全喉切除术后食管语康复实践

目的总结喉全切除术食管发声训练和效果。方法对我院自1998年6月～2003年6月的59例喉癌、下咽癌全喉切除术后患者,进行食管发声康复训练。结果53例(89.8%)获得不同程度的发声功能,46例无喉者的言语水平接近正常喉言语水平,他们的最大发音时程较长、听距较远,言语可懂度高,较流利;7例发音效果差,但言语可懂度仍高;不能发声者仅6例。结论与其它发声重建相比,食管发声能很快学会发基本音,并具有发声成功率高、发声质量良好等优点。     

Strategies for the prevention of microbial biofilm formation on silicone rubber voice prostheses

Total laryngectomy, a surgical treatment for extensive cancer of larynx, which alters swallowing and respiration in patients, is followed up with a surgical voice restoration procedure comprising tracheoesophageal puncture techniques with insertion of a "voice prosthesis" to improve successful voice rehabilitation. However, microbial colonization is a major drawback of these devices. Antimicrobials are usually used to prevent the colonization of silicone rubber voice prostheses by microorganisms. However, long-term medication induces the development of resistant strains with all associated risks and the development of alternative prophylactic and therapeutic agents, including probiotics and biosurfactants, have been suggested. The inhibition of microbial growth on surfaces can also be achieved by several other techniques involving the modification of physicochemical properties of the biomaterial surface or the covalently binding of antimicrobial agents to the biomaterial surface. An overview of the different approaches investigated to date and future perspectives to reduce the frequent replacements of voice prostheses in laryngectomized patients through microbial biofilm retardation is presented and discussed.     

Biofilm formation and design features of indwelling silicone rubber tracheoesophageal voice prostheses--an electron microscopical study

After total laryngectomy, voice can be restored with a silicone rubber tracheoesophageal voice prosthesis. However, biofilm formation and subsequent deterioration of the silicone material of the prosthesis will limit device life by impairing valve function. To simulate the natural process of biofilm development under dynamic nutrient conditions, a modified Robbins device was used to evaluate the biofilm-related valve dysfunction of the Groningen, Provox2, Blom-Singer indwelling, and VoiceMaster voice prostheses. Obstruction of the semicircular slit-valved Groningen prosthesis leading to increased airway resistance was caused not only by a buildup of deposits on the esophageal flange and valve hat, but also by accumulation of deposits on the semicircular valve seating. The hinged flap valved Provox2 and indwelling Blom-Singer prostheses failed to close sufficiently because of biofilm formation on the valve seating. The esophageal flange of the VoiceMaster prosthesis was affected, but the tripod structure of the ball valve was fully colonized up to the titanium sleeve, which interfered with proper valve opening and closure. These findings on biofilm formation could be used for the further development and modification of critical design features of voice prostheses to facilitate tracheoesophageal speech.     

A study of sounds produced by Algerian esophageal speakers

Background

Total Laryngectomy is a mode of treatment of patients with advanced laryngeal cancer. It affects the voice and the speech communication.

Objective

To present an acoustic analysis of the new voice after total laryngectomy in Algerian hospital environment.

Methods

A corpus of sounds was collected from October 2008 to September 2009 and pronounced by eight male speakers who have undergone total laryngectomy. Minimum age of patients was 47 years and maximum age was 59 years with mean age 54.87 years. Recordings were made before the beginning of reeducation and after three, six, and eleven months using esophageal voice. The acoustic analysis includes the Pitch F₀ (Hz), Formants, intensity, Jitter (%), Shimmer (dB), harmonic to noise ratio HNR (dB), and degree of unvoiced frames DUF (%).

Results

We note a restriction in F₀, increasing of Jitter and Shimmer, decreasing of HNR values, and reduced intensity compared to the voice of normal laryngeal speakers. In addition, we note a higher percentage of DUF during the pronunciation of sustained vowels.

Conclusion

Some deficiencies were reported in the taking care of patients. Therefore, the acoustic analysis may be used in evaluating the reliability of the technique of reeducation.     

全喉切除后 I期粘膜瓣法气管食管发音重建术失败原因分析

目的:探讨全喉切除后 I期粘膜瓣法气管食管发音重建术的失败原因,进一步完善手术操作及适应证选择方法.方法:对1991年1月至2010年6月行全喉切除后 I期粘膜瓣法气管食管发音重建术失败的9例患者的临床资料进行回顾性分析,特别是对其年龄、有无基础疾病、病变大小、手术方式、术后并发症的情况、术后放疗的剂量、术后心理因素以及术后有无进行发音康复训练等方面进行详细分析.结果:9例发音失败者中,2例不明原因瘘口闭锁,1例术后感染导致瘘口闭锁,1例术后感染导致气管食管瘘,1例年老体弱肺活量低,2例下咽组织切除较多、术后放疗剂量超过50GY,2例术后语言康复信心不足且未做规范的发音训练.结论:掌握好手术适应证和技巧,术后避免感染,重视术后个体化的综合治疗和规范的发音训练,可提高全喉切除后 I期粘膜瓣法气管食管发音重建术治疗中晚期喉癌的疗效.     

Isolated word recognition of silent speech using magnetic implants and sensors

There are a number of situations where individuals wish to communicate verbally but are unable to use conventional means—so called ‘silent speech’. These include speakers in noisy and covert situations as well as patients who have lost their voice as a result of a laryngectomy or similar procedure. This paper focuses on those who are unable to speak following a laryngectomy and assesses the possibility of speech recognition based on a magnetic implant/sensors system. Permanent magnets are placed on the tongue and lips and the changes in magnetic field resulting from movement during speech are monitored using a set of magnetic sensors. The sensor signals are compared to sets of pre-recorded templates using the dynamic time warping (DTW) method, and the best match is identified. Experimental trials are reported for subjects with intact larynx, typically using 500–1000 utterances used for speaker dependant training and testing. It is shown that recognition rates of over 90% are achievable for vocabularies of at least 57 isolated words: sufficient to drive command-and-control applications.     

Development of a Double-Membrane Sound Generator for Application in a Voice-Producing Element for Laryngectomized Patients

For voice rehabilitation after total laryngectomy a shunt valve is usually placed in the tracheo-esophageal (TE) wall, thereby enabling the production of a TE voice. Some patients, however, are unable to produce a voice of sufficient quality. Furthermore, the TE voice is low pitched, which presents a problem especially for female laryngectomized patients. The voice quality after laryngectomy might be improved by introducing a voice-producing element (VPE) into the TE shunt valve. In this study a sound generator was developed that is suitable for application in such a VPE. This sound generator consists of two elastic membranes placed parallel inside a circular housing. A substitute voice source is created when the membranes start to vibrate via a constant flow of air passing between them. To determine the optimal membrane configuration for proper functioning under physiological conditions, up-scaled physical VPE models with different membrane geometries were evaluated using in vitro experimental tests. For certain membrane geometries the tests showed that a basic sound, containing multiple harmonics, could be successfully produced under physiological air pressure and airflow conditions. The fundamental frequency (60–95 Hz) and sound pressure level (57–78 dB, at 15 cm microphone distance) were regulated via changes in the driving pressure, thereby enabling the possibility of intonation in laryngectomized patients’ speech. The obtained frequency range is considered appropriate for producing a substitute voice source for female patients. The geometry considerations in this study can be used for the development of a true scale VPE that can be evaluated clinically, to eventually replace the voice after laryngectomy.     

环咽肌的应用解剖及其临床意义

了解环咽肌的形态特征,提高全喉切除术后用发音管发音重建的成功率,探讨与环咽肌相关疾病的机理、对４０具正常成人尸体标本环咽肌的形态和解剖结构进行详细的观察和测量。结果环咽肌在咽后壁的形态略呈形,其上、下角的形态均分为弧形和三角形两种,上角的平均角度为９１．９５度,下角的平均角度为４６．２度,结论对于开展环咽肌切断术有一定的临床意义。     

喉全切除术后二期发音功能重建术的临床应用

目的 探讨喉全切除术后失声病人重新恢复喉功能的手术法。方法 对36例病人行喉二期发音功能重建术。喉全切除术后时间为2－43个月，平均15个月，采用颈部肌皮瓣连结咽和气管，同时用皮瓣制做会厌，达到能发音，呼吸，吞咽保护功能的目的。结果 全部患者能发，用于指堵管可以口头交谈，1例已拔除气管套管，3例可完全堵管，并发症为误吸较重3例，其中1例并发严重肺内感染后死亡，2例再次封闭喉口失音。术后气管造口复发癌2例。结论 喉全切除术后二期发音重建术能恢复喉发音功能。     

中年患者128例生物型全髋置换和骨水泥全髋置换后的随访比较

背景：许多学者均认为骨水泥型全髋置换适合应用于年老且合并较严重的骨质疏松患者,生物型全髋置换适用于较为年轻的患者。 目的：对比中年患者生物型全髋置换和骨水泥型全髋置换的临床效果。 方法：对比分析58例骨水泥型全髋置换者与70例生物型全髋置换者置换后6个月、2年及5年的肢体功能恢复与影像学评估结果以及Harris评分,均为40~60岁中年患者。 结果与结论：生物型假体置换后6个月、2年、5年的Harris评分明显优于骨水泥型假体(P < 0.05),5年生存率也高于骨水泥型假体(P < 0.05)。骨水泥型假体置换后6个月,3例发生自发溶骨性疾病,3例2年后发生假体松动,3例5年后发生线性渗透溶;生物型假体置换2年后2例发生自发溶骨性疾病,置换后5年1例发生假体松动。说明生物型假体较骨水泥型假体更能促进中年患者置换后髋关节功能的恢复,减少并发症的发生,至少在5年的随访过程中获得了更令人满意的临床和影像学结果。关键词：生物型假体;骨水泥型假体;全髋关节置换;Harris评分;人工假体 doi:10.3969/j.issn.1673-8225.2012.17.008     

Transversal laryngotomy. Oncologic and functional results in laryngeal sarcoma. (Malignant fibrous histiocytoma). Case report and literature review

Sarcomas of the larynx are rare neoplasmas that consitute less than 1% of laryngeal malignancies, and their usual treatment is surgery including partial and total laryngectomy and endoscopic laser cordotomy with reported 20% recurrence. Due to previous positive experience from transversal laryngotomy in patients who underwent aritenoidectomy to treat bilateral cord paralysis after total thyroidectomy, the purpose of this work was to report on the surgical treatment of this rare case with such technique. Thus, a 47 year-old physician who complained of hoarseness for four months without dyspnea, stridor, or dysphagia and with no history of irradiation or chemotherapy was operated after both endoscopic and tomographic studies showed a 3 to 4 cm glotic tumor in its right side, with no ulceration. The pathology proved to be malignant fibrous histiocytoma. Five years after surgery the patient is alive with no evidence of disease.     

Three cases of carcinoma of the hypopharynx developing as metachronous second primary cancers after total laryngectomy with radiotherapy for carcinoma of the larynx

We describe 3 cases of metachronous hypopharyngeal cancer developing after laryngeal cancer had been treated with both radiotherapy and total laryngectomy. All 3 patients were men, 2 were 89 years old, and 1 was 65 years old. All patients had undergone total laryngectomy and radiotherapy for cancer for the glottis more than 20 years earlier. All patients underwent total hypopharyngectomy with jejunal free flap reconstruction. Surgery was complicated by scars from previous cancer treatment, and highly sophisticated surgical skills are needed, especially for preparing the recipient vessels. The postoperative period was largely uneventful and without fatal complications, however, 2 of the 3 patients died of distant metastasis 22 months and 31 months after surgery.     

低温等离子射频手术治疗喉部良性病变的临床疗效

目的 探讨低温等离子射频手术在治疗喉部部分良性病变的临床疗效。方法 选取2016年1月~2017年3月我院收治的喉部部分良性病变患者116例,随机分为观察组和对照组,各58例。对照组应用喉钳切除术治疗,观察组应用低温等离子射频手术治疗,比较两组临床疗效、疼痛程度及24个月后复发情况。结果 观察组总有效率为96.56%,高于对照组的86.21%,差异有统计学意义（P＜0.05）。术后3 d,观察组喉部嗓音VAS评分低于对照组［（2.04±0.42）分vs（3.11±0.45）分］,差异有统计学意义（P＜0.05）。观察组复发率为1.72%,低于对照组的12.07%,差异有统计学意义（P＜0.05）。结论 等离子射频消融治疗喉部分良性病变疗效显著,可有效缓解术后疼痛程度,且复发率低,具有较高的临床应用价值。     

In vitro leakage susceptibility of tracheoesophageal shunt prostheses in the absence and presence of a biofilm

Although leakage through a tracheoesophageal shunt prosthesis is the main cause of prosthesis failure in a laryngectomy patient, this has never been the subject of in vitro evaluation. The aim of this study was to compare three commercially available voice prostheses by comparison of their in vitro leakage patterns, in absence or presence of a biofilm. To compare in vitro leakage patterns, a model comprised of an artificial throat equipped with a single prosthesis coupled to a water reservoir was developed. By varying the height of the water reservoir, different pressures on the voice prosthesis can be obtained. Both in absence and presence of a biofilm, the Blom Singer voice prosthesis demonstrated the lowest leakage, followed by Groningen Low Resistance. The Provox2 showed significantly the most leakage, however, in presence of a biofilm the leakage of the Provox2 significantly decreased. Regular airflow during biofilm formation significantly increased leakage through the Provox2. Out of 746 clinical replacements, Provox2 showed 76% and Groningen Low Resistance 57% replacements due to leakage. The model used in this study showed significant differences in leakage of the three types of voice prostheses used. Leakage occurred more readily through Provox2 than through Groningen Low Resistance and Blom Singer prostheses, which is in line with clinical observations and enforces the model.     

Aggressive fibromatosis of the larynx: report of a new case in an adult patient and review of the literature

We describe a case of aggressive fibromatosis of the larynx occurring in a 75-year-old man. The lesion manifested with voice hoarseness and swallowing difficulty. A computerized tomographic scan of the neck revealed distortion of the glottic profile. A malignant tumor was suspected. Although a laryngoscopy-driven biopsy was non-diagnostic, total laryngectomy was done, since the lesion was not deemed amenable to conservative therapy. Grossly, the glottic rim was infiltrated by a hard, grey-white tissue showing a tentacular outline. Tissue sections featured a moderately cellular lesion composed of spindle cells with bland, tapered nuclei, enmeshed in a variably collagenized ground substance. Delicate spindle cell fascicles surrounded the native submucosal seromucous glands and had invaded the thyroid cartilage and the thyroid gland as well. The spindle cells were immunopositive for actins and vimentin, and negative for keratins, epithelial membrane antigen, desmin, and S-100 protein. No further therapy was administered. Periodic follow-up visits were negative. The patient died 5 years after surgery of myocardial infarction with no clinical evidence of lesion recurrence. Based on the available literature, our data confirm that laryngeal fibromatosis in adult patients is a locally infiltrating and progressive disease. Total laryngectomy with clear margins is needed as to avoid the high risk of local recurrence.     

半肩关节置换治疗复杂肱骨近端骨折

背景：半肩或全肩关节置换治疗复杂的肱骨近端骨折,在迅速消除患者疼痛、有效恢复关节功能等方面临床疗效较好。 目的：分析人工半肩关节置换治疗复杂肱骨近端骨折的技术方法及临床疗效。 方法：对12例人工半肩关节置换治疗的复杂肱骨近端骨折患者进行疗效分析。按Neer分型：其中,三部分骨折2例,四部分骨折10例。以X射线观察、Neer评分标准对半肩关节置换后肩关节功能进行临床评估。 结果与结论：12例随访时间平均18个月(6-48个月)。Neer评分：优10例,良1例,可1例,优良率92%。随访期X射线显示内假体位置良好,无关节周围骨折、神经损伤、感染、脱位和松动等并发症。说明人工半肩关节置换是治疗复杂肱骨近端骨折的有效方法之一。半肩关节置换中须注意肩袖的有效修复和大、小结节的正确重建,结合置换后早期、规范的功能锻炼,可取得满意的临床效果。中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程全文链接：     

Embryonal "Botryoid" rhabdomyosarcoma of the larynx: a clinicopathologic and immunohistochemical study of two cases

Two cases of embryonal rhabdomyosarcoma of the larynx are reported. The tumors occurred in a 16-year-old boy and in a 66-year-old man. They manifested clinically with nonspecific symptoms, including voice hoarseness and sense of throat fullness. Treatment consisted of total and partial laryngectomy, respectively. Grossly, both lesions had an exophytic growth pattern and microscopically featured a proliferation of small round to oval cells. Cell cytoplasms were occasionally stainable and fibrillary. Quite often, tumor cellularity was denser beneath the covering mucosa, recalling a "cambium layer" pattern. Tumor cells immunoreacted for desmin, actins, myoglobin, and sarcomeric actin; no immunostaining was noted for epithelial markers. No further antitumoral treatment was administered after surgery. There has been no recurrence of tumor at 2 and 10 years, respectively. Based on our series and the available literature, it seems that rhabdomyosarcoma of the larynx pursues a less-aggressive course than that seen in the homonimic juvenile or adult soft tissue lesion. Surgery alone appears to be a valid treatment option, especially when a polypoid, or "botryoid" gross pattern, coupled with the embryonal small cell histotype is encountered. In light of these findings, it is suggested that botryoid rhabdomyosarcoma of the larynx may deserve a specific consideration among the various laryngeal mesenchymal malignancies.     

Adult laryngeal rhabdomyosarcoma: report of a case and literature review

Rhabdomyosarcoma is relatively seen in the pediatric age group with the head and neck region as the commonest site. To the best of our knowledge, few cases of laryngeal involvement in adult have been described in the literature. Biologically, rhabdomyosarcoma is different from squamous cell carcinoma, which is the commonest tumor of the larynx. A previously healthy non-smoker 77-year-old lady presented to the ENT outpatient with a six weeks history of intermittent alteration of voice quality. She had no history of sore throat, or any symptoms suggesting laryngo-pharyngeal reflux. Examination showed asymmetry of the left arytenoid cartilage and aryepiglottic fold. She subsequently had a direct laryngoscopy and biopsy. Histology and immunohistochemistry examination suggested the diagnosis of mesenchymal neoplasm. Following discussion at MDT she subsequently had a total laryngectomy. Histology confirmed a completely excised laryngeal rhabdomyosarcoma. Rhabdomyosarcoma of larynx in adult is a rare disease. Surgical treatment with or without adjuvant radiotherapy is currently the treatment of choice for this disease.     

Functional morphology of phonation evaluated by dynamic MRI

The complex anatomy of the larynx is a consequence of its various airway functions. The aim of the present study was to evaluate which anatomical structures of the larynx soft tissues could be defined using MRI, and to investigate the feasibility of using this technique to assess the dynamic functions of the larynx. MRI images of the larynx of six healthy volunteers during speech production were obtained in vivo. The volunteers were asked to breathe out long and deep in order to prolong in a normal voice the emission of the vowels [i] (as in key) and [a] (as in car) and the consonant [ch] (as in ship). We demonstrated the modification of the larynx position, which is high for [i] and low for [a], and the modification of the vocal folds which is adducted and abducted in [i] and kept abducted in [ch]. Dynamic MRI allows the possibility of multiplanar high-resolution imaging. It can provide information about the anatomy of the larynx and, it also has the ability to image moving laryngeal structures and to analyze vocal fold vibrations during phonation.     

Chondrosarcoma of the larynx: report of two cases and review of the literature

Primary chondroid tumors of the larynx represent less than 1% of all laryngeal tumors. Most of them are chondromas and they often involve to the cricoid cartilage. They are characterized by a low tendency to metastatic diffusion (low grade). The treatment of choice is surgery, which may be endoscopic or “open partial surgery”, if extension of the cancer is limited. Prognosis is generally good. In this report, two cases of low grade chondrosarcoma of the larynx are presented, one was treated surgically with cricoidectomy and partial laryngectomy, and another was treated surgically with hemicricoidectomy. Laryngoscopy reveals tumefaction of the larynx, covered by intact mucosa. Computerized tomography imaging with contrast and magnetic resonance imaging defines not only coarse calcifications, pathognomonic of chondromatous neoformations but also the relationship of the neoformation with the surrounding tissues. Treatment is essentially surgical, given the importance of preserving the larynx to patients’ quality of life, the only risk is recurrence, which is treated by a second surgery.