喉部分切除术后不同声源振动模式转换与代偿研究

目的研究喉部分切除术后喉的振动源变化及声带振动模式的代偿、转归,以探讨嗓音功能保留情况. 方法研究93例喉部分切除术患者(28例水平喉部分切除、35例垂直喉部分切除、30例3/4喉部分切除)及50例健康对照者不同嗓音声学、气流动力学及频闪喉镜下喉功能特点. 结果水平喉部分切除术后声带对称、表层肥厚,粘膜波活跃,嗓音声学参数与正常差异有显著性(P<0.05).垂直喉部分切除患者为非声门源振动发音,新振动体为健侧室带与对侧修复肌瓣或修复肌瓣与喉前庭粘膜(杓区、会厌根粘膜)振动发音,健侧声带未参与,嗓音声学参数与正常差异有极显著性(P<0.01).3/4喉部分切除后为部分非声门源振动发音,代偿振动模式为修复肌瓣与健侧声带振动发音和修复肌瓣与健侧杓区肥厚粘膜形成振动体颤动发音2种,嗓音声学参数与正常差异有显著性(P<0.01).3/4喉部分切除与垂直喉部分切除比较后者嗓音声学参数略差,但无统计学意义. 结论在喉部分切除术中,水平喉部分切除术后嗓音功能最佳,而垂直喉部分切除术后最差;修复体形态、功能特性直接影响术后效果.手术修复过程应充分利用机体的代偿功能,使术后声音质量有所提高.     

Vocal function following hemilaryngectomy

Vocal function following hemilaryngectomy was investigated in 54 cases in which a superiorly based sternohyoid muscle flap was used for glottic reconstruction. Four types of material were employed for covering the muscle flap: hypopharyngeal mucosa, lip mucosa, thyroid perichondrium, and island cervical skin flap. The vocal function varied greatly from individual to individual; however, the following tendencies were observed in many cases: 1) the glottis did not close completely; 2) supraglottic structures (false fold, arytenoid region, and epiglottis) were hyperfunctional and vibrated instead of or together with the unaffected vocal fold; 3) vibrations of the laryngeal structures were irregular; 4) maximum phonation time was short; 5) mean airflow rate was high; 6) fundamental frequency and intensity ranges of phonation were limited; 7) the voice was rough, breathy, and/or strained; and 8) cases with poor vocal function were most frequent in the skin flap group and least frequent in the lip mucosa group.     

胸舌骨肌瓣或舌骨-胸舌骨肌瓣用于垂直喉部分切除术后声带重建

目的：探讨垂直喉部分切除术后改善发声，恢复喉功能的修复手段，以提高喉癌患者术后的生存质量。方法：垂直喉部分切除术后，用患侧甲状软骨外膜修复上半喉腔缺损，取健侧胸舌骨肌瓣（或舌骨－胸舌骨肌瓣）修复下半喉腔缺损并重建声带。结果：修复的新喉腔呈三角形，重建的声带具有一定的张力并参与发声，恰似一侧居于正中位麻痹的声带，发声时由健侧声带代偿运动与新声带前2／3相互靠近。93．4％的患者发声近乎正常或自觉发声质量较术前明显好转。结论：垂直喉部分切除术后采用患侧甲状软骨外膜和健侧胸舌骨肌瓣（或舌骨－胸舌骨肌瓣）修复缺损并重建声带，方法简单，取材方便，创伤小，效果满意，可作为垂直喉部分切除术后声带重建的首选方法。     

Comparative study of vocal function after near-total laryngectomy.

OBJECTIVES: To assess vocal function after near-total laryngectomy (NTL) and to compare that with after vertical hemilaryngectomy (VHL), both of which use the laryngeal mucosa as the vibratory tissue. STUDY DESIGN: We retrospectively evaluated 29 patients, 11 of whom underwent NTL and 18 of whom underwent VHL. However, 2 patients failed to speak and 1 patient's voice sample was lost following NTL, so we analyzed the voices of 8 patients who underwent NTL and 18 patients who underwent VHL. METHODS: Vocal function was examined by acoustic and aerodynamic analysis. Acoustic analysis involved the evaluation of pitch, intensity, pitch perturbation quotient, amplitude perturbation quotient, and normalized noise energy. In aerodynamic analysis, we studied the mean airflow rate, vocal efficiency index (alternating current/direct current [AC/DC]), and maximum phonation time. RESULTS: Vocal function except pitch after either NTL or VHL had much variability, but the results following each procedure did not differ significantly. CONCLUSIONS: There are no significant differences between vocal function following NTL and VHL. Fiberscopic examination of the mucosa of the arytenoid was observed to vibrate in patients who underwent NTL, so that the phonatory mechanism after NTL resembled that after VHL.     

Histopathologic investigations of the unphonated human vocal fold mucosa

CONCLUSION: Vocal fold vibration (phonation) after birth is one of the important factors in the growth and development of the human vocal fold mucosa. OBJECTIVES: Stellate cells in the maculae flavae located at both ends of the vocal fold mucosa are inferred to be involved in the metabolism of extracellular matrices. Maculae flavae are also considered to be an important structure in the growth and development of the human vocal fold mucosa. Tension caused by phonation (vocal fold vibration) is hypothesized to stimulate stellate cells to accelerate production of extracellular matrices. Vocal fold mucosae unphonated since birth were investigated histologically. SUBJECTS AND METHODS: Vocal fold mucosae, which were unphonated since birth, of three younger adults (17, 24, 28 years old) were investigated by light and electron microscopy. RESULTS: Vocal fold mucosae were hypoplastic and rudimentary and did not have a vocal ligament, Reinke's space or a layered structure. The lamina propria appeared as a uniform structure. Some stellate cells in the maculae flavae showed degeneration. Not many vesicles were present at the periphery of the cytoplasm. The stellate cells synthesized fewer extracellular matrices, such as fibrous protein and glycosaminoglycan. Cytoplasmic processes of the stellate cells were short and shrinking. The stellate cells appeared to have decreased activity.     

Histopathologic investigations of the unphonated human vocal fold mucosa

Conclusion. Vocal fold vibration (phonation) after birth is one of the important factors in the growth and development of the human vocal fold mucosa. Objectives. Stellate cells in the maculae flavae located at both ends of the vocal fold mucosa are inferred to be involved in the metabolism of extracellular matrices. Maculae flavae are also considered to be an important structure in the growth and development of the human vocal fold mucosa. Tension caused by phonation (vocal fold vibration) is hypothesized to stimulate stellate cells to accelerate production of extracellular matrices. Vocal fold mucosae unphonated since birth were investigated histologically. Subjects and methods. Vocal fold mucosae, which were unphonated since birth, of three younger adults (17, 24, 28 years old) were investigated by light and electron microscopy. Results. Vocal fold mucosae were hypoplastic and rudimentary and did not have a vocal ligament, Reinke's space or a layered structure. The lamina propria appeared as a uniform structure. Some stellate cells in the maculae flavae showed degeneration. Not many vesicles were present at the periphery of the cytoplasm. The stellate cells synthesized fewer extracellular matrices, such as fibrous protein and glycosaminoglycan. Cytoplasmic processes of the stellate cells were short and shrinking. The stellate cells appeared to have decreased activity.     

切除杓状软骨的喉垂直部分切除术中的残喉修复

目的探讨切除杓状软骨的喉垂直部分切除术残喉的修复方法。方法总结1991年1月—2000年12月87例(T1、12和，13分别有7、54和26例)声门型喉癌的疗效。因杓区或杓状软骨声带突受累，行切除杓状软骨的喉垂直部分切除术，术中利用局部组织修复残喉，重建喉功能。全部病例均未行填充物加高患侧杓区或利用皮瓣等其他组织重建声门。结果全部病例术后8～19d内恢复正常饮食。全部病例恢复了发音功能。86例患者拔除气管套管，拔管率为98，9％(86／87)。术后无咽瘘和肺部并发症，3例局部感染者7d内治愈。术后局部复发率为8，0％(7／87)，颈部淋巴结转移率为6．9％(6／87)。失访患者均按死亡计算，用直接法计算生存率，术后满3年者87例，3年内死亡5例、失访3例，3年生存率为90，8％(79／87)；术后满5年者63例，5年内死亡10例、失访2例，5年生存率为81．0％(51／63)。结论利用局部组织修复切除杓状软骨的喉垂直部分切除术的残喉，术后无严重误咽，发音效果良好，此修复方法既节约了手术时间，又避免了过度修复可能带来的负面影响。     

Vocal fold fixation in laryngeal carcinomas

The mechanisms of vocal fold fixation were determined by means of a whole-organ serial section study. A total of 80 laryngectomy specimens, 36 supraglottic and 44 glottic carcinomas, was investigated. In the supraglottic carcinomas, the most frequent cause of fixation of the ipsilateral vocal fold was a deep massive tumor invasion in the arytenoid eminence and the second most frequent cause was an extensive involvement of the thyroarytenoid (TA) muscle. Fixation of the contralateral vocal fold resulted from a deep tumor invasion in the contralateral arytenoid eminence. In the glottic carcinomas, fixation of the ipsilateral vocal fold resulted from an extensive invasion into the TA muscle. Fixation of the contralateral vocal fold was caused chiefly by an invasion into the contralateral TA muscle through the anterior commissure region. It resulted occasionally from an invasion into the interarytenoid muscle and contralateral arytenoid cartilage and cricoarytenoid joint via the posterior part of the larynx.     

Vocal fold injury following endotracheal intubation

Vocal fold scarring results in the formation of fibrous tissue which disturbs the vibratory pattern of the fold during phonation. However, vocal fold scarring in humans is poorly understood because of the lack of clear case reports focusing on voice quality. The authors present a case of vocal fold scarring with changes in voice quality. At the time of injury the pedicle mucosa was cemented with fibrin glue. Phonation was inhibited for two weeks and tranilast (300 mg/day) was given for 3 months. Sixty-nine days later, perceptual evaluation showed a normal result and the phonation time became better, but the mucosal vibration was still lacking. Ninety-seven days later, mucosal vibration was finally restored. We suggest that characterization of vocal fold scarring in humans may be different from that in animals, and recommend that surgical management should be avoided for at least three months after injury.     

声带不同CO2激光术式对嗓音功能的影响

目的 :探讨在喉部支架完整保留状态下 ,以CO2 激光手术对声带多种疾病行不同术式治疗后的嗓音功能改变。方法 :以CO2 激光对 5 0例喉角化症及白斑病患者行局部病变粘膜切除 ;对 90例声门癌行声带粘膜剥脱 30例 ,声带切除 6 0例。比较不同术式的嗓音声学、气流动力学及频闪喉镜下嗓音功能特点。结果 :局部病变粘膜切除术后 ,嗓音声学检测接近正常 (P >0 .0 5 ) ,声带剥脱术后 ,基频、基频微扰、振幅微扰与正常比较差异有显著性意义 (P <0 .0 5 ) ,谐噪比与正常比较差异有非常显著性意义 (P <0 .0 1) ;声带切除术后 ,嗓音声学参数与正常比较差异有非常显著性意义 (P <0 .0 1)。结论 :随着CO2 激光治疗深度的渐进 ,声带体层受累加重时 ,声带振动功能逐渐丧失 ,但代偿机制逐渐发挥作用 ,嗓音功能发生本质变化。     

Aerodynamic, acoustic, and vibratory comparison of arytenoid adduction and adduction arytenopexy

HYPOTHESIS: Adduction arytenopexy (AP) with thyroplasty provides improved physiologic placement of the vocal fold and therefore provides improved acoustic, aerodynamic, and vibratory function as compared with arytenoid adduction (AA) with thyroplasty. METHODS: Five cadaveric human larynges were prepared by removing supraglottic tissues and fixing the nontest vocal fold medially on the cricoid facet with a needle in a physiologic phonating position. Each test vocal fold was then sequentially tested using an excised larynx phonation system, first with AA with silastic medialization and then converted to AP without changing the contralateral fold position or silastic wedge. The excised larynx setup allowed for simultaneous collection of data, specifically subglottic pressure (including measurement of phonation threshold pressure [PTP]), mean airflow, acoustic output, and full-frame high-speed digital video. RESULTS: Aerodynamic evaluation was similar for each group with similar subglottic pressure versus output curves. Conditions involving AP typically had PTP values that were 80% of that for comparable AA conditions. Acoustic evaluation revealed differences between the two groups. Each AA was found to be vibrating with two dominant frequencies with their associated harmonics. Each AP vibrated at a single dominant frequency with its harmonics. CONCLUSION: AP provides improved vocal outcomes by decreasing system noise and decreasing PTP, which may lead to a stronger glottal signal with decreased vocal effort.     

A new paramedian approach to arytenoid adduction and strap muscle transposition for vocal fold medialization

OBJECTIVE: To develop a prosthesis-free medialization laryngoplasty for the treatment of glottal incompetence. STUDY DESIGN: Twenty-two consecutive patients with glottal incompetence underwent vocal fold medialization using a new paramedian approach to arytenoid adduction and/or strap muscle transposition. METHODS: Under local anesthesia, the thyroid lamina on the involved side was parasagittally separated 5 mm off the midline. The inner perichondrium was carefully freed from the overlying thyroid cartilage. After dividing the thyrohyoid and cricothyroid membranes, the lamina was retracted laterally, the inner perichondrium was opened, and the lateral cricoarytenoid muscle identified. Tracing the muscle fibers posterosuperiorly, the muscular process of the arytenoid was identified. A 2-0 or 3-0 Prolene suture was placed through the muscular process and tied to the cricoid cartilage at the origin of the lateral cricoarytenoid muscle. A bipedicled strap muscle flap was then transposed into the space between the lamina and the inner perichondrium and the thyroid cartilages sutured back into place. Pre- and postoperative voice evaluations measured mean fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, and maximal phonation time, as well as assessments of voice quality. RESULTS: Vocal improvement was obtained in 95% (21 of 22) of patients. There was a significant improvement (P <.05) in all parameters except shimmer. No major complications were noted in any patient, except for dyspnea in one patient resulting from arytenoid overrotation. CONCLUSION: The results suggest that a paramedian approach to arytenoid adduction combined with strap muscle transposition is a safe and effective method for treating glottal incompetence, particularly in patients with unilateral paralytic dysphonia.     

Voice function following CO2 laser microsurgery for precancerous and early-stage glottic carcinoma

CONCLUSIONS: With the cover layer injured, vocal function of mucosal ablation could be protected and even return to normal after surgery and vocal function of mucosal stripping was slightly affected with extensive mucosal injury. Once the body layer was injured, the compensatory mechanism would play an important role in phonation. OBJECTIVES: To investigate voice function following CO2 laser microsurgery for precancerous and early-stage glottic carcinoma. PATIENTS AND METHODS: Vocal function was examined by acoustic analysis, aerodynamic analysis and videostroboscopic examination. RESULTS: For mucosal ablation, vocal quality recovered 1 month after surgery. For mucosal stripping, although vocal quality was steady 3 months after surgery, slight hoarseness persisted in this group. The contour of the treated fold recovered postoperatively. There were no complications in recovery. For cordectomies, vocal quality became steady 6 months after the surgery. The supraglottal hyperfunction with supraglottal structure squeezing played an important role in phonation. The affected vocal fold mucosal wave was absent instead of a regular ventricular fold wave or mucosal wave of the vocal process during phonation. In comparison with the type III-IV cordectomy, the results of extended cordectomies (type Va and Vc) were worse; however, the difference was not statistically significant. Granulomas and anterior commissure webs were present. All granulomas resolved spontaneously 3 months postoperatively.     

胸骨舌骨肌瓣在垂直喉部分切除声带重建中的应用

目的评价胸骨舌骨肌瓣在垂直喉部分切除声带重建中的应用效果.方法21例声门癌患者,行垂直喉部分切除术,并应用单蒂胸骨舌骨肌瓣行声带重建.结果21例患者术后均发声质量较好,喉功能得到较好的保留.结论垂直喉部分切除术后应用单蒂胸骨舌骨肌瓣行声带重建,术后发声质量良好.     

Arytenoid appearance and vertical level difference between the paralyzed and innervated vocal cords

OBJECTIVES/HYPOTHESIS: In unilateral vocal fold paralysis, it has been generally accepted that the paralyzed vocal fold presents at a higher level than a normally innervated vocal fold. In this study, we correlate the appearances of the paralyzed arytenoid and the differences in level between the paralyzed and innervated vocal folds. STUDY DESIGN: Retrospective review using video-recorded images of larynx. METHODS: A total of 38 patients were selected for this study who reported symptoms of voice change attributable to a paralyzed vocal fold unilaterally. Video recordings were obtained using the laryngeal telescope. The heights were assessed according to the paralyzed positions, status (inspiration or phonation), and appearances of the paralyzed arytenoid. The appearances of paralyzed arytenoid were further clarified as the portions of the medial surface of the arytenoid that were visualized. RESULTS: In medial paralysis, the paralyzed vocal fold appeared mainly as being at an equal vertical level or as having no distinct difference from normal vocal fold during phonation. However, a few cases of medial paralysis showed a lower than normal or higher than normal vocal fold during phonation, depending on the appearance of the paralyzed arytenoid. In lateral paralysis, most of the paralyzed vocal folds were not higher than the innervated vocal folds during phonation. CONCLUSIONS: The heights of paralyzed vocal folds were variable depending on the paralyzed positions, the status of the larynx, and appearances of the paralyzed arytenoid. The fact that the paralyzed vocal fold is at a higher level than the normal vocal fold should be reconsidered.     

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...     

Ventricular dysphonia: clinical aspects and therapeutic options

OBJECTIVE/HYPOTHESIS: Ventricular dysphonia, also known as dysphonia plica ventricularis, refers to the pathological interference of the false vocal folds during phonation. Despite its low incidence and prevalence, Vd is a well-known phenomenon in voice clinics. The present report reviews symptoms, etiology, diagnosis, and therapeutic options regarding this voice disorder. STUDY DESIGN: Literature review and case studies. METHODS: The literature pertaining to all clinical aspects of V(D) was reviewed to define diagnostic and therapeutic clinical decision making. RESULTS: Ventricular dysphonia is characterized by a typical rough, low-pitched voice quality resulting from false vocal fold vibration. Ventricular dysphonia may be compensatory when true vocal folds are affected (resection, paralysis). Noncompensatory types may be of habitual, psychoemotional, or idiopathic origin. Because perceptual symptoms may vary considerably, diagnosis should rely on a meticulous voice assessment, including laryngeal videostroboscopic, perceptual, aerodynamic, and acoustic evaluation. Various therapeutic approaches for the noncompensatory type of ventricular dysphonia may be considered: voice therapy, psychotherapy, anesthetic or botulinum toxin injections, or surgery. CONCLUSION: The study presents the state of the art with respect to ventricular dysphonia and may be helpful in diagnosis and therapeutic decision-making.     

Partial laryngectomy with imbrication laryngoplasty for unilateral glottic carcinoma

Treatment options for unilateral glottic carcinoma include radiation therapy, partial laryngectomy, and endoscopic cordectomy. We use partial laryngectomy with imbrication laryngoplasty (PLIL) as a single modality curative approach in a selected group of patients with unilateral glottic carcinoma. PLIL includes a composite resection of the entire vocal fold with its ligament, muscle, adjacent paraglottic tissues, and the adjacent block of thyroid cartilage. A neocord is reconstructed by imbricating the remaining thyroid cartilage strips and covering them with a false vocal fold flap. PLIL provides a rapid recovery of oral/nasal airway and swallowing, excellent voice quality, and a disease-control rate similar or better than other treatment modalities.     

Airflow and temperature distribution inside the maxillary sinus: a computational fluid dynamics simulation

Conclusions. With the cover layer injured, vocal function of mucosal ablation could be protected and even return to normal after surgery and vocal function of mucosal stripping was slightly affected with extensive mucosal injury. Once the body layer was injured, the compensatory mechanism would play an important role in phonation. Objectives. To investigate voice function following CO₂ laser microsurgery for precancerous and early-stage glottic carcinoma. Patients and methods. Vocal function was examined by acoustic analysis, aerodynamic analysis and videostroboscopic examination. Results. For mucosal ablation, vocal quality recovered 1 month after surgery. For mucosal stripping, although vocal quality was steady 3 months after surgery, slight hoarseness persisted in this group. The contour of the treated fold recovered postoperatively. There were no complications in recovery. For cordectomies, vocal quality became steady 6 months after the surgery. The supraglottal hyperfunction with supraglottal structure squeezing played an important role in phonation. The affected vocal fold mucosal wave was absent instead of a regular ventricular fold wave or mucosal wave of the vocal process during phonation. In comparison with the type III–IV cordectomy, the results of extended cordectomies (type Va and Vc) were worse; however, the difference was not statistically significant. Granulomas and anterior commissure webs were present. All granulomas resolved spontaneously 3 months postoperatively.     

Functional outcomes after supracricoid laryngectomy

OBJECTIVES: Local control and 5-year survival rates are similar for patients undergoing total laryngectomy and supracricoid laryngectomy for the treatment of advanced-stage laryngeal carcinoma. However, comprehensive studies of functional outcomes after supracricoid laryngectomy are lacking. STUDY DESIGN: Cohort study. METHODS: This investigation provides objective voice laboratory data, skilled listener impressions of voice samples, swallowing evaluations, and patient self-perceptions of speech ability obtained from 10 supracricoid laryngectomees. RESULTS: Results demonstrated variable acoustic and speech aerodynamic disturbances, hoarse-breathy vocal quality, and speech dysfluency. Patients' self-perceptions of voice revealed severe dysphonia that induced certain emotional, physical, and functional setbacks. However, blinded judges rated these individuals as possessing intelligible speech and communication skills. All patients demonstrated premature spillage of the bolus and varying degrees of laryngeal penetration, aspiration, and retention during swallowing studies. However, each patient used a compensatory strategy to protect the airway. Voice and swallowing abilities appeared to depend on the mobility of the arytenoid cartilages, base of tongue action, and residual supraglottic tissue for the creation of a competent neoglottal sphincter complex that vibrated during phonation efforts and protected the airway during deglutition. CONCLUSIONS: Supracricoid laryngectomy avoids the potential complications, limitations, and emotional problems associated with a permanent tracheostoma. All patients demonstrated intelligible voice and effective swallowing function postoperatively, supporting supracricoid laryngectomy as a suitable alternative surgical approach to the total laryngectomy in select patients.