杓状软骨内移联合喉返神经修复术治疗单侧声带麻痹

目的 探讨杓状软骨内移联合颈袢喉返神经吻合术治疗长期喉返神经损伤单侧声带麻痹的疗效.方法 病程3～22年外伤性喉返神经损伤单侧声带麻痹患者12例,行患侧杓状软骨内移的同时,作颈袢喉返神经吻合术.治疗前后以电子喉镜、频闪喉镜、声音评估、嗓音声学参数分析和喉肌电图检查等评价治疗效果.结果 所有患者杓状软骨内移术后即刻声嘶均明显好转,但无恢复正常者,声学四参数频率微扰、振幅微扰、标化噪音能量和最长发声时间分析均明显好转,差异均有显著性意义(P值均＜0.05);喉镜检查见杓状软骨明显内移,声门后裂隙消失9例,缩小3例.术后12个月时声音恢复正常、明显好转、好转、无改善分别为9、3、0、0例;声学四参数较术后即刻又有明显好转,差异均有显著性意义(P值均＜0.05);术侧声带虽未恢复运动,但肌张力和肌体积与健侧基本对称.肌电图检查显示术后12个月声带肌恢复与健侧同步的密集型自发电位.结论 杓状软骨内移联合颈袢喉返神经吻合治疗长期喉返神经损伤单侧声带麻痹能恢复患者的正常发音功能.     

内镜下单侧杓状软骨固定的杓状软骨复位术

环杓关节固定最常见的原因是钝挫伤、穿通伤、医源性创伤及炎症性关节疾病 ,进而导致发音困难和 /或气道梗阻。杓状软骨固定的诊断方法 :1物理检查 (动态喉镜 ) ;2喉肌电图 ;3直接喉镜下被动移动性试验。本文介绍了单侧杓状软骨固定伴喉后部开放所致严重呼吸性发音困难的治疗 ,即用内镜将外展位固定的杓状软骨内收的新技术。该作者回顾了 5年内 (1994～ 1999)内镜下杓状软骨复位术治疗的 8例病人 ,平均年龄 4 5 .9岁 ,均有呼吸性发音困难或失音。患者术前和术后的嗓音数值由言语病理师进行分析。应用 5点分级法 :1声音正常 ;2声音接近正常 ;…     

经间接喉镜和直接喉镜杓状软骨拨动术的比较研究

目的 :探讨在局麻下经间接喉镜和直接喉镜杓状软骨拨动术对气管插管致环杓关节脱位的疗效。方法 :将 2 3例气管插管致环杓关节脱位患者随机安排在局麻下经间接喉镜或直接喉镜行杓状软骨拨动术 ,并对两组进行比较。结果 :每组患者的治疗起始时间与发音功能康复时间呈正相关 ;两组患者的治疗起始时间和发音功能康复时间的比较差异无显著性意义 (P >0 .0 5 ) ,复位次数差异有显著性意义 (P <0 .0 5 ) ,术后咽喉疼痛反应持续时间的差异无显著性意义 (P >0 .0 5 )。结论 :喉损伤的治疗起始时间对患者完全恢复发音功能有重要影响。两种方式对环杓关节脱位均有良好疗效。直接喉镜杓状软骨拨动术对喉损伤病程偏长的患者较为适合     

喉内进路杓状软骨切除术

杓状软骨切除术治疗双侧外展肌麻痹所致通气障碍的进路有:喉裂开进路(B aker,1916);喉外进路(Woodm an,1946);内窥镜下喉内进路(Thornell,1948)。Brown(1951)指出,喉内进路较喉外简单,血肿形成和感染率均低,术中容易判断声门裂的大小。作者报道双侧外展肌麻痹喉内进路杓状软骨切除术6例。4例行一侧杓状软骨切除,术后发音通气良好。2例行双侧杓状软骨切除,其中1例通气尚好但发音略差;另一例仍需气管造口。无严重并发症。手术方法:投予抗生素,全麻下行悬吊喉镜检查。未曾气管造口者,手术开始前先行气管造口。按Thornell(1948)氏法切口稍加改进,使呈“T”形。锐分离暴露杓状软骨后用喉钳抓住,继续剥离至杓     

改良杓状软骨复位术治疗环杓关节脱位

目的 探讨环杓关节脱位临床特征及改良杓状软骨复位术的疗效.方法 改良杓状软骨复位术,即应用直角喉钳握持杓状软骨上部表面,根据脱位位置将杓状软骨向后外侧或前内侧方向旋转拨动.67例声带运动不良患者表面麻醉间接喉镜下行改良杓状软骨复位术,其中全身麻醉插管导致环杓关节脱位57例,非插管原因10例(6例为顿挫性喉外伤).对患者临床特征、嗓音功能、手术方法及疗效进行分析.结果 患者均有明显声音嘶哑,频闪喉镜下均见不同程度的声带运动障碍(50例为左侧,占74.6％)及声门闭合不良,杓状软骨向前内侧移位63例,向后外侧移位4例.行喉肌电图检查的38例插管患者中,10例(26.3％)肌电异常,可见失神经电位.改良杓状软骨复位后,57例全身麻醉插管导致环杓关节脱位患者声音均有改善,其中51例发音正常,6例轻度嘶哑;54例声带运动恢复正常,3例声带运动改善.10例非插管原因患者中,声带运动及发音7例恢复正常,1例改善,2例无效.结论 环杓关节脱位部分病例合并喉返神经损伤(多为暂时性损伤),脱位后6周内改良杓状软骨复位术可使声带运动及发音功能得到满意恢复.钝挫性喉外伤导致的声带运动不良原因复杂,即使杓状软骨复位,喉部瘢痕挛缩也可能影响疗效.     

改良杓状软骨内收术治疗单侧声带麻痹

目的评估改良杓状软骨内收术治疗单侧声带麻痹的疗效。方法回顾性分析2001年2月～2007年12月22例行改良杓状软骨内收术的单侧声带麻痹患者的临床资料,对术前和术后3个月的误吸指数、主观听感知评估参数（GRBAS）、声学检测参数[基频（F0）、基频微扰（jitter）、振幅微扰（shimmer）、标准化噪声能量（NNE）]、最大声时（MPT）、平均气流率（MFR）进行统计学分析。结果22例患者术后误吸指数分值较术前明显下降,GRBAS评估各参数比术前明显下降,声学检测各参数（F0、jitter、shimmer、NNE）较术前明显降低,最大声时明显延长,平均气流率明显降低,差异均有统计学意义（均为P〈0.001）。结论改良杓状软骨内收术是一种治疗单侧声带麻痹有效的声带内移术,既可恢复良好的发声功能,又可缓解误吸。     

双蒂肌转入充填联合杓状软骨内移喉成形术治疗单侧声带麻痹

目的 探讨双蒂胸骨舌骨肌瓣转入声门旁联合杓状软骨内移治疗单侧声带麻痹的疗效.方法 不适合行喉返神经探查修复术的单侧声带麻痹19例.在甲状软骨板正中旁开0.5 cm裂开甲状软骨板,在杓状软骨内收固定的同时将带双蒂的胸骨舌骨肌瓣转入患侧声门旁内.治疗前后以电子喉镜、频闪喉镜、嗓音听评委主观评估、声学参数客观分析等评价治疗效果.结果 所有患侧声带膜部及声带突部术后即刻均明显内移,声带体积增大,发声时增大更为明显.术后2个月声门后裂隙消失6例,缩小13例;12个月后嗓音总嘶哑度评估:恢复正常6例,轻度声嘶12例,中度声嘶1例,较术前明显好转,采用等级资料数据秩和检验,差异具有统计学意义(z值为-4.062,P＜0.01).术后12个月的声门后裂隙、嗓音总嘶哑度与术后2个月比较无明显区别(P值均＞0.05).术后2个月及12个月声学客观指标的4个参数(基础频率、频率微扰、振幅微扰和谐噪比)平均值均明显小于术前,最长声时明显长于术前,差异均有统计学意义(P值均＜0.05).术后12个月与2个月比较上述参数差异均无统计学意义(P值均＞0.05).结论 双蒂胸骨舌骨肌充填联合杓状软骨内移喉成形术治疗不适合行喉返神经探查修复术的单侧声带麻痹患者的创伤小,无排异反应,远期效果较稳定.     

保留杓状软骨喉次全切除喉功能重建的体会

目的　探讨应用保留杓状软骨的喉次全切除喉功能重建术治疗T3 喉癌 (声门及声门上型 )的拔管率和 3、5年生存率。方法　对 2 0例T3 级喉癌 ,其中声门型 3例 (T3 N0 M0 )、声门上型 17例(T3 N1 M0 5例 ,T3 N0 M0 12例 ) ,根据病变范围行保留单侧或双侧杓状软骨喉次全切除及功能重建术 ,并设计环咽吻合术式。结果　 3、5年生存率分别为 16/ 17(94 1% )和 11/ 12 (91 8% )。全部患者均恢复了吞咽和发音功能 ,拔管率为 95 0 %。结论　保留杓状软骨喉次全切除及功能重建术是治疗T3 喉癌的一种很好术式。手术的关键是不能损伤杓状软骨及喉返神经 ,设计好环咽吻合方案。     

环状软骨上喉部分切除术嗓音的演化

目的：研究环状软骨上喉部分切除术后的嗓音声学特征。方法应用计算机言语实验室言语系统对５是否 状软骨上喉部分切除术的患者术后１８个月中嗓音及言语的演化过程进行前性研究。结果：环状软骨上部分切除术后患者发音参烽不稳定，而言语参数一直保持稳定。结论：在喉癌环状软骨上喉部分切除术中只保留一侧的杓状软骨，发音功能仍能保留。     

声带注射治疗声带麻痹及检测喉发音的研究

对30例不同病因所致单侧声带麻痹患者,采用经环甲间隙穿刺声带注射硅胶的方法进行治疗.治疗前后对患者的最长发音时间(MPT)、喉平均呼气流率(MFR)、基频值(F_0)、声强级(SPL)、频率微扰商(PPQ)、振幅微扰商(APQ)、噪声能量级(NNE),频闪喉镜下声带振动发音过程中的对称性(SYM)、规则性(REG)、振幅(AMP)、闭合状态(GLO)、粘膜波动(MUC)、等质性(NON)和嗓音心理听觉评价参数:音哑总分度(G)、粗糙型(R)、气息型(B)、无力型(A)、紧张型(S)进行检测,并对测试结果进行统计学分析.实验结果表明,上述各项参数值在治疗后较治疗前有明显改善,其中MPT、GLO值的增高,MFR、PPQ、APQ、NNE值下降表现最明显:心理听觉评价参数GRBAS值治疗后较治疗前也有明显好转.对各参数进行统计学分析得出:声带麻痹嗓音中噪音成分主要同声带振动的规则性、振幅和粘膜波呈正相关(P<0.05或 P<0.01).声带麻痹嗓音的主观心理听觉评价是以气息型和无力型为主.它主要与喉平均呼气流率,声带振动的规则性、闭合度、振幅、声带粘膜波及对称性呈正相关.从而证明,经环甲间隙声带注射硅胶治疗单侧声带麻痹是一种简单、实用、安全的治疗方法.若一次不成功还可以重复治疗.     

Combination of direct pull of lateral cricoarytenoid muscle and thyroplasty type I for severe unilateral vocal cord paralysis

Techniques and the outcome of our approach that combined two operations, a direct pull of the lateral cricoarytenoid muscle (LCA-Pull) and Isshiki's thyroplasty type I are reported. LCA-Pull is very simple and allows natural adduction of arytenoid by pulling LCA. The subjects were five patients whose maximal phonation time (MPT) were under 5 seconds. All patients achieved MPT over 13 seconds. Mean flow rates (MFR) varied from 340ml/s to over 1000 ml/s before the operation. In all patients, the post operative MFR improved to under 150 ml/s. Sometimes severe unilateral vocal cord paralysis requires both arytenoid adduction and medialization thyroplasty to obtain good voice. Combination of LCA-Pull and thyroplasty type I is very effective for severe case, and could be done in the same operating field by creating an additional window in the thyroid ala.     

A "fenestration approach" for arytenoid adduction through the thyroid ala combined with type I thyroplasty

OBJECTIVE: To develop and evaluate the voice outcomes of an approach of arytenoid adduction (AA) through a fenestration of the thyroid ala for unilateral vocal cord paralysis. STUDY DESIGN: Twelve consecutive patients with severe unilateral vocal cord paralysis, whose maximum phonation times (MPTs) were less than or equal to 5 seconds, underwent laryngoplasty using an approach of AA performed through a fenestration of the thyroid ala combined with type I thyroplasty. METHOD: Two surgical windows were made in the lower part of the thyroid ala. The anterior window was for typical type I thyroplasty, and the posterior window was for AA. AA was performed by pulling the lateral cricoarytenoid muscle (LCA) (5 patients) or muscular process (7 patients) through the posterior fenestration in the contractile direction of the LCA without releasing the cricoarytenoid joint. The operation was performed under local anesthesia with sedation except in two patients who underwent general anesthesia using a laryngeal mask. The vocal cord medialization was confirmed endoscopically during the operation. For all patients, the MPT and mean airflow rate (MFR) were measured before and after the operation. The postoperative voices were analyzed using shimmer and jitter. RESULT: All patients achieved a MPT of over 12 seconds. The MFR, which ranged from 340 to 1902 mL/second before the operation, improved to less than 200 mL/second, except in one patient whose MFR was 210 mL/second. Shimmer and jitter improved significantly after the operation. Perceptual evaluation using the GRBAS (grade, roughness, breathiness, aesthenia, strain) scale also improved significantly. CONCLUSION: A fenestration-based approach simplified the combination of AA and type I thyroplasty because the two treatments could be performed in the same operating field and provided good voice improvement. Pulling the AA braid in the contractile direction of the LCA and endoscopic vocal cord observation during surgery may have contributed to the positive results.     

Immediate recurrent laryngeal nerve reconstruction and vocal outcome

OBJECTIVE: The objective of this prospective study was to assess the long-term effects of immediate reconstruction of the recurrent laryngeal nerve (RLN) during thyroid cancer extirpation on postoperative phonatory function. SUBJECTS AND METHODS: The subjects were 22 patients with advanced thyroid cancer who underwent resection of the primary lesion and involved RLN. RLN paralysis was seen in 12 patients preoperatively and involvement of the RLN was noted intraoperatively in 10. Immediate reconstruction of the RLN was performed on eight patients using the great auricular nerve and one underwent direct anastomosis of the RLN stumps (group I). Nine patients opted not to have phonosurgical procedures (group II). The remaining four had arytenoid adduction immediately after cancer extirpation (group III). Phonatory function (stroboscopy, maximum phonation time [MPT], mean airflow rate [MFR], harmonics-to-noise ratio [HNR], jitter, and shimmer) was followed for at least 9 months. RESULTS: Minimal or no glottal gap during phonation was observed in six patients in group I, whereas the patients in group II had a large gap along the entire fold. HNR, MPT, and MFR were significantly better in group I (17.7 +/- 3.6 dB, 15.1 +/- 6.3 s, and 100 +/- 32 mL/s, respectively) than in group II (12.1 +/- 2.9 dB, 5.4 +/- 3.1 s, and 430 +/- 207 mL/s, respectively). Patients in group III had a gap of varying degrees along the membranous fold. Although HNR, shimmer, and MPT in group III were comparable to group I, the other parameters were less favorable than in group I. CONCLUSION: Immediate RLN reconstruction at the time of thyroid cancer extirpation can provide excellent postoperative phonatory function.     

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...     

Three-dimensional laryngeal model for planning of laryngeal framework surgery

CONCLUSION: The three-dimensional prototype model was useful for planning of laryngeal framework surgery. OBJECTIVE: To discuss the usefulness of a three-dimensional laryngeal model for laryngeal framework surgery. MATERIALS AND METHODS: A three-dimensional laryngeal model was created based on the postoperative helical computed tomography (CT) data of the larynx (case 1) which underwent lateral cricoarytenoid muscle (LCA) pull surgery. LCA pull surgery is a kind of arytenoid adduction for unilateral vocal cord paralysis. A three-dimensional model of case 1 larynx was prototyped using a selective laser sintering method. In case 1, the patient's voice did not improve after LCA pull surgery. The three-dimensional model revealed that the original surgical procedure was not appropriate to obtain optimal arytenoid adduction. According to the analysis of this three-dimensional model, we changed the surgical approach and performed this new refined LCA pull surgery on another patient with unilateral vocal cord paralysis (case 2). RESULTS: We were able to pull LCA precisely in case 2. Three-dimensional CT of case 2 after refined LCA pull surgery allowed the correct pulling of LCA and complete adduction of arytenoid. The postoperative voice improved remarkably.     

Three-dimensional laryngeal model for planning of laryngeal framework surgery

Conclusion. The three-dimensional prototype model was useful for planning of laryngeal framework surgery. Objective: To discuss the usefulness of a three-dimensional laryngeal model for laryngeal framework surgery. Materials and methods. A three-dimensional laryngeal model was created based on the postoperative helical computed tomography (CT) data of the larynx (case 1) which underwent lateral cricoarytenoid muscle (LCA) pull surgery. LCA pull surgery is a kind of arytenoid adduction for unilateral vocal cord paralysis. A three-dimensional model of case 1 larynx was prototyped using a selective laser sintering method. In case 1, the patient's voice did not improve after LCA pull surgery. The three-dimensional model revealed that the original surgical procedure was not appropriate to obtain optimal arytenoid adduction. According to the analysis of this three-dimensional model, we changed the surgical approach and performed this new refined LCA pull surgery on another patient with unilateral vocal cord paralysis (case 2). Results. We were able to pull LCA precisely in case 2. Three-dimensional CT of case 2 after refined LCA pull surgery allowed the correct pulling of LCA and complete adduction of arytenoid. The postoperative voice improved remarkably.     

Collagen injection as a supplement to arytenoid adduction for vocal fold paralysis

OBJECTIVES: Dysphonia associated with vocal fold paralysis can persist even after successful medialization procedures, including arytenoid adduction. It is hypothesized that laryngeal collagen injection could improve phonation following arytenoid adduction in selected patients. Our objective was to evaluate how collagen injection could result in measurable improvements in vocal function and voice quality. METHODS: Forty patients with unilateral vocal fold paralysis who had undergone arytenoid adduction underwent transoral injection of non-cross-linked bovine dermal collagen by means of indirect laryngoscopy and a curved injection device. A control group of 40 patients underwent arytenoid adduction but not collagen injection. The patients' voice quality was assessed perceptually with the GRBAS scale, and vocal function was assessed by acoustic and aerodynamic measures (maximum phonation time and transglottal DC flow). The relative glottal area was also assessed by videostroboscopy. RESULTS: Significant improvements in vocal function and voice quality were observed with collagen injection for those patients who did not achieve satisfactory glottal competence with arytenoid adduction alone. Glottal area measurements revealed that glottic insufficiency was significantly reduced after arytenoid adduction as well as after collagen injection. CONCLUSIONS: The findings suggest that collagen injection could be an effective supplementary treatment for improving voice following arytenoid adduction. It has the advantage of being a minimally invasive outpatient office procedure. The long-term efficacy of the procedure should be explored.     

Perineurioma originating from the recurrent laryngeal nerve, and the phonochirurgical treatment of the developed vocal fold palsy

Perineurioma is a rare, benign tumour of the perineurium, which develops mostly on the nerves of the extremities. The neoplasm related to a genetic mutation on the 22nd chromosome, is a rarity on the vagal nerve branches. Authors report the case of a 15-year-old female with an immunhistochemically verified (focal EMA positive, vimentin, CD56 positive) perineurioma originating from the left recurrent laryngeal nerve. After the removal of the tumour together with the involved 2-cm-long part of the nerve, vocal fold palsy developed with aphonia (left vocal fold was in intermedian position). The treatment had to be chosen carefully as the larynx was still in growth. In our case there was no possibility of spontaneous regeneration, thus we chose lipoaugmentation of the left vocal fold, which does not affect the laryngeal framework, so causes the least harm to the larynx. Following surgery the patient’s voice reached the normal range (before lipoaugmentation perception (0–100): G40 B80 R40 Acoustics: Ji 1.1%, Shi 10.8% Harmonicity: 13.9 dB maximum phonation time (MPT) 5 s after augmentation, Perception: G10 B10 R20, Acoustics: Ji 0.3 %, Shi 2.6%, Harmonicity: 21.2 dB MPT 22 s). This result was permanent, as the regularly performed objective voice evaluations confirmed during the 2-year follow-up.     

喉返神经修复术及非喉返神经修复术治疗声带麻痹

目的 探讨喉返神经修复术及非喉返神经修复术这两种不同术式治疗声带麻痹的疗效。方法 ①单侧声带麻痹21例, 其中采用喉返神经修复术(喉返神经减压术、颈袢神经与喉返神经吻合术、颈袢神经肌肉蒂环杓侧肌移植术)15例, 采用非喉返神经修复术(声带自体脂肪注射术、自体软骨Ⅰ型甲状软骨成形术)6例;②双侧声带麻痹16例, 其中采用喉返神经修复术(喉返神经减压术、颈袢神经肌肉蒂环杓后肌移植术)6例, 采用非喉返神经修复术(声带外移术、内镜下杓状软骨切除术)10例。治疗前后以电子喉镜、频闪喉镜、声音评估等评价手术疗效。结果 ①单侧喉返神经麻痹患者中喉返神经修复组15例, 术后术侧声带活动不同程度改善, 发音时声带突明显内收, 声带振动及黏膜波均恢复对称性, 声门闭合良好, 手术前后的最大声时为(5.51±1.05)s和(12.10±1.41)s, 差异有统计学意义(P<0.01);非喉返神经修复术术后声带均不同程度内移, 声嘶症状改善, 但声带均无运动, 手术前后的最大声时为(5.47±0.45)s和(11.83±1.47)s, 差异有统计学意义(P<0.01)。神经修复组和非神经修复组术后最大声时比较, 差异无显著性意义(P>0.05);②双侧喉返神经麻痹患者中喉返神经修复术6例中, 术后呼吸困难缓解及声带外展部分恢复4例;非神经修复术10例术后呼吸困难改善;神经修复组术后拔管率为66.7%, 非神经修复组术后拔管率为100%;Fisher精确概率法比较两组术后拔管率, 差异无统计学意义(P>0.05)。结论 对于单侧声带麻痹, 喉返神经修复术及非喉返神经修复术疗效相当, 前者的远期疗效更佳。对于双侧声带麻痹, 非喉返神经修复术疗效更佳, 但喉返神经修复术不影响患者的发音功能。选择喉返神经修复术或非喉返神经修复术治疗声带麻痹, 需要医师根据自身的专业知识及技能、患者的身体状况及需求, 作出慎重的决定, 以取得可靠的疗效。     

Three-dimensional anatomic characterization of the canine laryngeal abductor and adductor musculature

The biomechanics of vocal fold abduction and adduction during phonation, respiration, and airway protection are not completely understood. Specifically, the rotational and translational forces on the arytenoid cartilages that result from intrinsic laryngeal muscle contraction have not been fully described. Anatomic data on the lines of action and moment arms for the intrinsic laryngeal muscles are also lacking. This study was conducted to quantify the 3-dimensional orientations and the relative cross-sectional areas of the intrinsic abductor and adductor musculature of the canine larynx. Eight canine larynges were used to evaluate the 3 muscles primarily responsible for vocal fold abduction and adduction: the posterior cricoarytenoid, the lateral cricoarytenoid, and the interarytenoid muscles. Each muscle was exposed and divided into discrete fiber bundles whose coordinate positions were digitized in 3-dimensional space. The mass, length, relative cross-sectional area, and angle of orientation for each muscle bundle were obtained to allow for the calculations of average lines of action and moment arms for each muscle. This mapping of the canine laryngeal abductor and adductor musculature provides important anatomic data for use in laryngeal biomechanical modeling. These data may also be useful in surgical procedures such as arytenoid adduction.