Bilateral vocal fold immobility: diagnosis and treatment

Vocal fold immobility may be due to bilateral neurogenic paralysis, cricoarytenoid joint fixation, laryngeal synechiae, or posterior glottic stenosis. Treatment aims to establish a patent airway and preserve the function of the glottic sphincter and voice quality.ObjetivesTo analyze the diagnostic and therapeutic approaches in cases of bilateral vocal fold immobility seen at our unit.Materials and MethodsA retrospective study of 35 patient registries at our unit with a diagnosis of bilateral vocal fold immobility; the etiology and treatment results were evaluated.ResultsAmong the patients, 18 (51.4%) were cases of bilateral vocal fold palsy, and 17 (48,6%) were cases of posterior glottic stenosis. Patients with bilateral palsy underwent unilateral subtotal arytenoidectomy, and patients with stenosis were treated with the microtrapdoor flap technique, subtotal arytenoidectomy, and/or posterior cricoidotomy (Rethi).ConclusionBilateral vocal fold immobility is a potentially fatal condition; it is essential to differentiate vocal fold palsy from fixation to choose the appropriate treatment. Subtotal arytenoidectomy with microscopy is our surgery of choice for treating bilateral paralysis; the technique for treating stenosis depends on the amount of stenosis.     

Vascular lesions of the vocal fold

The aim of the study was to present symptoms, laryngological findings, clinical course, management modalities, and consequences of vascular lesions of vocal fold. This study examined 162 patients, the majority professional voice users, with vascular lesions regarding their presenting symptoms, laryngological findings, clinical courses and treatment results. The most common complaint was sudden hoarseness with hemorrhagic polyp. Microlaryngoscopic surgery was performed in 108 cases and the main indication of surgery was the presence of vocal fold mass or development of vocal polyp during clinical course. Cold microsurgery was utilized for removal of vocal fold masses and feeding vessels cauterized using low power, pulsed CO₂ laser. Acoustic analysis of patients revealed a significant improvement of jitter, shimmer and harmonics/noise ratio values after treatment. Depending on our clinical findings, we propose treatment algorithm where voice rest and behavioral therapy is the integral part and indications of surgery are individualized for each patient. Part of the study results was presented as oral presentation at 5th Pan European Voice Congress (PEVoC), Graz, Austria, 28–31 August 2003.     

Value of ultrasonography in diagnosis of pediatric vocal fold paralysis

Objectives

To investigate the appearance of the pediatric larynx on ultrasound images and the diagnostic potential of ultrasound in cases of pediatric vocal fold paralysis.

Methods

First, we confirmed the ultrasonographic features of the laryngeal landmarks in 2 pediatric cadaveric larynxes. Secondly, 45 children were enrolled in a clinical study (13 patients with vocal fold paralysis and 32 normal children). Quantitative analysis of vocal fold mobility was carried out by measuring the maximum glottic angle (MGA) and vocal fold-arytenoid angle (VAA).

Results

All the paralyzed vocal folds showed abnormal mobility, and were flaccid during breathing and phonation. The rima glottis appeared as a hyperechoic air-column band in ultrasound images during phonation. The mean value of the MGA was 61.47 ± 9.00 in the normal larynx and 42.25 ± 10.41 in the paralyzed larynx. In the affected side of the paralyzed larynx, the VAA in maximum abduction was smaller than that in the normal larynx or in the unaffected side. The median difference of the VAA between maximum abduction and maximum adduction was less than that in the normal larynx. The kappa value was 0.96.

Conclusion

MGA and VAA are quantitative indicators of vocal fold immobility. Ultrasound is a reliable method of diagnosis of pediatric VFP. To diagnose VFP from an ultrasound image, the criteria are: (1) abnormal mobility (this was the most important and direct evidence), (2) hyperechoic air-column band of the glottic rima during phonation, (3) flaccid vocal fold and (4) asymmetry of the glottal structures.     

声带振动功能的无创检测

检测60例正常人和20例单侧声带麻痹患者的EGG参数CQ、CI和声学参数NNE,并进行统计分析。结果显示：正常人声门闭合较完全,声门接触相中,逐渐关闭的过程快于逐渐张开的过程（CI为负数）。麻痹患者声门闭合程度下降（NNE增大）,声门闭合过程中渐触相时程延长（CI增大）。麻痹组与正常组间CQ值无显著性差异。提示EGG和NNE的无创测试可用来分析声带振动功能;单侧声带麻痹后声带振动模式出现病理性改变。     

Effect of sugarcane biopolymer gel injected in rabbit vocal fold

IntroductionAlterations in the vocal folds that involve volume reduction and glottal closure failure result in exaggerated air escape during speech. For such situations, the use of implants or grafts of different materials has been proposed.ObjectiveTo define the effect of sugarcane biopolymer gel when implanted in the vocal folds of rabbits.MethodsThis was an experimental study. The vocal folds of rabbits injected with sugarcane biopolymer and saline solution were histologically evaluated after 21 and 90 days.ResultsMild to moderate inflammation and increased volume were observed in all vocal folds injected with biopolymer, when compared to controls. There were no cases of necrosis or calcification.DiscussionThis study showed higher inflammatory reaction in cases than in controls and biopolymer biointegration to the vocal fold. This fibrogenic response with absence of epithelial repercussions suggests that the biopolymer in its gel form can be bioactive and preserve the normal vibratory function of the epithelium.ConclusionWe show that in spite of producing an inflammatory reaction in vocal fold tissues, the material remained in vocal fold throughout the study period.     

The first case of osteoma in the false vocal fold

Objectives

This article reports the first evidence of a larynx osteoma of the false vocal fold.

Study design

Case report and literature review.

Methods

Case report and review of previously published cases of larynx osteomas.

Results

A 79-year-old patient was referred to our institution for dysphagia and hoarseness. Fibrolaryngoscopy showed a regular surface tumefaction of the false fold and the left ventricle, with preserved cordal motility. Patient underwent direct laryngoscopy with CO₂ laser excision of the lesion. Pathologic examination of the lesion (1.6 cm × 1 cm) showed features consistent with an osteoma. Complete regression of symptoms was observed after surgery, with no lesions found on routine 1-year follow-up.

Conclusions

Osteomas are benign, slow growing tumors of the craniofacial bone area, very rarely located in the larynx. Although the etiology is unknown, accepted theories point to embryologic, post-traumatic and infectious causes. Surgical excision is indicated only in symptomatic cases. This case report is the fourth evidence of laryngeal osteoma and, to our knowledge, the first finding of a false vocal fold osteoma.     

声带息肉的电镜观察

目的 探讨声带息肉病变组织中成纤维细胞、胶原纤维、弹性纤维超微结构改变.方法对手术切除的10例声带息肉和3例正常声带对照(下咽癌行喉全切除见声带未受肿瘤侵犯)行透射和扫描电镜观察.透射电镜采用常规方法;扫描电镜采用组织消化法,观察弹性纤维的标本用90%甲酸消化,观察胶原纤维的标本用10%NaOH水溶液消化.结果 透射电镜下声带息肉固有层中成纤维细胞数量增多,细胞器丰富,可见大量内质网、高尔基复合体、线粒体,表明成纤维细胞处于功能活跃状态.固有层内可见炎性细胞浸润,提示炎症反应与发病有关.声带息肉中血管数量明显增多.扫描电镜观察,声带息肉中胶原纤维和弹性纤维的形态发生改变,纤维排列紊乱.结论 声带息肉中成纤维细胞、弹性纤维、胶原纤维形态改变,这些变化可能是影响声带发声功能的病理学基础.     

自体筋膜移植填充治疗声带沟

目的探讨筋膜移植填充术在声带沟治疗中的价值及预后转归。方法23例双侧声带沟患者全麻显微镜下行声带沟瘢痕松解、筋膜移植填充手术，合并声带肌萎缩者同时行声门旁间隙脂肪注射。患者手术前、后行嗓音声学、气流动力学及频闪喉镜检查。结果4例手术失败者未进行疗效评价。19例术后6—8周患者发音开始改善，术后3个月发音改善明显。术后6个月音质趋于稳定，主、客观声学评价及气流动力学参数较术前改善明显，17例（89．5％）患者音质改善明显，声带结构及黏膜振动接近正常，声门闭合明显改善；2例患者音质改善不明显，声带形态接近正常，声门闭合改善，但黏膜振动不良。声音嘶哑主观评分与术前比较改善明显（P值均〈0．05），总评分2例患者（10．5％）提高2个等级，15例患者（79．0％）提高1个等级，2例患者（10．5％）评级无明显改变。除基频外，嗓音声学参数及最大发音时间与术前比较差异均有统计学意义（P值均〈0．01），8例（42．0％）患者声学参数达到正常范围，17例患者（89．5％）最大发音时间达到正常范围。19例患者随诊均6个月-1年，未发现筋膜吸收，其中5例患者随诊满2年，音质稳定。结论筋膜移植填充声带沟的手术可在一定程度上矫正声带固有层缺陷，改善声门闭合不良，恢复声带振动特性。     

声带外侧自体脂肪注射填充术治疗声门闭合不良

目的对声带外侧自体脂肪注射填充术方法选择、预后及其影响因素进行研究,探讨声带外侧自体脂肪注射在声门闭合不良性发声障碍治疗中的价值。方法病例选择:29例声门闭合不良、发声障碍患者,27例为单侧声带麻痹(麻痹时间均超过半年),2例为声带萎缩。手术选择:全麻支撑喉镜下,应用特制Brunning高压脂肪注射器进行自体脂肪声带外侧注射。患者手术前后均行嗓音声学、气流动力学及频闪喉镜检查,确定患者发音质量及疗效。结果术后随诊10～18个月,24例患者发声明显改善,2例发声好转,3例无效。注射1个月后脂肪部分吸收,声门闭合程度及发音逐渐改善。3～6个月声带振动、声门闭合正常,发声明显改善,音质稳定,主、客观声学评价及气流动力学参数改善明显(P<0.01)。结论单侧声带麻痹或声带萎缩引起的声门闭合不良,选择声带外侧声门旁间隙脂肪注射手术,使声带膜部内移,改善声门闭合,并保留声带振动特性,患者可获得良好的发音效果。     

A retrospective analysis of revision framework surgeries for unilateral vocal fold paralysis

IntroductionRevision framework surgeries might be required for unilateral vocal fold paralyses. However, outcomes and indications of revision surgeries have not been adequately documented. For a better understanding of indications for the procedure and to help in achieving better vocal outcomes, we performed a retrospective chart review of patients who underwent revision framework surgeries for unilateral vocal fold paralysis.ObjectivesThis study aimed to present clinical features of patients who underwent revision framework surgeries for the treatment of unilateral vocal fold paralysis.MethodsOf the 149 framework surgeries performed between October 2004 and October 2019, 21 revision framework surgeries were performed in 19 patients. Self-assessments by patients using the voice handicap index-10 questionnaire, and objective aerodynamic and acoustic assessments performed pre- and post-operatively were analyzed using the Wilcoxon’s signed-rank test for paired comparisons.ResultsUndercorrection was indicated as reasons for revision surgeries in all cases. The revision techniques included type I thyroplasty, type IV thyroplasty, and arytenoid adduction, and revision surgeries were completed without any severe complication in all cases. Pre- and post-operative voice handicap index-10 scores were obtained in 12 cases, and other parameters were evaluated in 18 cases. Significant improvements were observed in voice handicap index-10 scores, maximum phonation time, mean flow rate, Current/Direct Current ratio, and pitch perturbation quotient.ConclusionUndercorrection was observed in all patients who underwent revision framework surgeries for unilateral vocal fold paralysis, and the initial assessment and planning are thought to be important in order to avoid revision surgeries. Revision surgeries were performed safely in all cases, and significantly improved vocal outcomes were observed, even after multiple procedures. Revision surgery should be considered for patients with unsatisfactory vocal functions after primary framework surgeries for unilateral vocal fold paralysis.     

A new classification of vocal fold leukoplakia by morphological appearance guiding the treatment

Objective: To provide a reference for classification and treatment of vocal cords leukoplakia.

Methods: 640 cases of patients with vocal cords leukoplakia were divided into three groups based on the appearances. There were respectively 81 smooth flat lesions, 155 smooth hypertrophy lesions and 13 rough lesions were treated with conservative methods and 26, 153 and 212 cases were resected surgically for biopsy.

Results: A majority of smooth flat leukoplakia lesions were cured by non-operational methods and no atypical hyperplasia. Most of rough lesions were invalid and even progressed treated with conservative therapy and were severe dysplasia or canceration. Although 67.6% smooth hypertrophy lesions were cured or improved by conservative methods and 47% lesions had no or mild dysplasia, over 30% of lesions were still invalid or progressed and over 50% had moderate, severe dysplasia and canceration. By statistical analysis, the appearance of leukoplakia was concordant with pathological changes.

Conclusions: It is suggested that smooth flat vocal cords leukoplakia could be treated with conservative methods and rough lesions should be resected operationally, while for smooth hypertrophy vocal cords leukoplakia could be first followed-up and then adopt measures based on the appearance changes.     

高频超声与喉镜诊断声带麻痹的对照研究

目的探讨超声诊断声带麻痹的价值及局限性。方法分析33例声带麻痹的超声表现,并与喉镜对照。结果超声诊断为单侧和双侧声带麻痹者各为30和3例。单侧者声像图表现为单侧声带变形18例,运动和振动减弱或固定27例,声门裂扩大19例,杓状软骨运动减弱或固定30例,伴前移12例,梨状窝扩大25例,环杓后肌变薄、回声增强10例。双侧者声像图均表现为双声带变形、声门裂扩大、杓状软骨运动减弱。喉镜诊断单侧声带麻痹28例,双侧5例。超声诊断声带麻痹的符合率达93.9%。结论超声是诊断声带麻痹的一种无创、便捷、有效的方法,尤其可借助观察杓状软骨的运动来判断声带麻痹。     

嗓音显微外科技术的临床应用

目的　对于喉部病变 ,在得到有效治疗的同时 ,最大限度地保留正常和高质量的发声功能。方法　 1986～ 2 0 0 0年中日友好医院耳鼻咽喉科应用嗓音显微外科技术治疗 115 3例喉部疾病。根据喉部各种良性病变 (声带小结、声带息肉、Reinke水肿、声带囊肿等 )和不同阶段早期恶性病变及声带癌前病变侵犯的组织学深度 ,分别采用显微切除技术、外侧微瓣技术、内侧微瓣技术、黏膜下注射技术、黏膜剥脱及激光切除术等 ,切除病变组织 ,最小伤及正常组织和对发音质量的影响。结果10 4 4例 (99 8% )声带小结、声带息肉、声带囊肿和 12例Reinke水肿在通过显微切除技术、外侧微瓣技术、内侧微瓣技术等治疗后均能在 1周后获得正常发音 ,2例巨大声带息肉患者半年内声嘶改善不满意 ;2 0例Reinke水肿、31例癌前病变经黏膜剥脱及黏膜表皮剥脱处理 ,除 3例癌前病变术后复发又经 2、3次手术 ,其余均在 1～ 3个月内恢复正常发音。 34例声带癌经黏膜剥脱处理 ,5例声带癌和 5例喉乳头状瘤经激光切除 ,术后 5年以上随访 5例声带癌复发 ,其中 2例再次行黏膜剥脱术 ,1例乳头状瘤反复 4、5次手术。治疗后的发音效果均比经颈部切除手术好。结论　嗓音显微外科技术是彻底治疗喉部疾病同时可以最大限度保留声带发声功能的重要手术方法     

切取悬吊拉伸法在犬喉中段声带固有张力测量中的应用

目的 探讨切取悬吊拉伸法在犬喉中段声带固有张力测量中的应用效果。 方法 切取游离的犬喉中段声带(包括完整的声带5层结构),用悬吊拉伸的方法将声带样本拉升至原有长度,通过拉伸所需要的砝码质量测量其固有张力。测量喉腔样本的主要几何参数,评估样本的可靠性。 结果 将声带样本悬吊拉伸至固有10 mm长度所需要的砝码质量均数为22.06 g。所需砝码质量与实验动物的体质量及体型大小无相关关系(P=0.985)。实验测量的主要几何参数与文献报道较为一致。 结论 切取悬吊拉伸可较为精确测量出犬喉中段声带的固有张力。     

The role of laryngeal electromyography in the diagnosis of vocal fold immobility in children

INTRODUCTION: Pathology may affect the muscles that control vocal function directly by affecting peripheral function or indirectly by affecting the central nervous system. Clinically, muscle function can be assessed by observing the movements of the structures themselves or by recording the electrical activity of the muscles (electromyography, EMG). Since EMG is an invasive technique, it has enjoyed limited use in the diagnosis and management of voice disorders, especially in children. Laryngeal EMG may be helpful in those patients with voice problems of suspected neurological or neuromuscular etiology. OBJECTIVE: The purpose of this paper is to study the role of laryngeal EMG in the clinical evaluation of unilateral vocal fold immobility in children. MATERIALS AND METHODS: Twenty-five children with unilateral vocal fold paralysis were studied. Twenty-five patients with vocal pathologies secondary to vocal abuse and misuse were studied as controls. The sensitivity and specificity of the EMG as a diagnostic marker for vocal fold paralysis were obtained. Additionally, nine patients with traumatic arytenoid dislocation were also studied. All patients were subjected to laryngeal EMG. EMG showed a sensitivity of 100%, and specificity of 92%. Only two patients, present with a functional voice disorder, showed abnormalities in the EMG recordings. In the nine patients with arytenoid dislocation, EMG showed normal parameters. CONCLUSION: EMG seems a safe and reliable test for evaluating patients with vocal fold immobility. Moreover, the EMG recordings were helpful in differentiating vocal fold paralysis from arytenoid dislocation. EMG can provide useful data concerning muscle denervation, and more importantly, reinnervation. Besides its utility for the diagnosis, serial EMG can be useful for monitoring recovery and for establishing a reliable prognosis, and hence, an adequate treatment plan.     

Ⅰ型甲状软骨成形术治疗单侧声带麻痹的嗓音学分析

目的 探讨Ⅰ型甲状软骨成形术治疗单侧声带麻痹的嗓音学特征.方法 应用美国Kay公司的MDVP 5105软件对16例单侧声带麻痹患者手术前、后嗓音声学参数进行分析.结果 16例(100％)患者声学参数基频、频率微扰、振幅微扰及最长声时平均值与术前明显改善(P＜0.050,主观感觉满意.结论 Ⅰ型甲状软骨成形术对改善单侧声...     

Detection of hormone receptors in the human vocal fold

Until now only limited and controversial data are available concerning the presence of steroid hormone receptors in the human vocal fold. A sum of 140 slides from 104 patients were investigated including 25 Reinke's edemas, 19 cases of recurrent respiratory papillomatosis, 19 polyps, 10 epithelial hyperplasias without or with dysplasias, 4 carcinomas in situ, 20 laryngeal carcinomas as well as 7 fresh cadaver samples without macroscopic alterations. The median patient age was 58 years. Paraffin-embedded tissue was incubated with monoclonal antibodies for estrogen-alpha, androgen and progesterone. Androgen receptors were expressed most frequently, followed by estrogen receptors, whereas no progesterone receptors were identified. Receptor staining could be detected with different densities and locations within the different vocal fold pathologies, but not in the autopsy samples. Our study could clearly demonstrate the presence of hormone receptors in the human vocal fold. Androgen receptors were most frequently detected, especially in the basal and intermediate layer of the stratified epithelium and the lamina propria. Whether the high incidence of steroid hormone receptors in some vocal fold pathologies has implications on their pathogenesis must be evaluated by further studies.     

脂肪干细胞复合脱细胞真皮基质用于声带注射的实验研究

目的 探索脂肪干细胞(adipose-derived stem cell,ASC)与脱细胞真皮基质微粒(micronized acellular dermal matrix,MADM)复合培养后用于声带内注射的可行性.方法 体外分离培养兔ASC,取第3代细胞,用细胞膜红色荧光探针(DiI)标记,并与已制备好的MADM复合培养,形成细胞和材料复合体,应用荧光显微镜、扫描电镜了解ASC黏附材料情况,四唑类化合物3-(4,5-dimethylthizazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfonyl)-2H-tetrazolium,inner salt(MTS)比色法检测细胞增殖情况.ASC-MADM复合体培养3 d后与适量胶原混合后注入异体兔单侧声带内,术后2、4、8周内镜观察,并分别处死动物,检测ASC在声带中存活、分布情况.结果 MADM所含胶原纤维松散、多孔隙,具有良好三维结构;ASC可黏附其生长并能不断增殖,与没有复合MADM的对照组比较细胞增殖水平差异有统计学意义(P值均＜0.05或＜0.01).ASC-MADM复合体注入兔声带肌后均存活良好,连续内镜观察、冰冻切片、HE染色显示声带局部无不良反应,ASC-MADM复合体在兔声带内基本无炎症细胞浸润,ASC可在声带内存活8周.结论 MADM是较理想的细胞支架材料,ASC能黏附MADM生长并增殖.ASC-MADM复合体异体动物声带内注射可存活且无不良反应.

Abstract：

Objective To explore the feasibility of adipose-derived stem cells (ASC) combined with micronized acellular dermal matrix (MADM) for vocal cord injection. Methods The adipose-deprived stem cells were harvested from rabbit adipose tissue in vitro. The 3rd generation of ASC was labeled with DiI ( 1, 1-dioctadecyl-3,3,3,3-tetramethylindocarbocyanine perchlorate) and cultured with MADM to form a complex. The adhesion of ASC to MADM was observed by fluorescence microscope and electron microscope.The proliferation of ASC on MADM was evaluated by 3-(4, 5-dimethylthizazol-2-yl)-5-( 3-carboxy methoxyphenyl)-2-(4-sulfonyl )-2H- tetrazolium, inner salt (MTS). Three days after the culture, the complex was mixed with appropriate amount of collagen, and then injected into the unilateral vocal cord of the rabbit. The animals were sacrificed 2, 4, 8 weeks after injection, the survival time and distribution of ASC in vocal fold were tested, and the responses of vocal cord to ASC-MADM and the degradation of MADM were observed. Results The ASC adhered to MADM and grew well (P ＜0. 05 or ＜0. 01 ), showing good compatibility with MADM in vocal cord tissue. The complex of ASC-MADM could be injected into the rabbit vocal cords, while no adverse reactions was observed in the vocal cord by endoscope, frozen section and HE staining. ASC could survive for 8 weeks in vocal cords, and no inflammatory cell infiltration was observed.Conclusions MADM is an ideal scaffold material and shows perfect compatibility with ASC which can adhere and proliferate well on it. The complex of ASC-MADM can be injected into the vocal cord and can survive. There is no adverse reaction in vocal cords.     

支撑喉镜下喉硅胶膜置入及声带缝合手术治疗喉蹼

目的探讨喉硅胶膜置入及声带黏膜缝合术在治疗喉蹼中的价值及预后转归。方法21例喉蹼患者，4例儿童，17例成人；其中既往有双侧声带手术史（声带任克水肿、声带小结、声带息肉、声带角化）8例，喉乳头状瘤手术史6例，喉部外伤史6例，先天性喉蹼1例。患者在全麻支撑喉镜下行喉蹼瘢痕松解后，15例成人行声带黏膜缝合及喉硅胶膜置入术；4例儿童及2例成人行单纯声带黏膜缝合术。结果15例喉硅胶膜置入患者3—4周后取出支撑的硅胶膜，除1例既往曾有喉裂开史，治疗后前联合处仍残留2—3mm粘连带外，其余14例患者声带前联合均获得良好三角形形态，发音明显改善，无呼吸困难。6例行单纯声带黏膜缝合患者呼吸及发音得到明显改善，2例成年患者前联合处残存2～3mm正常黏膜，术后声带即获得很好成形效果；4例患儿术后前联合残留2—3mm粘连。全部患者随诊6个月-3年，无瘢痕再生。结论喉硅胶膜置入及声带缝合手术治疗喉蹼，利于患者呼吸及发音功能的改善，避免颈外入路手术或气管切开及长期声门支撑，创伤小，并发症少。而声带黏膜单纯缝合手术还可以单独应用于粘连带相对较薄（小于5mm）、黏膜相对丰富的儿童及前联合残存正常黏膜的喉蹼患者。