal cartilage graft placement cannot be used in all cases of laryngotracheal stenosis, it was the method of choice in previously operated patients with segmental resection of the stenotic segment. This method requires use of Montgomery T-tube or anesthesiological tube, which is very hard to keep clean. Better recovery, short hospitalization and excellent results were obtained with the cricotracheal segmental resection.

A 60-Year-Old Woman With History of Hoarseness and Dysphagia

A 60-Year-Old Woman With History of Hoarseness and Dysphagia

Benign parathyroid cyst causing vocal fold paralysis: A case report and review of the literature

Parathyroid cysts are uncommon, frequently asymptomatic lesions of the neck and superior mediastinum. Symptomatic parathyroid cysts are very rare, with roughly only 200 cases reported in the literature. Of these, only nine cases have been reported with recurrent laryngeal nerve (RLN) paralysis We report a case of a 49-year-old man initially seen with a 6-month history of worsening hoarseness. Physical examination revealed a palpable 3-cm, firm, smooth, nontender mass of the right thyroid lobe. Fiberoscopic laryngoscopy showed right vocal cord immobility consistent with RLN paralysis. After CT and fine-needle aspiration of the mass, the patient underwent a right thyroid lobectomy. During surgery, the recurrent laryngeal nerve was found to be stretched and adherent to a right inferior lobe mass. Histologic analysis of the surgical specimen revealed a benign parathyroid adenomatous cyst. Postoperatively, the patient's voice improved markedly. This case represents an extremely rare return of function of the RLN after cyst removal. Parathyroid cysts should be included in the differential diagnosis for vocal fold paralysis.

Surgical treatment for bilateral vocal cord fixation

In 1984, Ejnell et al, reported a simple method for laterofixation of the vocal cord to relieve dyspnea caused by bilateral vocal cord fixation. The merits of the method are as follows: 1) technical ease because of no need to access the arytenoid cartilage, 2) non-destructive surgical procedure and 3) no need for tracheostomy. There are several demerits: 1) difficulty to determine the points for in-serting needles on thyroid cartilage, 2) need for two surgeons, and 3) necessity of insertion of direct laryngoscope. The cause of the difficulty of determining the insertion points is that there have been no report on surgical landmarks on thyroid cartilage. In this paper, we report a surgical technique in detail.

Swallowing in Patients with a Tracheotomy: Does Vocal Cord Immobility Make a Difference?

Swallowing in Patients with a Tracheotomy: Does Vocal Cord Immobility Make a Difference?

Predictors of Thyroid Gland Invasion in Glottic Squamous Cell Carcinoma

This study examines preoperative clinical and intraoperative histopathologic characteristics that can be used to predict thyroid gland invasion in the setting of squamous cell carcinoma (SCC) of the glottis. The study was retrospectively performed using 30 serially sectioned whole-organ total laryngectomy with thyroidectomy specimens with associated preoperative clinical data. Histopathologic and clinical variables including true vocal cord (TVC) fixation, cricoarytenoid joint invasion, subglottic extension (SGE) of tumor, patterns of laryngeal spread, and prior radiation were examined as univariate and multivariate correlates of thyroid gland invasion. Twenty-three percent of thyroid gland specimens demonstrated SCC invasion. Five were T4 stage, two were T3 stage, and all demonstrated direct extension to the thyroid gland. Of these, all had a fixed ipsilateral TVC (P = .003) and SGE of tumor greater than 15 mm (P = .003). Using multivariate analysis, SGE of tumor and TVC fixation contribute independently as correlates of thyroid gland invasion. Prior radiation of the larynx did not correlate with thyroid gland invasion and did not significantly influence the predictive capacity of these variables. Tumors invading the thyroid gland also invaded the cricothyroid membrane (100%), anterior commissure (100%), laryngeal ventricle (100%), and thyroid cartilage (86%). Preoperative assessment of TVC mobility and extent of SGE are significant correlates of thyroid gland invasion by SCC of the glottis. Distinct patterns of laryngeal spread are associated with thyroid gland invasion. Prophylactic hemithyroidectomy with isthmusectomy is indicated for glottic SCC in the preoperative setting of a fixed TVC and SGE greater than 15 mm. Additional study correlating patterns of laryngeal spread with thyroid gland invasion will add to these data in determining when to selectively perform thyroidectomy in this setting.

Extending the Inferior Limits of Supracricoid Partial Laryngectomy: A Clinicopathological Correlation

The study examined preoperative clinical characteristics that can be used to predict secure inferior margins of glottic squamous cell carcinoma extending toward the cricoid cartilage when performing organ preservation surgery of the larynx. The study was retrospectively performed using 31 serially sectioned whole-organ total laryngectomy specimens with associated preoperative clinical data. Histopathologic and clinical variables including true vocal cord (TVC) fixation, cricoarytenoid joint invasion, subglottic extension (SGE) of tumor, and prior radiation were examined as independent and multivariate correlates of cricoid cartilage invasion. All tumors with subglottic extension of 15 mm or less and without arytenoid fixation were free of cricoid invasion. Of tumors invading cricoid with subglottic extension of 15 mm or less, all had a fixed arytenoid cartilage and local cricoid invasion type only. Correcting for subglottic extension using multivariate analysis, cricoarytenoid joint invasion and fixed true vocal cord independently predicted cricoid invasion. However, in a multivariate model together, true vocal cord mobility adds no predictive power to cricoarytenoid joint invasion. Prior radiation of the larynx did not significantly change the predictive capacity of these variables. Preoperative assessment of arytenoid mobility and extent of subglottic extension are reliable predictors of cricoid invasion by glottic squamous cell carcinoma. Organ preservation surgery is oncologically safe in the setting of glottic squamous cell carcinoma with subglottic extension of 15 mm or less and without arytenoid fixation.

Neurinoma laríngeo: a propósito de un caso

Neuromas or Schwannomas are extremely rare among tumors of the larynx. They are Shwann cell tumors that can be difficult to distinguish from neurofibromas. They present usually as supraglottic masses, since they may arise from the internal branch of the superior laryngeal nerve. Nuclear magnetic resonance imaging is the best diagnostic technique, conferring a high degree of suspicion. We present an exceptional case of a laryngeal neuroma, with a very long evolution, a large tumor volume, dyspnea and vocal cord fixation, with complete resolution through an external approach following surgical removal. The difficulties encountered with its pathological and clinical diagnosis are discussed as well as a review of the literature

T3 Supraglottic Cancer: Treatment Results and Prognostic Factors

Objective—A retrospective study was performed in order to analyze the treatment results and prognostic factors in patients with T3 supraglottic carcinoma and to differentiate between the treatment results obtained for T3 transglottic carcinoma and T3 pure supraglottic carcinoma.Material and Methods—Thirty-two patients who underwent surgery with or without postoperative radiation therapy between 1990 and 2000 were studied. Neck dissection was performed in 27 patients and 24 received postoperative radiation therapy.Results—The 3-year overall survival rate was 81.7%. The 3-year overall survival rates for T3 pure supraglottic carcinoma and T3 transglottic carcinoma were 91.7% and 73.2%, respectively (p<0.05). Univariate analysis revealed a prognostic significance for vocal cord fixation. T3 transglottic carcinoma was significantly correlated with vocal cord fixation.Conclusions—We suggest that surgery, either alone or in combination with postoperative radiation therapy, provides acceptable cancer control and survival rates for patients with T3 supraglottic carcinoma. Vocal cord fixation detected during preoperative fiberoptic laryngoscopy is a significant prognostic factor. T3 transglottic cancer needs more aggressive management.

Management of bilateral arytenoid cartilage fixation versus recurrent laryngeal nerve paralysis.

Bilateral arytenoid cartilage fixation (ACF) closely resembles vocal cord immobility due to recurrent laryngeal nerve paralysis (RLNP). This study sought to determine the etiologic differences between these two entities and to derive conclusions about treatment. The charts of 218 consecutive adult patients with immobility of both vocal cords requiring surgery for airway restoration were reviewed. The results of laryngeal electromyography and laryngotracheoscopy were used to distinguish ACF from RLNP. In 186 patients (85.3%), RLNP was identified. Of these, 154 paralyses (82.8%) were caused by surgical interventions, 5 (2.7%) were caused by previous intubation, 16 (8.6%) were caused by various malignancies, and 7 (3.8%) were neurogenic. In 4 patients (2.2%), the cause remained unclear. We identified ACF in 32 patients. The etiologic factors included previous long-term intubation in 22 patients (68.8%), short-term intubation in 3 patients (9.4%), Wegener's granulomatosis in 3 patients (9.4%), rheumatoid arthritis in 2 patients (6.3%), previous laryngeal surgery in 1 patient (3.1%), and caustic ingestion in 1 patient (3.1%). Additional second-site airway stenosis was found in 10 of the RLNP patients (5.4%) and in 15 of the ACF patients (46.9%). All RLNP patients had endoscopic surgery without temporary tracheotomy. Eighteen ACF patients required open surgery, and 4 were managed endoscopically but required temporary tracheotomy. The etiologic factors were significantly different for the two entities under study. Additional sites of stenosis were more frequent in ACF patients. Stenosis due to RLNP could be managed endoscopically without preliminary tracheotomy, while ACF frequently required open surgery and temporary tracheotomy.

Voice characteristics of patients with glottic carcinoma analyzed using 'RBH' and 'GIRBAS' scales

Subjective voice analysis represents a diagnostic tool in phoniatry and is a part of everyday practice if a phoniatrist has a "trained ear". This clinical prospective study included a sample of 20 male patients with malignant tumors involving one vocal cord-right or left. All patients underwent otorhinolaryngological and phoniatric examinations. Subjective acoustic analysis was done when patients pronounced numbers from 1 to 10. Afterwards, voice quality was evaluated separately by two professionals using a 4-levels scale: RBH scale (roughness-breathiness-hoarseness) and GIRBAS scale (grade-instability-roughness-breathiness-asthenia-strain). 60% of patients presented with vocal cord immobility. Subjective acoustic analysis revealed hoarseness in 100% of patients (the most frequent value was Mod = 3 intense hoarseness in 45% patients). Instability existed in 100% of patient (40% moderate, 40% intense). Strained voice existed in 100%, most frequently intense (45%). All patients with glottic carcinoma presented with hoarseness, strain and instability of phonation. Non vibration of vocal cord significantly affects the degree of dysphonia, roughness, strain and instability. Aerodycnamic changes affect voice hoarseness. RBH scale is simple, but GIRBAS scale described more psyhoacoustic phenomena most important in patients with glottic carcinoma.

Vías de diseminación del cáncer de comisura anterior: estudio clínico-patológico e implicaciones quirúrgicas

The aim of the present study is to describe the spread c h a nnels of the anterior commisure cancer, its clinical significance and its surgical implications. Patients and methodsa prospective study was performed at the ENT Department of the Complutense University in about 31 patients with anterior commisure carcinoma wo underwent surgery between 1994/97. Specimens were processed with Whole-Organ Serial Sections. ResultsPatients were differenciated into two groups: 1) Patients with glottic tumors, with a good cord mobility and no invasive tumor in commisure region (18 patients); In these patients, conservative surgery was possible; 2) Another group (13 patients) with agressive lesions (80% with cartilage involvement), vocal cord fixation and transglottic lesions. In these group, conservative surgery was contraindicated. ConclusionsThis report emphasizes the importance of laryngoscopy in surgical technique of anterior commisure c a n c e r.

気管内挿管が原因と思われた披裂軟骨脱臼例

We report a case of arytenoid dislocation, which may have been caused by endotracheal intubation.A 44-year-old man underwent surgery for middle ear cholesteatoma under general anesthesia with endotracheal intubation. The intubation was performed with no difficulty, but at the end of the operation the patient moved strongly before extubation. Postoperatively, he presented hoarseness. Fiberscopic study revealed immobility of the right vocal cord but normal mobility of right arytenoid cartilage, suggesting that the right crico-arytenoid joint may have been dislocated. After two weeks, there was no improvement, and we performed closed reduction. Immediately after fixation with laryngomicrosurgery, there was neither improvement of voice nor mobility of right vocal cord. After he started voice therapy, his voice began to improve, three weeks after the last surgery. Four weeks later, fiberscopic examination showed almost normal mobility of the right vocal cord.From the literature review, we concluded that closed reductions should be performed as soon as possible after such an incident.