Surgical closure of the larynx for intractable aspiration, using double hinged flaps of the vocal folds and false vocal folds

We report a new surgical procedure to treat intractable aspiration: closure of the larynx, using double hinged flaps of the vocal folds and false vocal folds. The anterosuperior portion of the thyroid cartilage is ablated. A small horizontal incision is made just above the anterior commissure and is continued posteriorly along the laryngeal ventricle; these incisions are continued across the posterior wall of the glottis. Incisions are made into the bilateral vocal folds and false vocal folds in order to create the hinged flaps. The glottis and the supraglottis are closed by approximating the bilateral vocal folds and false vocal folds hinged flaps. Superiorly or inferiorly based sternohyoid muscle pedicles are then inserted into the dead space between the approximated bilateral vocal folds and false vocal folds hinged flaps. The removed lamina of the thyroid cartilage is obliterated between both sternohyoid muscle flaps to enforce the closure of the larynx.     

Comparative Histology and Vibration of the Vocal Folds: Implications for Experimental Studies in Microlaryngeal Surgery

Objectives/Hypothesis To determine the most suitable animal model for experimental studies on vocal fold surgery and function by a histological comparison of the microflap surgical plane and laryngeal videostroboscopy (LVS) in different species of animals. A second goal was to determine how the layered vocal fold structure in humans and three different animal species affects surgical dissection within the lamina propria. Study Design Prospective laboratory. Methods Three larynges each from dogs, monkeys, and pigs were compared with three ex vivo human larynges. Microflap surgery was performed on one vocal fold from each larynx. Both the operated and nonoperated vocal folds were examined histologically using stains specific for elastin, mature collagen, and ground substance. Based on the histological results, LVS was performed on two dogs and two pigs after first performing a tracheotomy for ventilation and airflow through the glottis. Arytenoid adduction sutures were placed to facilitate vocal fold adduction. Results The distributions of the collagen and elastin fibers were found to differ among the species with concentrations varying within species. Unlike the human vocal fold, which has a higher elastin concentration in the deeper layers of the lamina propria, both the pig and the dog had a thin band of elastin concentrated just deep to the basement membrane zone in the superficial layer. Just deep to this thin band, the collagen and the elastin were less concentrated. The monkey vocal fold had a very thin mucosal layer with less elastin throughout the mucosa. The microflap dissections in each of the dog, pig, and human vocal folds were similar, being located within that portion of the superficial lamina propria where the elastin and mature collagen are less concentrated. The microflap plane in the monkey vocal fold was more deeply located near the vocalis fibers. Despite the differences in elastin concentration, the microflap plane in both the dog and the pig was found to be similar to that in humans. The dog anatomy was much more suitable for microsuspension laryngoscopy and stroboscopic examination. The dog vocal folds vibrated in a similar fashion to human vocal folds with mucosal waves and vertical phase differences, features not seen in the pig vocal folds. Conclusions Based on both the histological and stroboscopic results, the dog was believed to be a more suitable animal model for studies on vocal fold surgery, acknowledging that no animal's laryngeal anatomy is identical to that of the human. The dog LVS model presented allows for longitudinal laryngeal studies requiring repeated examinations at multiple time periods with histological correlation applied at sacrifice.     

闭合性喉外伤伴杓区损伤的临床特征和内镜下治疗

目的:探讨闭合性喉外伤伴杓区损伤的临床特征、内镜下手术治疗及疗效。方法:回顾性研究2007年4月至2018年12月因明显声音嘶哑就诊于首都医科大学附属北京同仁医院耳鼻咽喉头颈外科的闭合性喉外伤伴杓区损伤患者12例,其中男10例,女2例,年龄7~48岁,中位年龄21岁,患者均在全身麻醉和支撑喉镜下行喉显微修复手术。评估其...     

Mikrolaryngoskopie und Phonomikrochirurgie

Microlaryngoscopy is a reliable technique and the most frequently applied method in laryngeal surgery. The design of new laryngoscopes and the application of video endoscopes may permit further improvements in laryngeal exposure, whilst minimizing the damage caused by their insertion. In contrast to this, the principle microsurgical procedures for improvement, restoration and preservation of the vocal function have remained almost unchanged. These techniques are oriented towards minimal excision of pathological tissue with maximal conservation of normal tissue, in particular the epithelium of the vocal folds and the lamina propria—the basic structures for vocal fold vibration. Phonomicrosurgy can only be justified on the basis of a proven improvement as evidenced by vocal function analysis.     

Laryngeal synkinesis revisited

First described in 1982, laryngeal synkinesis continues to play an important diagnostic and therapeutic role following recurrent laryngeal nerve (RLN) injury. Vocal fold motion impairment (formerly called "vocal cord paralysis"), hyperadducted and hyperabducted vocal folds, and certain laryngeal spasmodic and tremor disorders are often best explained by synkinesis. A closer look at these mechanisms confirms that following RLN injury, immobile vocal folds may be nearly normally functional (favorable), or spastic, hyperadducted, or hyperabducted (unfavorable). This has resulted in a functional classification of laryngeal synkinesis as follows: type I laryngeal synkinesis, with satisfactory voice and airway (vocal fold poorly mobile, or immobile); type II synkinesis, with spasmodic vocal folds and an unsatisfactory voice and/or airway; type III synkinesis, with hyperadducted vocal folds and airway compromise; and type IV synkinesis, with hyperabducted vocal folds, poor voice, and possible aspiration. This classification facilitates the understanding of laryngeal pathophysiology following RLN injuries and promotes a more scientific basis for management.     

Low-cost high-speed imaging system for observing vocal fold vibration in voice disorders

Purpose: The aim of this study was to establish a method to observe vocal fold vibration using a low-cost high-speed laryngeal imaging system. Procedures: We assembled a high-speed imaging system with a consumer digital camera and a rigid laryngeal endoscope. The camera can shoot digital images at a rate of 1,200 frames per second and be purchased for about USD 1,000 in Japan. Results: We examined the normal and pathological vocal folds of 215 subjects with our new system and analyzed the vocal fold vibration in these subjects by playback of a video and kymograph images. Conclusions: Our high-speed laryngeal imaging system is highly cost-effective and can be a useful tool for examining the vocal folds of patients with voice disorders.     

Experimental study on simultaneous selective reinnervation of the adductors and the abductor muscle for the treatment of the laryngeal paralysis

OBJECTIVE: The aim of this study is to estimate the value of a new surgical procedure in the treatment of the chronic unilateral laryngeal paralysis. METHODS: The recurrent laryngeal nerve of the left side of the dog was totally cut and served as a model of unilateral laryngeal paralysis at the first step of the research. The adductor and abductor branches of the recurrent laryngeal nerve were then, selected and cut. Afterwards, they were micro-sutured respectively with one branch of ansa cervicalis and phrenic nerve immediately (group 1) and 4 months later (group 2). Six months after this reinnervation, the laryngeal physiologic function of the lateral crico-arytenoid muscle (LCA) and the posterior crico-arytenoid muscle (PCA) have been checked by the methods of electromyography (EMG) and direct laryngoscopy. All the data have been analysed by the statistic methods. RESULTS: Among all the data of EMG, only the wave amplitude of action potential of the LCA muscle of the group 2 was diminished (p < 0.05). Under the direct laryngoscopy, the adductor movement of the left vocal cord of the group 2 was also lightly reduced. But the adductor and abductor movements of the left vocal cord were synchronous with the mouvements of the right vocal cord. CONCLUSION: Though the result of nervous reinnervation of a four month's laryngeal paralysis was not so good by comparison with that of an immediate reinnervation, this surgical procedure can however on the clinical point of view, reach a satisfactory level. The duration maximum of the reinnervation operation after laryngeal paralysis, is, at the present, not clear. It is necessary for us to make further studies.     

Quantitative measures of laryngeal function following teflon® injection or thyroplasty type I

Laryngeal/voice function was evaluated in six patients with unilateral true vocal fold paralysis following treatment with Teflon® injection (TEF) compared to six patients treated with thyroplasty type I (THY). Auditory perceptual, aerodynamic, and endoscopic assessments were conducted. Three judges rated nine voice characteristics. Aerodynamic measures included estimated subglottal pressure, airflow, and laryngeal resistance. Two judges rated laryngeal characteristics from flexible fiberoptic assessment. The THY group had significantly better voice quality and better quantitative aerodynamic findings compared to the TEF group. The TEF group also was more likely to have an irregular vocal fold edge, an irregular glottal closure pattern, a higher occurrence of hyperfunction and hypertrophy of the false vocal folds, edema, and erythema of the paralyzed folds. Results suggest that THY was associated with more favorable measures of laryngeal/voice function than TEF. It is likely that the poorer perceptual, aerodynamic, and endoscopic findings associated with TEF injection may be due to violation of the true vocal fold cover, particularly increased true vocal fold mass and stiffness.     

Therapie von Rekurrensparesen

Whereas static vocal fold medialization or lateralization are currently the standard procedures, new dynamic treatment methods such as reinnervation and laryngeal pacing focus on better toning and remobilization of the paralyzed vocal folds. End-to-end or jump anastomoses of the recurrent laryngeal nerve can preserve muscle mass and avoid atrophy, thus enabling subsequent dynamic therapeutic options. Prognostic evaluation and the time point of therapeutic intervention are important issues in the management of patients with recurrent laryngeal nerve paralysis. Irreversible interventions should be avoided at early time points or during childhood in order to allow for spontaneous remission and dynamic therapeutic options.     

Geometric characterization of the laryngeal cartilage framework for the purpose of biomechanical modeling.

Some new anatomic data on the laryngeal cartilage framework have been obtained for the biomechanical modeling of the larynx. This study attempted to define and measure some biomechanically important morphometric features of the laryngeal framework, including both the human and the canine laryngeal frameworks, because the canine larynx has been frequently used as an animal model in gross morphology and in physiological experiments. The larynges of 9 men, 7 women, and 9 dogs were harvested and dissected after death. Linear and angular geometric measurements on the thyroid cartilage, the cricoid cartilage, and the arytenoid cartilage were made with a digital caliper and a protractor, respectively. The results are useful for constructing quantitative biomechanical models of vocal fold vibration and posturing (abduction and adduction), eg, continuum mechanical models and finite-element models of the vocal folds.     

Fat implantation into Reinke's space: a histologic and stroboscopic study in the canine.

The scarred vocal fold is a cause of persistent dysphonia after laryngeal trauma, microsurgery, and tumor resection. The loss of Reinke's space with scar and stiffness is the primary cause. This study explores the technical aspects of endoscopic implantation of fat as an autologous implant for restoring the bulk and pliability of the vocal folds. Fat from the buccal area was harvested and prepared in 6 dogs. A mucosal flap submucosal pocket was prepared by means of microlaryngoscopy instrumentation. The fat implant was placed into the submucosal pocket. The mucosal flap was sutured endoscopically. Six weeks later, the larynx was harvested and mounted, and vocal fold oscillation was studied while driven by a humidified flow source. The vibratory patterns were studied by stroboscopy. Histologic sections of the vocal folds were made in the coronal plane. All 6 specimens had histologic evidence of viable implanted fat and/or fibrous tissue at the implant site. The site of implantation was in the superior aspect of the vocal fold, but contributed to mass in vocal fold bulk. This increase in bulk histologically corresponded to stroboscopic evidence of increased mass. On stroboscopy, the implant side continued to demonstrate good vibratory function. The study shows that fat implantation can be carried out as an endoscopic procedure. Fat implantation may be useful as a surgical procedure for restoration of Reinke's space. It may be applicable in patients with scars, sulcus vocalis, or vocal fold atrophy.     

Configuration of the glottis in laryngeal paralysis. I: Clinical study

It is widely accepted in the American literature that the cricothyroid muscle is responsible for the paramedian position of the vocal fold in recurrent laryngeal nerve paralysis. However, support in the literature for this theory is not conclusive, and the cadaveric vocal fold position expected after lesions of the vagus nerve has also been reported in patients with an intact superior laryngeal nerve. This study compares the configuration of the glottis in patients with unilateral paralysis due to known lesions of either the recurrent laryngeal or vagus nerve. Normal subjects were studied as controls. Results indicate that the alteration of glottic configuration in laryngeal paralysis cannot be adequately characterized by standard terms of vocal fold position. The paralyzed vocal fold is shortened, with anterior rotation of the arytenoid. Patients with vagus nerve lesions had a statistically insignificant tendency for a more lateral vocal fold position, but a discrete difference in position between the two groups was not identified. This study also confirms prior observations that paralyzed vocal folds are frequently not denervated. These findings have significant implications for management of laryngeal paralysis.     

Hemangioma of the larynx in children

Hemangiomas were diagnozed in 11 patients (4.6%) out of 235 children with chronic laryngeal stenoses of various etiology. The most frequent symptom was hoarse voice. The children examined were not older than 5 months. In 5 patients, laryngeal hemangiomas were associated with hemangiomas of other body compartments--most frequently on the skin of the face, neck or upper chest. Out of the 11 laryngeal hemangiomas 6 were located below vocal folds, 4 on gastric and aryepiglottic folds and only 1 on vocal folds. The first line method of treatment was cryosurgery. Local freezing was performed on 6 patients. They all were decannulated within 2 to 4 months after intervention. There children with disseminated hemangiomas of the face, neck and upper chest were exposed to radiotherapy. A year after, two of them were decannulated and the third one developed a postradiation scar below vocal cords. In 2 children when they were 2 or 3 years of age, laryngeal hemangiomas disappeared spontaneously without any treatment.     

Human laryngeal reinnervation: the Northwestern experience

Recent publications have reported impressive success with laryngeal reinnervation utilizing a nerve-muscle pedicle. This innovative surgical procedure is claimed to be useful for unilateral and bilateral vocal cord paralysis. Although the surgical results reported by Tucker have been good, they have lacked corroboration from other centers. We have performed six laryngeal reinnervation procedures at Northwestern University Medical School. Four patients presented with bilateral vocal cord paralysis and two patients with unilateral paralysis. All six operations were successful in restoring vocal cord function. The technique, problems, and results are discussed. Our experience supports the initial reports of success with this new operation.     

Sarcoidosis with vocal fold involvement and hypercalcaemia

Sarcoidosis affects many different organ systems. However, laryngeal involvement is rare and most cases with laryngeal involvement affect the supraglottis, occasionally secondarily extending to the vocal fold. The features of sarcoidosis in the supraglottic region have been described in several reports, but vocal fold involvement has not been presented in detail. We report an unusual case of laryngeal sarcoidosis initially involving the vocal folds in a 66-year-old man, associated with hypercalcaemia. Our report describes characteristics of the involved vocal folds. Hypercalcaemia is one of the characteristics of sarcoidosis. We concluded that laryngeal sarcoidosis should be added to the differential diagnosis of vocal fold lesions, particularly in patients with hypercalcaemia.     

Videostrobolaryngoscopy of mucus layer during vocal fold vibration in patients with laryngeal tension-fatigue syndrome

The mucus layer on the vocal folds was examined by videostrobolaryngoscopy in patients with laryngeal tension-fatigue syndrome, a chronic functional dysphonia due to vocal abuse and misuse. Besides the findings in previous reports (such as abnormal glottal closure, phase or amplitude asymmetry, and the irregular mucosal wave), the vocal folds during vibration had an uneven mucus surface. The occurrence of an uneven mucus layer on vocal folds was significantly greater in subjects with this voice disorder (83% or 250 of 301 patients in this series) than in those without voice disorders (18.5% or 5 of 27). The increase of mucus viscosity, mucus aggregation, and the formation of rough surfaces on the vocal folds alter the mechanical properties that contribute to vibration of the cover of the vocal folds, and thereby worsen the symptoms of dysphonia in patients with laryngeal tension-fatigue syndrome.     

Complications of laryngeal framework surgery (phonosurgery)

The rising popularity of surgery involving the laryngeal framework (surgical medialization of immobile vocal folds, vocal fold tightening, pitch variation, etc.) has resulted in increasing case experience. Little has appeared in the literature regarding complications or long-term results of this type of surgery. Several years' experience in a major referral center with various types of laryngeal framework surgery has led to a small number of complications. These have included late extrusion of the prosthesis and delayed hemorrhage. A review of these complications and recommendations for modification of technique to minimize them in the future are discussed.     

Update Larynx: funktionelle Anatomie unter klinischen Gesichtspunkten

ENT specialist and phoniatricians are not the only professionals for whom diseases of the larynx occupy centre stage; this applies to those in all fields involving conservative or surgical treatment of the larynx, such as speech therapists, paediatricians, anaesthetists, oncologists, pulmonologists, radiologists and general practitioners. On the basis of current knowledge and taking account of results yielded by their own research in recent years and of clinical aspects, in this paper the authors give a short overview of basic knowledge on the anatomy and physiology of the larynx. Part 1 deals with its development and division, the laryngeal skeleton and joints, the insertion structures of the vocal folds and the laryngeal musculature and describes new insights into the mineralization and ossification of the laryngeal skeleton and their implications for phonation, arytenoid subluxation, degenerative joint changes and the biomechanics of vocal cord insertion.     

Stroboscopy--a pertinent laryngological examination

When observing the vocal fold movements in their laryngoscopic examination, most laryngologists seem to be trained to consider only the gross respiratory movements of the folds, i.e. abduction and adduction. these movements constitute an essential part of the vitally important valve function of the larynx, preventing aspiration and providing parts of the mechanisms for normal swallowing, coughing, and straining. The second important function of the larynx is to serve as a transducer of aerodynamic to acoustic energy; the voice function. Probably for reasons of tradition, the examination of the voice function is generally left to the speech pathologists, who can make an auditory perceptual evaluation of the voice qualities, possibly supplemented by electro-acoustic analyses. By focussing also on the small vibratory movements of the vocal folds during phonation, using laryngeal stroboscopy, the laryngologist can contribute considerably to the diagnosis of voice disorders. For the laryngeal surgeon stroboscopy should be of particular interest, as it is a useful tool for early detection of (cancerous) invasion and for the evaluation of laryngeal paresis. This paper describes the clinical procedure of laryngeal stroboscopy, based on some introductory remarks on vocal anatomy and function.     

Voice quality following laryngeal reinnervation by ansa hypoglossi transfer

Recurrent laryngeal nerve injury resulting in chronic unilateral vocal fold paralysis has been treated traditionally by implantation of various materials into the paralyzed vocal fold. Although the usage of these techniques, especially Teflon®-glycerin paste injection, has been clinically established, they do not restore full functionality to the larynx (abduction, adduction, and vibratory synchronization of the vocal folds). Restoration of these functions, necessary for improved phonation, has been achieved at least on an experimental basis by reinnervation techniques previously described. This study demonstrates excellent human voice quality following reinnervation of the vocal folds in two cases using ansn hypoglossi-recurrent laryngeal nerve anastomosis. Although the reinnervated vocal fold neither abducted nor adducted, it presented itself in the midline for precise apposition with the nonparalyzed cord. Voice data were analyzed within a single subject experimental design at the following intervals: preoperatively, immediately postoperatively, midterm, and long-term (3 and 6 years). The data was analyzed by subjective and objective means, including acoustics and electroglottography. Patient selection, surgical techniques, results, and implications are reviewed.