二种显微喉镜手术方法的疗效分析

目的 比较间接显微喉动态镜手术和显微支撑喉镜手术二种方法的疗效及适应证。方法 对218例喉部良性病变患者中116例行间接显微喉动态镜手术,102例显微支撑喉镜手术,术后1月随访并行喉动态镜检查。结果 二种手术方法均取得满意疗效,全部患者声嘶消失,发声接近正常,未见病变残留,喉动态镜检查未见明显异常。结论 间接显微喉动态镜手术是一种功能控制下的手术,声带功能的恢复较快,显微支撑喉镜手术的应用范围广,两者各有优缺点,如掌握好各自的适应证,可使喉显微外科技术更为完善。     

Histological basis for indirect videostroboscopic phonosurgery —a scanning electron microscopic study

Indications for indirect videostroboscopic surgery are well established for small, benign functional lesions of the vocal folds. Epithelial cells of the vocal folds are spindle-shaped and by their long axies run parallel to the free edge of the vocal fold. This occurrence is used clinically by surgeons to obtain an even operative defect when using a cup forceps during single-handed manipulations. Nevertheless, there are still some doubts about single-handed procedures, so that many surgeons prefer the convenience of bimanual manipulation offered by direct (suspension) microlaryngoscopic surgery. The aim of this study was to demonstrate that single-handed manipulation during indirect videostroboscopic surgery permitted obtaining regular edges of an operative defect during laryngeal surgery. A scanning electron microscopic study was conducted on five cadaver larynges following indirect videoscopic excisions at the vocal fold's free edge and ten controls. Results demonstrated a clearly regular edge of the operative defects in cases when a posterior traction surgical procedure was followed. These findings reaffirm the value of indirect videostroboscopic surgery for small, benign functional lesions of the vocal folds.     

间接显微喉动态镜手术

目的　介绍间接显微喉动态镜手术治疗声带良性病变的方法并总结临床经验。方法　在表面麻醉间接喉镜下，通过与喉动态镜频闪光源连接的手术显微镜切除声带良性病变５０ 例。结果　效果满意，治愈率９２ ％ ，未发生并发症。结论　间接显微喉动态镜手术具有安全、声带功能恢复良好等优点，是治疗声带良性病变的较好的手术方法之一     

Granuloma of the membranous vocal fold: an unusual complication of microlaryngoscopic surgery

OBJECTIVES: We describe the clinical features of granuloma of the membranous vocal fold (as opposed to granuloma of the vocal process, or "contact granuloma"), a poorly recognized sequela of microlaryngoscopic surgery. Membranous vocal fold granuloma may mimic the initial lesion in appearance, and thus be mistaken for recurrence. METHODS: We performed a retrospective review of cases from 2 institutions. RESULTS: Fifteen cases of membranous vocal fold granuloma from 2 institutions were identified. In all but 1 case, granuloma developed in the early postoperative period, within 8 weeks. Of the 15 cases, 10 followed laser resection of carcinoma. Five were noted following cold steel resection of benign lesions (2 papillomas, 2 cysts, 1 Reinke's edema). Technical aspects of these cases suggest that membranous vocal fold granulomas result from surgical violation of deep tissue planes and/or epithelial defects. All patients were treated with proton pump inhibitors. In 12 cases, the granulomas proved self-limited, resolving over weeks to months following surgery. Three patients underwent surgical removal of the lesion, which confirmed the diagnosis. One of these cases recurred and was treated nonsurgically. CONCLUSIONS: Granuloma should be suspected when a mass lesion appears at the surgical site early in the postoperative course. Surgical excision is generally not necessary and may provoke further growth of granulation tissue.     

支气管潜窥镜在喉显微手术中的应用

目的探讨支气管潜窥镜下行喉显微手术的可行性.方法全麻支撑喉镜下应用支气管潜窥镜Hopkings     

表面麻醉支撑喉镜喉显微手术治疗声带良性病变

目的:探讨喉显微手术治疗声带良性病变的效果及麻醉选择。方法:手术在1%丁卡因表面麻醉支撑喉镜下进行,采用普通手术显微镜连接300mm焦距镜头观察病变。结果:872例中声带息肉353例,声带小结438例,声带囊肿81例,851例完成手术,697例1次治愈,总有效率为96.9%。结论:青、壮年患者,无明显心血管疾病,可选择表面麻醉手术,表面麻醉并发症少,恢复快,支撑喉镜下显微手术清除病变彻底。     

Videoendoscopic laryngeal surgery

This paper introduces videoendoscope-assisted laryngeal surgery with office-based equipment. With this technique, a patient is seated and the nose, pharynx, and larynx are topically anesthetized. A flexible videoendoscope with a light-sensitive charge-coupled device chip built into the tip is transnasally inserted by an assistant. Specially designed fine-tipped forceps and scalpels were developed for removal of laryngeal lesions. Videoendoscopic laryngeal surgery was undertaken in 114 cases of laryngeal lesions such as polyps, granuloma, and cancer. For benign vocal fold lesions, postoperative vocal function was shown to be improved on aerodynamic and perceptual analyses. For laryngeal tumors, biopsy of the lesion was easily undertaken. Videoendoscopic laryngeal surgery presents the following advantages. It is applicable to outpatients not requiring general anesthesia, it enables functional monitoring of the patient's voice and vocal fold during phonation, it allows for delicate manipulations with both hands, and it gives high-resolution images in comparison to conventional fiberscopy.     

嗓音声学分析在喉显微手术疗效评估中的应用

目的 :探讨声带息肉患者声学参数值的变化与手术疗效的关系。方法 :采用 Dr.Speech软件 ,对 80例声带息肉患者于术前、术后进行测试 ,经计算测得所需要的主要声学参数与已建立的正常嗓音和病理嗓音数据库进行比较分析 ,判断受测嗓音是否正常。结果 :80例声带息肉患者中 ,其主要声学参数基音频率微扰 (jitter)、基音振幅微扰 (shim mer)及声门噪声 (NNE)术前较高 ,术后较低 ,分别与术前比较 ,其差异均有极显著性意义 (P <0 .0 1) ;术后第 1周分别与术后第 2周和第 4周相比较 ,其差异亦有显著性意义 (P <0 .0 5或 0 .0 1)。在 3个声学参数中以 NNE的敏感性最高。结论 :NNE,shimmer值变化对手术疗效观察有较大意义。     

Report of a rare case of vocal fold carcinoma that was obscured by a prominent vocal fold polyp.

We report the case of a 56-year-old man who was evaluated for hoarseness. Telescopic and fiberoptic examination revealed a huge, pedunculated polyp that obscured the vocal folds. Upon further examination, microlaryngoscopy revealed a coexisting superficial irregular lesion on the upper surface of the left vocal fold, which was identified as a microinvasive carcinoma. This unusual presentation emphasizes the importance of a microlaryngoscopic examination.     

Videoendoscopic surgery for inaccessible glottic lesions

OBJECTIVES: Lesions in the anterior segment of the vocal fold are sometimes difficult to access by means of conventional suspension microlaryngoscopy under general anaesthesia because of anatomical factors such as short, stout and inflexible necks, reduced jaw protrusion, and long incisors. Various techniques have recently been proposed for the management of inaccessible glottic lesions, most of which are performed under general anaesthesia. The use of flexible videoendoscopic surgery under topical anaesthesia in two cases of anterior glottic lesions that could not be treated by means of conventional suspension laryngoscopy is described. STUDY DESIGN: Case report. METHODS: A flexible videobronchoscope with an instrument channel was inserted transnasally on an out-patient basis. While the examiner carried out the endoscopy, an assistant maneuvered the biopsy forceps through the instrument channel, and removed the lesion. RESULTS: Both patients underwent successful removal of an anterior glottic polyp, and the one-year follow-up evaluation revealed normal anatomy of the vocal folds and normal vocal function. CONCLUSIONS: Flexible videoendoscopic surgery under topical anaesthesia is a safe, simple and minimally invasive procedure that can be considered as an alternative to traditional endoscopic surgery for inaccessible anterior glottic lesions.     

内侧微瓣技术治疗声带良性病变手术前后嗓音主客观分析

目的探讨经支撑喉镜显微镜下内侧微瓣技术治疗声带良性病变的手术疗效及嗓音主客观分析在评价其疗效中的作用。方法对34例声带息肉、6例声带囊肿共40例患者行显微嗓音手术内侧微瓣技术切除病变,手术前后分别行动态喉镜检查、嗓音声学检测及嗓音障碍指数量表评估。以20例(男、女各10例)嗓音正常成年人作对照组。结果全组病例术后第4周行动态喉镜检查示声带黏膜光滑,活动好,开闭佳,手术前后各嗓音声学参数及嗓音障碍指数量表评分变化均有统计学意义(P<0.05),声学参数与嗓音障碍指数评分之间无明显相关性。结论内侧微瓣技术治疗局限声带内侧的良性病变具有安全、切除病变精确彻底、创伤小等优点,疗效满意,符合微创和功能外科的发展趋势;嗓音声学检测、动态喉镜检查及患者自我评估三者相结合可对手术疗效起到综合评估作用。     

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。     

Vocal fold paralysis following carotid endarterectomy.

Injury to the vagus nerve or one of its branches during carotid endarterectomy (CEA) can result in vocal fold paralysis (VFP). This study assessed prospectively 73 patients undergoing CEA. A total of 76 procedures were performed in these patients over a one-year period. All patients underwent pre-operative and post-operative assessment of vocal fold mobility by indirect laryngoscopy and/or flexible nasendoscopy. All patients had normal vocal fold mobility pre-operatively. Eight patients (10 per cent) complained of hoarseness after surgery and in three patients (four per cent) examination confirmed an ipsilateral VFP. This persists in all three patients at six-month follow-up. Vocal fold assessment is important in patients undergoing CEA, particularly when performing second side surgery. We recommend that patients should be informed of the risk of VFP following CEA when obtaining consent.     

Measurement of adult vocal fold length

Laryngeal photographs from 165 Taiwanese subjects were taken during microlaryngoscopy. Photographs of the vocal fold during the open phase were chosen. For measuring the vocal fold length, both the photograph of a ruler and the larynx were taken under the operating microscope, thus forming a 'new scale'. Photographs of the vocal fold and the ruler were then processed at the same power of magnification. The length of the vocal folds was measured with the 'new scale'. In 100 patients receiving direct laryngoscopy under neuroleptic anaesthesia, the vocal fold length was 14.6 +/- 1.2 mm (n = 35) for males and 11.1 +/- 1.0 mm (n = 65) for females. In 65 patients under general anaesthesia, the vocal fold length was 15.3 +/- 1.6 mm (n = 23) for males and 13.5 +/- 1.3 mm (n = 42) for females. Statistical analysis revealed a significant difference between both groups and both sexes. Elongation of the vocal fold under general rather than neuroleptic anaesthesia may be important when performing functional surgery of the vocal fold.     

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.     

One-year follow-up results of combined use of CO<Subscript>2</Subscript> laser and cold instrumentation for Reinke’s edema surgery in professional voice users

The purpose of this study was to present our experience with combined use of CO₂ laser and cold instrumentation for Reinke’s edema surgery and to evaluate 1-year follow-up results of the technique in a series of professional voice users. Fifteen patients with Reinke’s edema who underwent microlaryngoscopic surgery were included. Videolaryngostroboscopy, perceptual and acoustic voice analyses were performed before and after surgery. During the 1-year follow-up, no recurrence of Reinke’s edema was encountered. Significant postoperative improvement was obtained in the quality of voice, in terms of GRBAS scores, Fo, jitter, shimmer and NHR. No evidence of laryngeal cancer was found on the histological examinations. Combined use of CO₂ laser and cold instrumentation provides a reliable and safe method for Reinke’s edema surgery, and cessation of smoking, voice rest and control of the laryngopharyngeal reflux contribute to the success of surgery. We consider that the removal of redundant mucosa of the vocal fold reduces the risk of the recurrence of Reinke’s edema and provides better quality of voice. However, it does not imply that our method is superior to others’, but this procedure constitutes an effective treatment of choice for Reinke’s edema patients, including professional voice users.     

Indications for vocal cord augmentation with collagen]

BACKGROUND: Vocal fold augmentation through an indirect laryngoscopic injection has been largely supplanted by the external approach of vocal fold medialization. Vocal fold augmentation with collagen is still of clinical importance for the temporary treatment of glottic insufficiencies. The different elimination time of certain collagen compounds in the vocal fold tissue enables individual therapeutic applications. PATIENTS AND METHODS: The collagen compounds Zyderm I and II and Zyplast were injected into the vocal fold in 37 patients with neurogenic glottic insufficiency and 2 patients with vocal fold atrophy during indirect laryngoscopy. The choice of compound was made depending on the case, prognosis, severity of the disorder, the persistence of the glottic insufficiency, and the patient's age and condition. RESULTS: Thirty-three patients showed an significant improvement of the glottic closure. However, 6 patients showed hardly any change. CONCLUSION: Collagen augmentation can be used for the temporary medialization of the vocal fold. It is a suitable method for the treatment of vocal fold paralysis a) within the neural regeneration time, and b) in patients with reduced condition and/or a short life expectancy due to severe diseases.     

支撑喉内镜下手术治疗声带息肉小结体会

目的 探讨支撑喉镜下喉显微手术治疗声带息肉或声带小结的效果.方法 将我科2011年5月～2013年10月收治的声带息肉,声带小结的病历资料46例,进行术后1～6个月回顾性分析.结果 治愈44例声音恢复正常（95.6％）属临床治愈;1例声嘶明显改善（2.17％）为有显著效果;l例声嘶改善（2.17％）为有效;0例无效（声嘶无明显改善）.结论 支撑喉镜下喉显微手术治疗声带息肉、声带小结,整体治疗效果显著,治愈率高,并发症少,安全可靠。     

Functional results after external vocal fold medialization thyroplasty with the titanium vocal fold medialization implant

OBJECTIVES/HYPOTHESIS: A persistent insufficiency of glottal closure is mostly a consequence of a unilateral vocal fold movement impairment. It can also be caused by vocal fold atrophy or scarring processes with regular bilateral respiratory vocal fold function. Because of consequential voice, breathing, and swallowing impairments, a functional surgical treatment is required. The goal of the study was to outline the functional results after medialization thyroplasty with the titanium vocal fold medialization implant according to Friedrich. METHODS: In the period of 1999 to 2001, an external vocal fold medialization using the titanium implant was performed on 28 patients (12 women and 16 men). The patients were in the age range of 19 to 84 years. Twenty-two patients had a paralysis of the left-side vocal fold, and six patients, of the right-side vocal fold. Detailed functional examinations were executed on all patients before and after the surgery: perceptive voice sound analysis according to the "roughness, breathiness, and hoarseness" method, judgment of the s/z ratio and voice dysfunction index, voice range profile measurements, videostroboscopy, and pulmonary function tests. In case of dysphagia/aspiration, videofluoroscopy of swallowing was also performed. The respective data were statistically analyzed (paired t test, Wilcoxon-test). RESULTS: All patients reported on improvement of voice, swallowing, and breathing functions postoperatively. Videostroboscopy revealed an almost complete glottal closure after surgery in all of the patients. All voice-related parameters showed a significant improvement. An increase of the laryngeal resistance by the medialization procedure could be excluded by analysis of the pulmonary function test. CONCLUSIONS: The results confirm the external medialization of the vocal folds as an adequate method in the therapy of voice, swallowing, and breathing impairment attributable to an insufficient glottal closure. The titanium implant offers, apart from good tissue tolerability, the advantage of an easy, time-saving, and individually adjustable application during the operation.     

Glottic configuration after arytenoid adduction

It has been recently noted that laryngeal paralysis results in a complex alteration of the glottis. The membranous segment of the paralyzed vocal fold is shortened, and, during phonation, patients use hyperfunction to shorten the normal vocal fold to about the same length. Additionally, if the paralyzed vocal fold is not near the midline, the angle between the membranous and cartilaginous segments of the vocal fold is decreased, resulting in a “posterior” gap which cannot be closed by hyperadduction of the normal side. To determine whether arytenoid adduction addresses these problems, videolaryngoscopy was analyzed in 11 patients before and after surgery, and results were compared to patient satisfaction and acoustic and aerodynamic assessment. The posterior gap and glottic competence were improved in all patients, but only 6 had improvement in symptoms. Two had persistent vocal fold bowing but achieved good function after Teflon® injection. Three patients, all with paralysis for more than 20 years, had no increase in vocal fold length and very little subjective vocal improvement. Arytenoid adduction is most effective in acute cases. Poor functional results in chronic paralysis are related to failure to achieve vocal fold lengthening, presumably due to soft-tissue contracture.