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披裂軟骨脱臼は全身麻酔の気管挿管の合併症として報告され, 外力のかかり方によって前方, または後方に脱臼する. 今回全身麻酔後に発症した前方脱臼症例と後方脱臼症例を経験したので各症例の臨床的特徴について報告する. 症例1：全身麻酔下の手術直後から高度嗄声を認めた. 初診時は右披裂部が固定し, 喉頭筋電図検査では発声時の両側甲状披裂筋に左右同等の活動電位を認めた. 右披裂軟骨前方脱臼と診断し全身麻酔下に整復術を行った. 術後右声帯の可動性と嗄声は徐々に改善し, 術後６ヵ月で声帯運動の左右差はなくなった. 症例2：全身麻酔下の手術直後より高度嗄声を認めた. 初診時は右披裂部の固定を認め, 発声時に左声帯は過内転していた. 右披裂部の固定位より右披裂軟骨後方脱臼と診断し整復術を予定した. しかし, 子供が背後から前頸部にぶらさがり, その直後より嗄声が改善, 再診時は右声帯の動き, 形態も正常となり予定していた手術は中止した. 本症例は後方脱臼が偶然ではあるが徒手整復されたものと考えた.

A certain degree of subclinical extrathoracic airway compromise may ensue after thyroplastic surgery, although none of the patients reported the presence of dyspneic symptoms in their normal daily lives.To determine the effects of thyroplastic surgery on respiratory function and compare them with the improvement of vocal function.The study included 53 patients; 7 had type I thyroplasty (type I), 9 had arytenoid adduction (AA), 10 had AA with type I, and 27 had AA with neuromuscular pedicle flap implantation (NMP). Phonatory and respiratory functions were measured preoperatively and postoperatively. The presence of dyspnea during daily activities was determined postoperatively.The difference between the pre- and postoperative values was statistically significant in five comparisons. Forced expiratory volume in 1 s/forced expiratory volume (FEV(1%)) in the AA with type I group, FEV(1)/peak expiratory flow rate (PEFR) in the AA group, and PEFR in the three groups (type I, AA, and AA with NMP). Forty-six patients associated with AA were combined for statistical analysis. The differences were statistically significant for FEV(1%), PEFR, and FEV(1)/PEFR. Changes in maximum phonation time (MPT) were found to have a significant correlation with changes in FEV(1)/PEFR. All the patients denied episodes of dyspnea during their normal daily activities.

The factors responsible for the observed failures can be broken into two major groups: (1) a wrong indication and (2) an inadequate technique to achieve relief from an excessively tight glottal closure. The use of a titanium bridge in place of a silicone shim was found to be essential. Type II thyroplasty can relieve the symptoms of adductor spasmodic dysphonia (AdSD) when implemented with a modern technique using titanium bridges.To identify the factor or factors that necessitated revision surgery in type II thyroplasty for AdSD, detailed analytical examinations were made of individual cases with unsatisfactory outcomes.A retrospective analysis of a case series with follow-up periods of 2-5 years.Ninety AdSD patients underwent type II thyroplasty. The results in one patient were limited because a pathological mechanism other than AdSD was also involved. One patient, a singer, who wanted a more intense voice for singing was dissatisfied with the results. In three patients, the material used for fixation was inadequate. In two other patients, the method of application of the fixative material was found to be insufficient as it did not include both the upper and lower sides.

Nerve-muscle pedicle (NMP) implantation was effective in the recovery from atrophic changes in long-term denervated thyroarytenoid (TA) muscle. Re-innervation occurred via the transferred nerve. However, the effectiveness of the NMP method may decline with increasing duration of denervation.To evaluate the effects of NMP implantation on long-term denervated rat TA muscle.Wistar rats (n=105) were divided into two groups in which the left recurrent laryngeal nerve (RLN) was transected without (DNV group) or with (NMP group) subsequent NMP implantation, and subgroups of each group were formed depending on the period after RLN transection (immediate to 48 weeks). In the DNV subgroups, we histologically assessed the area of muscle and the number of neuromuscular junctions. In the NMP subgroups, we performed electromyographic, videolaryngoscopic, and histologic assessments. The muscle area and muscle action potentials were evaluated by comparing the treated and untreated sides. The ratio of the number of nerve terminals to that of acetylcholine receptors was also assessed.The TA muscle area was significantly larger in most of the NMP subgroups compared with the DNV subgroups. Muscle action potentials were present in all NMP animals. All histologic and physiologic assessments revealed degradation as the denervation period in the five NMP subgroups.

Objectives: To determine the incidence of black spots after resolution of laryngeal granuloma (LG), to compare the disease duration from the beginning of treatment to resolution between patients with and without black spots, and to assess the histologic findings of LG in resected or biopsied specimens. Study Design: Retrospective. Methods: Forty-six patients with LG on the cartilaginous portion of the vocal fold were included. Their clinical records were reviewed. Histologic specimens were re-examined. Results: Causes of LG were postintubation in 10 patients, unilateral vocal fold immobility in 1, Candida infection in 1, and were not specified in 34 (either hyperfunctional vocal abuse, laryngopharyngeal regurgitation, or both). Of the 10 patients with postintubation LG, 9 resolved; of the 33 patients with LG from other causes, 21 resolved. Of the 28 resolved patients, 12 developed a black spot at the previous lesion site. Of the 18 patients whose LG resolved without surgical intervention, 11 developed a black spot at the previous lesion site, and the remaining 7 patients did not develop any black spots. The treatment period until LG resolution was significantly longer among patients with a black spot than those without a spot (P = .0372). Histologic examination revealed the presence of hemosiderin accumulation accompanied by infiltration of lymphocytes and macrophages in 8 of the 16 patients who had their LGs resected or biopsied. Conclusions: Accumulation of hemosiderin in the subepithelial layer, together with little blood flow and dense connective tissue in the cartilaginous portion of the vocal fold, are important factors contributing to the persistence of LG.

披裂軟骨内転術（Arytenoid Adduction：AA）は主に声門間隙の広い片側声帯麻痺症例に適応となるが，なかには内転だけでは音声の改善が得られない症例も存在する。その際には甲状軟骨形成術I型（I型）さらに同IV型（IV型）を併用すると効果的なことが多い。今回われわれは，AAにI型，IV型を併用した症例の検討を行った。症例は1994年～2006年に一色クリニック・京都ボイスサージセンターにおいて，片側喉頭麻痺に対してAAを施行した52例である。手術前後の音声の評価には最長発声持続時間（MPT）， Alternating Current / Direct Current Ratio （AC/DC比），GRBAS評価を用いた。手術中に，まずAAを施行し音声モニタリングし，改善度によってI型を併用するかどうかを判断した。52例中AA単独で音声が改善し得た症例は6例のみと少数であり，I型併用が必要であった症例が46例と多数であった。I型併用した46例のうち7例には，さらにIV型が併用された。術前平均MPTはAA群では5.3秒，AA+I型群では4.1秒，AA+I型+IV型群では3.3秒であり，術前平均が悪い症例ほど併用術式が多い傾向があった。術後平均MPTはAA群では9.8秒，AA+I型群では12.3秒，AA+I型+IV型群では11.4秒に改善した。AAの利点のひとつにオプションの併施が容易であることがあげられる。術中の音声モニタリングにて効果が不十分である際にはI型やIV型の併用を術中に考慮し，必要に応じて併施することが可能である。

甲状軟骨形成術3型（3型）は甲状軟骨の前後径を縮める術式である。その結果，声帯は弛緩し話声位（speaking fundamental frequency：SFF）のピッチは下がり，喉頭効率も改善する。主な適応疾患は，声帯萎縮や変声障害でのSFF高音化に対する音声治療の無効例，声帯の過緊張が気息性嗄声の要因となっている症例などである。今回われわれは3型を施行した症例について術前後の音声と喉頭効率，術式について検討した。症例は2001年から2006年までに一色クリニック・京都ボイスサージセンターにおいて3型を施行した19例である。男性17例女性2例で年齢は18～73歳（平均年齢32.6歳）であった。診断は，声帯萎縮が8例，変声障害が4例，声帯溝症が3例，声帯萎縮と声帯溝症の合併が2例，声を低くしたいという強い本人の希望と性同一性障害が各1例ずつであった。検討項目として術前術後のSFFと，2004年6月以降の10例ではAC/DC比も計測した。手術は局所麻酔下に施行した。3型を両側に施行したものは10例，片側は9例であった。声帯萎縮，声門閉鎖不全がある12例には1型も併施した。局所麻酔で施行しているため，全例において患者の満足のいく音声が得られた。3型はのべ29側に施行されており，軟骨断端処理法はface to faceが24側，overlappingが5側であった。face to faceの24側の平均軟骨切除幅は2.4mmであった。手術前後のSFFは両側施行例では術前平均43.0セミトーン（196.0Hz）が術後平均35.4セミトーン（127.8Hz）に，片側施行例では術前平均42.9セミトーン（198.4Hz）が術後平均37.7セミトーン（149.3Hz）に低下した。AC/DC比は術前平均36.7％,術後平均52.1％であった。3型によりSFFは下がり患者の満足する音声が得られ，SFFを低下させる手術として有用であった。多くの症例でAC/DC比も改善し，3型は喉頭効率の改善にも有効であった。両側施行症例は片側施行症例よりもSFFの低下効果が大きかった。

片側喉頭麻痺の手術治療にはいくつかの選択肢があるが，大きく分けると喉頭枠組み手術と声帯注入術に分けられる。全身麻酔下に施行する声帯注入術と喉頭枠組み手術では術中の音声モニタリングが不可能である。一方，局所麻酔下に施行する喉頭枠組み手術では，術中の音声モニタリングにより，細かな調節性に優れる。故に当クリニックでは伝統的に局麻下の喉頭枠組み手術を施行してきた。今回われわれは，一色クリニック・京都ボイスサージセンターにおいて片側喉頭麻痺に対し喉頭枠組み手術を施行した症例について検討した。症例は1994年から2006年までに当クリニックにおいて片側喉頭麻痺に対して喉頭枠組み手術を施行した110例である。男性66例，女性44例，平均年齢は52.9歳であった。麻痺側は左が68.8％，右が31.2％であった。麻痺の原因疾患は甲状腺腫術，食道癌手術，肺癌手術，縦隔手術，特発性，脳腫瘍などであった。術前術後の音声の評価には最長発声持続時間（MPT）とAlternating Current/Direct Current Ratio （AC/DC比）を用いた。術式の選択は声門間隙の大きいものには披裂軟骨内転術（Arytenoid Adduction：AA）を，声門間隙の小さいものには甲状軟骨形成術1型（1型）を選択し，声帯の緊張が足りない場合にさらに甲状軟骨形成術4型（4型）を追加した。術式の追加は術中に音声モニタリングにて判断した。術式のうちわけは1型単独：45例，1型+4型：13例，AA単独：6例，AA+1型：39例，AA+1型+4型：7例であった。110例の平均MPTは術前5.9秒，術後13.5秒であった。AC/DC比は2004年6月以降の42症例で測定されており，術前平均は24.4％，術後平均は46.2％であった。片側喉頭麻痺の術式の中で，局麻下喉頭枠組み手術の治療効果は確実であり有用である。

Objective/hypothesis To assess the effectiveness of type II thyroplasty with a titanium bridge in adductor spasmodic dysphonia (AdSD). Study design Retrospective chart review, patient response to a questionnaire on the ease of phonation and voice quality, and pre- and postoperative fiberoptic laryngoscope findings. Subjects Forty-one patients who underwent type II thyroplasty with a titanium bridge between December 2002 and December 2005 who have been followed for at least 12 months postoperatively. Results Six patients were male, and 35 were female. The voice was recorded before and at least 6 months after surgery. Initially, 97.6%, 61%, and 48.8% of the patients had a strangulated, interrupted, or tremulous voice, respectively. The mean ratings of strangulation, interruption, and tremor were calculated. The respective mean pre- and postoperative scores were 1.51 and 0.46 for strangulation, 0.76 and 0.05 for interruption, and 0.65 and 0.048 for tremor. In the postoperative questionnaire, 70% of the patients judged their voice as excellent and the remaining patients as improved to good or fair. Conclusions Type II thyroplasty is a highly effective therapy for AdSD. The voice in AdSD may roughly be classified into strangulated, tremulous, and interrupted types. The outcome measures justify the continued treatment of AdSD with type II thyroplasty.

右側喉頭麻痺は，左側に比べると頻度は低い。反回神経の走行が，解剖学的に左側が長く胸腔内を走行するため左側に麻痺が起こりやすいと考えられている。頻度が少ない右側喉頭麻痺の特色と術式について検討した。症例は1994年から2006年に一色クリニック・京都ボイスサージセンターにて手術を施行した片側喉頭麻痺110例のうち，右側喉頭麻痺の35例である。年齢は17歳から75歳（平均49.4歳），性別は男性22例女性13例であった。麻痺の原因は，甲状腺手術16例，頸部迷走神経鞘腫手術5例，特発性3例，縦隔迷走神経鞘腫手術3例，脳腫瘍3例，以下食道癌手術，頭部外傷，頸椎手術によるものが各1例ずつであった。術式は声門間隙の広いものは披裂軟骨内転術（Arytenoid Adduction：AA）を，狭いものには甲状軟骨形成術1型（1型）を選択した。声門間隙が広くかつ萎縮の強いものにはAAに加え1型を併施した。まずAAまたは1型またはAA+1型にて声帯正中移動を施行した。その後，甲状軟骨と輪状軟骨の接近テストを施行し，音声の改善を認めた10例には甲状軟骨形成術4型（4型）を追加した。4型追加症例は麻痺の原因疾患より，輪状甲状筋機能不全が疑われた症例であった。手術前後の音声の評価は最長発声持続時間（MPT）とAlternating Current/Direct Current Ratio （AC/DC比）を用いた。術後のMPTは1例のみ不変であったが34例は改善した。AC/DC比は1例を除き増加した。片側声帯麻痺で輪状甲状筋機能不全の疑いがある際には声門閉鎖不全の解消のみならず声帯前後方向の緊張が必要である。まずAAや1型，またAA+1型により声帯正中移動させ，その上で患者の音声をモニタリングし，術中にオプションとして4型の併用の選択を考慮することは重要である。

To examine modulation of M-cadherin, a marker for satellite cells (SCs); and MyoD, which may indicate the myogenic activity following recurrent laryngeal nerve (RLN) denervation and immediate reinnervation; and to elucidate the correlation between their modulations and establishment of neuromuscular junctions (NMJs) in the reinnervated rat thyroarytenoid (TA) muscle.Quantitative real-time polymerase chain reaction qPCR and histologic assessment of the TA muscle following RLN transection and anastomosis.Rats were divided into three groups: 1) denervation alone (DNV) (n = 60), 2) denervation with anastomosis (ANS) (n = 60), and 3) sham-operated controls (n = 12). Animals were sacrificed at 3 days and 1, 3, and 5 weeks after treatment. TA muscles harvested from 40 animals from each DNV and ANS group; all of sham group were subjected to qPCR for assessment of the modulation of M-cadherin and MyoD; and the remaining larynges of DNV and ANS group were used for histologic analysis.The expression levels of messenger RNAs (mRNAs) encoding M-cadherin and MyoD in the TA muscle of the DNV group were significantly higher (P0.05) than in the control throughout the study period. These mRNA levels in the ANS group were significantly higher (P0.05) at ≤ 1 week than in the controls but fell to control levels at ≥ 3 weeks. In the ANS group, recovery of muscle area and NMJs structure occurred by 3 weeks.These data suggested that NMJ formation following reinnervation might prompt recovery of M-cadherin and MyoD mRNA expression to the quiescent level of SCs.

Objectives:Evaluate the long-term efficacy of laryngeal reinnervation with refined nerve-muscle pedicle (NMP) flap implantation combined with arytenoid adduction for unilateral vocal fold paralysis (UVFP) using laryngeal electromyography (LEMG), coronal images, and assessment of phonatory function.Methods:We retrospectively reviewed 16 UVFP patients who received refined NMP implantation with arytenoid adduction. Videostroboscopy, perceptual evaluation, acoustic analysis, aerodynamic analysis, LEMG, and coronal imaging were performed pre- and 2 years after surgery. For LEMG analysis, a four-point scale was employed to grade motor unit (MU) recruitment where 4+ represented absent recruitment, 3+ represented greatly decreased recruitment, 2+ represented moderately decreased recruitment, and 1+ represented mildly decreased activity with less than full interference pattern. Coronal images were assessed for differences in thickness of the vocal folds during phonation and inhalation.Results:Phonatory function re...

To evaluate the long-term efficacy of laryngeal reinnervation via refined nerve-muscle pedicle (NMP) flap implantation combined with arytenoid adduction to treat unilateral vocal fold paralysis (UVFP), employing laryngeal electromyography (LEMG), coronal imaging, and phonatory function assessment.Case series with chart review.University hospital.We retrospectively reviewed 12 UVFP patients who underwent refined NMP implantation with arytenoid adduction. Videostroboscopy, phonatory functional analysis, LEMG, and coronal imaging were performed before and 2 years after surgery. In LEMG analysis, a 4-point scale was employed to grade motor unit (MU) recruitment: 4+ reflected no recruitment, 3+ greatly decreased recruitment, 2+ moderately decreased recruitment, and 1+ mildly decreased activity, associated with less than the full interference pattern. Coronal images were assessed in terms of differences in thickness and the vertical positions of the vocal folds.Phonatory function improved significantly after operation in all patients. In terms of LEMG findings, the preoperative MU recruitment scores were 1+ in no patients, 2+ in 4 patients, 3+ in 1 patient, and 4+ in 7 patients. Postoperative MU recruitment results were 1+ in 6 patients, 2+ in 5 patients, 3+ in 1 patient, and 4+ in no patients. Thinning of the affected fold during phonation was evident preoperatively in 9 of 10 patients. The affected and healthy folds were equal in volume in 4 of 9 patients postoperatively.The LEMG findings and coronal imaging suggest that NMP implantation may have enabled successful reinnervation of the laryngeal muscles of UVFP patients.

Over-adduction of the unaffected vocal fold may not compensate vocal function in unilateral vocal fold paralysis (UVFP).To determine whether over-adduction of the unaffected vocal fold has any impact on vocal function in patients with UVFP.A total of 101 patients with UVFP who underwent three-dimensional computed tomographic (CT) examination of the larynx served as subjects. Three-dimensional endoscopic images together with coronal images during phonation were produced to evaluate over-adduction of the unaffected fold, posterior glottal gap, and differences in the vertical position and thickness between the vocal folds. Maximum phonation time (MPT) and mean airflow rate (MFR) were measured.In all, 47 patients showed over-adduction. Their MPT and MFR were 4.9 ± 2.9 s and 653 ± 504 ml/s, respectively. The remaining 54 did not show over-adduction. Their MPT and MFR were 4.7 ± 2.7 s and 574 ± 384 ml/s, respectively. There were no significant differences in MPT or MFR between the two groups. Of the 47 patients with over-adduction, 9 showed no posterior glottal gap. However, their vocal function was not significantly different from that of 38 patients with posterior glottal gap or from that of 43 patients without over-adduction and having a posterior glottal gap.

To assess laryngeal muscle activity in unilateral vocal fold paralysis (UVFP) patients using laryngeal electromyography (LEMG) and coronal images.Case series with chart review.University hospital.Twenty-one patients diagnosed with UVFP of at least 6 months in duration with paralytic dysphonia, underwent LEMG, phonatory function tests, and coronal imaging. A 4-point scale was used to grade motor unit (MU) recruitment: absent = 4+, greatly decreased = 3+, moderately decreased = 2+, and mildly decreased = 1+. Maximum phonation time (MPT) and mean flow rate (MFR) were employed. Coronal images were assessed for differences in thickness and vertical position of the vocal folds during phonation and inhalation.MU recruitment in thyroarytenoid/lateral cricoarytenoid (TA/LCA) muscle complex results were 1+ for 4 patients, 2+ for 5, 3+ for 6, and 4+ for 6. MPT was positively correlated with MU recruitment. Thinning of the affected fold was evident during phonation in 19 of the 21 subjects. The affected fold was at an equal level with the healthy fold in all 9 subjects with MU recruitment of 1+ and 2+. Eleven of 12 subjects with MU recruitments of 3+ and 4+ showed the affected fold at a higher level than the healthy fold. There was a significant difference between MU recruitment and the vertical position of the affected fold.Synkinetic reinnervation may occur in some cases with UVFP. MU recruitments of TA/LCA muscle complex in UVFP patients may be related to phonatory function and the vertical position of the affected fold.

Twenty-seven patients with several laryngeal ailments underwent helical computed tomography (CT) on 37 occasions. Ten of these 27 patients suffered from unilateral vocal fold paralysis (UVFP). Three-dimensional (3D) images of the laryngeal lumen viewed from various angles were produced for all sets of CT volumetric data, except for three which contained excessive motion artifacts. The present paper examined whether 3D endoscopic images could offer useful diagnostic and therapeutic information about UVFP. The 3D endoscopic images viewed from the tracheal side and the hemilaryngeal images viewed from the opposite side could delineate the vocal folds, ventricular fold and ventricle three-dimensionally. Atrophy and hypotonic changes to the vocal fold and expansion of the ventricle on the affected side were clearly shown. The 3D endoscopic images accurately showed the phonosurgical effects on the laryngeal structures. The 3D endoscopic images could be produced even when the vocal folds could not be observed with conventional endoscopy due to their overadduction. Multiplanar reconstruction (MPR) images in the coronal plane were reconstructed at a right angle to the glottic axis when the whole larynx was deviated. In addition, coronal MPR images showed a better resolution among the different layers of the vocal fold soft tissue than X-ray tomography. In conclusion, 3D endoscopic images combined with coronal MPR images can provide useful diagnostic an therapeutic information about UVFP, although motion artifacts may occur.

Objectives:1) Describe operative procedures to reinnervate the thyroarytenoid muscle (TA) on the paralyzed side using a modified nerve-muscle pedicle (NMP) flap implantation harvested on the contralateral side combined with arytenoid adduction (AA). 2) Assess time-dependent improvement in vocal function during postoperative follow-up.Methods:Prospective case series. Four patients underwent modified NMP flap implantation combined with AA for paralytic dysphonia between August 2009 and January 2013. The NMP flap was harvested on the contralateral side because of scar formation on the paralyzed side and was secured to the TA under microscopic control. Three of them were followed over one year, and their voice outcomes, determined by 5 objective and 2 subjective parameters, were evaluated preoperatively and at 4 different time points after surgery.Results:On average, maximum phonation time and mean airflow rate improved from 5.4s and 569mL/s preoperatively to 24.2s and 116mL/s 12 months postoperatively, respe...

Objectives: We established an animal model of recurrent laryngeal nerve reinnervation with persistent vocal fold immobility following recurrent laryngeal nerve injury. Methods: In 36 rats, the left recurrent laryngeal nerve was transected and the stumps were abutted in a silicone tube with a 1-mm interspace, facilitating regeneration. The mobility of the vocal folds was examined endoscopically 5, 10, and 15 weeks later. Electromyography of the thyroarytenoid muscle was performed. Reinnervation was assessed by means of a quantitative immunohistologic evaluation with anti-neurofilament antibody in the nerve both proximal and distal to the silicone tube. The atrophy of the thyroarytenoid muscle was assessed histologically. Results: We observed that all animals had a fixed left vocal fold throughout the study. The average neurofilament expression in the nerve both distal and proximal to the silicone tube, the muscle area, and the amplitude of the compound muscle action potential recorded from the thyroarytenoid muscle on the treated side increased significantly (p < 0.05) over time, demonstrating regeneration through the silicone tube. Conclusions: Recurrent laryngeal nerve regeneration through a silicone tube produced reinnervation without vocal fold mobility in rats. The efficacy of new laryngeal reinnervation treatments can be assessed with this model.

Three different types of glottal configuration in unilaterally paralyzed larynx were proposed by utilizing three-dimensional computed tomographic (3DCT) images. This new classification might facilitate understanding of the behavior of the affected vocal fold in terms of vocal function.To develop a classification of glottal configuration in unilateral vocal fold paralysis (UVFP) based on the thickness and location of the vocal folds utilizing 3DCT and to compare each type of configuration with vocal function.Thirty-seven consecutive patients with UVFP underwent CT during phonation and inhalation. 3D endoscopic and coronal images on two occasions were produced. Maximum phonation time and mean airflow rate were also measured.Three types of glottal configuration were proposed. The thickness of the affected vocal fold during phonation was equal to or slightly thinner than the healthy fold in 10 patients (type A). The affected fold of the remaining 27 was thin during phonation; they were further classified into types B and C. In type B, the affected fold remained thin during phonation and inhalation (n = 12). Type C was allocated to those showing one or two paradoxical movements of the affected fold (n = 15). Those with type A showed significantly better vocal function.

To evaluate the impact of nimodipineon reinnervation of the long-term denervated rat thyroarytenoid (TA) muscle following nerve-muscle pedicle flap (NMP) implantation.Quantitative histologic and physiologic assessments.Using 120 Wistar rats, we performed NMP implantation at different times after transection of the left recurrent laryngeal nerve (RLN). Sixty animals received nimodipine treatment (NIMO [+] group), and the remaining 60 animals received no nimodipine treatment (NIMO [-] group). As a control, an additional 28 animals were subjected only to transection of the left RLN (DNV group). Subgroups were assigned based on the period after RLN transection (0 [immediate], 8, 16, and 32 weeks). In the DNV group, we assessed histologically the muscle area, axons, neuromuscular junctions (NMJs), and myosin heavy chains (MyHC) type IIA and IIB in the TA muscle. In the NIMO (-) and NIMO (+) groups, histologic assessments and evoked electromyography were performed on the TA muscle at 10 weeks post-NMP implantation.In 8-week interval subgroups, the muscle fiber area and the number of NMJs in the NIMO (+) group were significantly greater than in the NIMO (-) group (P0.05, each). In the 0-week and 32-week interval subgroups, the muscle fiber subtype changed significantly, from IIA to IIB (P0.01 and P0.05, respectively); and, at all time-points the muscle fiber area, number of NMJs, and action potentials in the TA muscle tended to be greater in the NIMO (+) group than in the NIMO (-) group.Nimodipine expedited the effects of NMP implantation on reinnervation of the long-term denervated TA muscle. Laryngoscope, 2012.

X-linked agammaglobulinemia (XLA) is caused by a mutation in the Bruton tyrosine kinase, leading to an arrest in B cell development. Consequently, patients with XLA show significant decreases in gammaglobulin. Here, we describe a child with postmeningitic deafness and XLA who underwent a cochlear implantation. His psychomotor development had been normal and his congenital immunodeficiency was noticed only postoperatively. Immunoglobulin replacement treatment was started, but he still suffered repeated infections. Eventually, his cochlear implant was removed. A preoperative check of immunological status might be advisable in postmeningitic patients undergoing cochlear implantation to reduce the risk of postoperative infectious complications.

Objective: 1) Develop a new classification of laryngeal synkinesis in patients with unilateral vocal fold paralysis (UVFP) based on images of the vocal fold using 3-dimensional computed tomography (3DCT) 2) Compare synkinesis type based on 3DCT image analysis with recruitment in electromyography during phonation.Method: Retrospective. Subjects included 50 patients with UVFP who underwent framework surgeries between 2000 and 2010. Three-dimensional images during phonation and inhalation preoperatively were assessed focusing on thickness of the affected fold to classify synkinesis. Recruitment of thyroarytenoid muscle was rated and compared with synkinesis type.Results: Two subjects were excluded because of poor performance during scanning. Three synkinesis types were identified. The affected fold in 12 subjects showed some degree of thickening during phonation. The affected fold of the remaining 36 was thin during phonation. Thickening of the affected fold was evident during inhalation in 20 of the 36 subj...

Objective: 1) Determine the effectiveness of type II thyroplasty for adductor spasmodic dysphonia (AdSD), through perceptual and accoustic analysis. 2) Assess the pre- and postoperative quality of life of AdSD patients using the Voice Handicap Index-10 (VHI-10).Method: Retrospective study. Twelve patients with AdSD underwent type II thyroplasty between March 2007 and December 2010. Measured outcomes included perceptual assessment, acoustic analyses (DVB, SDF0, jitter, shimmer, and HNR), and VHI-10 and were performed prior to and six months or more after surgery. VHI-10 and acoustic evaluation scores were compared.Results: Average follow-up interval was 12.6 months. In perceptual analysis (GRBAS), overall grade and strain significantly improved after surgery (P = .0017, P = .0002). There were no significant difference in roughness, breathiness, and asthenia. In acoustic analysis, DVB, SDF0, jitter, shimmer, and HNR (P = .039, P = .0003, P = .0016, P = .0011, P = .0003) improved significantly after surgery....

Our objective was to evaluate the efficacy of modified nerve-muscle pedicle (NMP) flap transfer combined with arytenoid adduction (AA) (AA + modified NMP) for treatment of unilateral vocal fold paralysis. The patterns of voice outcome assessed using phonatory function tests and auditory perceptual judgments were followed-up for 2 years.Prospective study.Thirteen subjects among those presented with paralytic dysphonia between March 2002 and December 2008 were treated with AA + modified NMP. The voice outcomes (six objective and two subjective voice parameters) were evaluated preoperatively and in four different time points postoperatively over 2-years duration.All voice parameters showed initial postoperative improvement. Moreover, five parameters showed significant continuous improvement over the 2-year follow-up (maximum phonation time, pitch range, shimmer, and grade overall and breathiness of the grade-roughness-breathiness-asthenia-strain scale (GRBAS), whereas two parameters revealed continuous improvement over the first 12 to 14 months after surgery (mean flow rate and harmonics-to-noise ratio).AA + modified NMP improves both short- and long-term voice outcomes in unilateral vocal fold paralysis patients. Therefore, AA + modified NMP is an effective surgical combination for the treatment of severe paralytic dysphonia.

To describe a new technique of nerve-muscle pedicle (NMP) flap implantation combined with arytenoid adduction (AA) to treat dysphonia due to unilateral vocal fold paralysis and to examine postoperative vocal function.Retrospective review of clinical records.Tertiary academic center.Twenty-two consecutive patients underwent NMP flap implantation with AA and were followed up short term over a period of 1 to 6 months (mean, 2.9 months) and long term over a period of 7 to 36 months (mean, 21.4 months).An NMP flap was made using an ansa cervicalis branch and a piece of the sternohyoid muscle. A window was opened in the thyroid ala at the level of the vocal fold. Then, AA was performed and the NMP flap was securely implanted onto the thyroarytenoid muscle through the window under microscopic guidance.The maximum phonation time, mean airflow rate, pitch range, and acoustic parameters (jitter, shimmer, and harmonics to noise ratio) were evaluated before surgery and twice after surgery.All parameters improved significantly after surgery (P.01). The measurements for maximum phonation time, mean airflow rate, and harmonics to noise ratio were within normal ranges after surgery. Furthermore, the maximum phonation time and jitter were significantly improved after long-term follow-up compared with early postoperative measurements (P.01 and P.05, respectively).Precise harvest of an NMP flap and its placement directly onto the thyroarytenoid muscle combined with AA provided excellent vocal function. The NMP method may have played a certain role in the improvement of postoperative vocal function, although further study with electromyographic examination is required to clarify the innervation status of the thyroarytenoid muscle.

Unilateral vocal fold paralysis (UVFP) is one of the most serious problems in conducting surgery for thyroid cancer. Different treatments are available for the management of UVFP including intracordal injection, type I thyroplasty, arytenoid adduction, and laryngeal reinnervations. The effects of immediate recurrent laryngeal nerve (RLN) reconstruction during thyroid cancer surgery with or without UVFP before the surgery were evaluated with videostroboscopic, aerodynamic, and perceptual analyses. All subjects experienced postoperative improvements in voice quality. Particularly, aerodynamic analysis showed that the values for all patients entered normal ranges in both patients with and without UVFP before surgery. Immediate RLN reconstruction has the potential to restore a normal or near-normal voice by returning thyroarytenoid muscle tone and bulk seen with vocal fold denervation. Immediate RLN reconstruction is an efficient and effective approach to the management of RLN resection during surgery for thyroid cancer.

Type II thyroplasty, or laryngeal framework surgery, is based on the hypothesis that the effect of adductor spasmodic dysphonia (AdSD) on the voice is due to excessively tight closure of the glottis, hampering phonation. Most of the previous, partially effective treatments have aimed to relieve this tight closure, including recurrent laryngeal nerve section or avulsion, extirpation of the adductor muscle, and botulinum toxin injection, which is currently the most popular. The aim of this study was to assess the effects of type II thyroplasty on aerodynamic and acoustic findings in patients with AdSD.Case series.University hospital.Ten patients with AdSD underwent type II thyroplasty between August 2006 and December 2008. Aerodynamic and acoustic analyses were performed prior to and six months after surgery. Mean flow rates (MFRs) and voice efficiency were evaluated with a phonation analyzer. Jitter, shimmer, the harmonics-to-noise ratio (HNR), standard deviation of the fundamental frequency (SDF0), and degree of voice breaks (DVB) were measured from each subject's longest sustained phonation sample of the vowel /a/.Voice efficiency improved significantly after surgery. No significant difference was found in the MFRs between before and after surgery. Jitter, shimmer, HNR, SDF0, and DVB improved significantly after surgery.Treatment of AdSD with type II thyroplasty significantly improved aerodynamic and acoustic findings. The results of this study suggest that type II thyroplasty provides relief from voice strangulation in patients with AdSD.

Objective To overcome the demerits of conventional postoperative aural packing, we developed a useful protocol for postoperative stenting of the external auditory canal after middle ear surgery which enables transcanal drainage and simultaneously allows for visual inspection and treatment of the canal, as necessary. Methods Twenty-four surgeries, 21 patients underwent tympanoplasty with a postaural incision. At the end of all surgical procedures, the external auditory canal was packed with a 0.3 mm thickness rolled, tapered silastic sheet (RTSS) with antibiotic ointment applied to one surface. The inserted RTSSs were removed at 5–10 days postoperatively. We assessed the efficacy and the reliability of the RTSS. Results In 23 ear surgeries on 20 patients, we achieved successful postoperative ear packing utilizing our RTSS. With these patients, the tympanic membrane and the external auditory meatus were able to be observed immediately after the completion of the stenting during the surgery and the removal of the gauze over the operated ear at Day 1 to Day 3 postoperatively. During 4 surgeries with ventilation tube insertion to the tympanic membrane, there was secretion through the inserted ventilation tube which was easy to suction. In one surgery, on one patient, additional packing materials were utilized once only during a sandwich graft myringoplasty. No patients showed any harmful effects during the postoperative period. Conclusions The useful and reliable RTSS, with antibiotic ointment applied to one surface, has several positive advantages that the conventional packing methods do not.

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 f/vorable than in group I. Conclusion: Immediate RLN reconstruction at the time of thyroid cancer extirpation can provide excellent postoperative phonatory function.

Objectives: To propose a simple technique to preserve, medialize and stabilize the middle turbinate through a planned medial synechiae formation using a nasal septal flap Methods: Study Design: Case series, surgical innovation Setting: Tertiary hospital (Kumamoto University Hospital, Japan) Participants, Patients or Population: Six patients suffering from chronic sinusitis unresponsive to medication. The indication for doing this technique was unstable turbinates after removal of diseased mucosa. Results: Twelve weeks after surgery, the patients reported significant resolution of symptoms (headache, nasal congestion, rhinorrhea, post-nasal drip and loss of smell). CT and endoscopic findings likewise revealed clear ostio-meatal complex, drained sinuses, and complete removal of polypoid mucosa. No major side effects were noted. Conclusions: This technique is especially encouraged when surgeons encounter an unstable middle turbinate after removing massive pathologic mucosal lesions. This is a preliminary report and further investigations are being carried out to validate the technique. Keywords: medial synechiae, nasal septal flap, ostio-meatal complex

We present a rare case of bilateral cerebrospinal fluid (CSF) otorrhea via multiple bony defects in the left tegmen and a single defect with the herniated brain tissue on the right side. Initially, the patient complained of left hearing loss and fullness and was diagnosed with serous otitis media. After myringotomy, the pulsating watery discharge suggested CSF otorrhea. Five months after surgical repair of the left side, right-side CSF leakage occurred. The right side was repaired surgically, and the patient recovered without incident. From our findings and a review of the literature, we postulate that bilateral CSF otorrhea resulted mainly from the thinness of the tegmen because of well-pneumatized mastoid air cells and the weakness of the dura after chronic inflammatory changes. In case of spontaneous CSF otorrhea, the roof of tegmen should be assessed bilaterally with care using radiologic examinations so as not to overlook a subclinical condition on the contralateral side.

Importance Optimal glottal closure as well as symmetrical vocal fold masses and tensions are essential prerequisites for normal voice production. Successful phonosurgery depends on restoring these prerequisites to achieve long-term improvement. Objective To evaluate the efficacy of the laryngeal framework surgical treatments (arytenoid adduction with and without thyroplasty type I [AA ± Th-I]) compared with arytenoid adduction combined with nerve-muscle pedicle flap transfer (AA + NMP) in unilateral vocal fold paralysis. Patterns of voice outcome were compared over a 2-year period. Design, Setting, and Participants Retrospective review of clinical records of 22 patients who presented to an institutional practice with severe paralytic dysphonia between March 1999 and December 2008, who received 2 different treatments. Postoperative follow-up was conducted over 2 years. Interventions Eleven patients were treated with AA ± Th-I and 11 patients were treated with AA + NMP. Main Outcomes and Measures Vocal function was evaluated preoperatively and at 3, 12, and 24 months postoperatively. Vocal parameters evaluated were jitter, shimmer, harmonics to noise ratio (HNR), maximum phonation time (MPT), and overall grade and breathiness grade of the Grade-Roughness-Breathiness-Asthenia-Strain (GRBAS) voice scale. The outcomes of voice measurements were compared within each group across time and among the 2 groups at each time point. Results All voice parameters showed initial postoperative improvement in both groups after 3 months. Moreover, the AA + NMP group showed significant steady improvement over the 2-year follow-up, which did not occur in the AA ± Th-I group. In the AA + NMP group, MPT increased from a mean (SD) of 5.4 (2.1) s at preoperative assessment to 21.5 (7.0) s at 24 months; jitter decreased from 8.6% (5.3%) to 1.2% (0.7%); shimmer decreased from 13.1% (6.0%) to 4.0% (1.6%); HNR increased from 3.8 (3.3) to 9.0 (0.8); overall grade of GRBAS decreased from 2.4 (0.9) to 0.2 (0.4); and breathiness grade of GRBAS decreased from 2.0 (1.0) to 0.1 (0.3). Conclusions and Relevance Unlike the conventional laryngeal framework surgical treatments, AA + NMP provided long-term voice improvement with nearly normal voice quality. Thus, it can be considered an effective surgical treatment for paralytic dysphonia due to unilateral vocal fold paralysis associated with large glottal gap.

Objectives To examine fibroblast growth factor-2 (FGF-2) immunoreactivity in the nucleus ambiguus (NA) after three different recurrent laryngeal nerve (RLN) injuries. Study Design Immunohistochemical analysis of FGF-2. Methods Thirty adult rats underwent left-sided RLN crush (group A). The left RLN was transected in groups B (n = 30) and C (n = 30); in group C, both nerve stumps were covered with silicone caps. FGF-2 in the NA was assessed as the ratio of the positive areas on the left (operated [O]) and right (unoperated [U]) sides. The ratio (O/U) was measured 1, 3, 7, 14, and 28 days after the procedure. Three rats underwent left-sided RLN exposure and were killed 7 days later (control). Results Left-sided RLN paralysis occurred until day 28 in group A. In the control group, O/U was approximately 1. In group A, O/U was significantly elevated on day 7; in group B, on days 3, 7, and 14; and in group C, on day 3. O/U in group B was significantly greater than that in group A on days 14 and 28. Maximal FGF-2 immunoreactivity was significantly lower in group C than in groups A and B. Conclusions We demonstrated elevated production of FGF-2 in the NA after RLN injury. This endogenous FGF-2 might contribute to preventing lesion-induced neuronal death. Blockage of axonal regeneration might suppress FGF-2 production in the NA. Further understanding of the roles of FGF-2 after RLN in-jury may contribute to the prevention of neuronal death and facilitation of axonal regeneration.

Objective To describe characteristics of 3-dimensional (3-D) computed tomographic (CT) endoscopic images of the larynx in unilateral vocal fold paralysis and the changes of the paralyzed vocal fold after phonosurgery as indicated by 3-D CT endoscopy. Setting A university medical center. Patients Twelve consecutive patients with unilateral vocal fold paralysis who underwent helical CT examination. Five of them underwent the CT examination before and after phonosurgical treatment. Interventions Three patients underwent arytenoid adduction, and 2 underwent type 1 thyroplasty. Main Outcome Measures "Sagging," defined as caudal displacement of the vocal fold; and "thinning," defined as a decrease in the vertical thickness of the vocal fold and expansion of the ventricle on the affected side, were evaluated. Results Excessive motion artifacts in one patient prevented detailed description of his 3-D images. Sagging and thinning of the vocal fold and expansion of the ventricle on the affected side were noted on 6, 11, and 8 occasions, respectively. Adduction or augmentation of the paralyzed vocal fold after phonosurgery was observed in 3-D CT endoscopic images when displayed with bony densities. Conclusions The use of 3-D CT endoscopy enables description of 3-D characteristics of unilateral vocal fold paralysis and supplements stroboscopic findings. Furthermore, CT endoscopic images, when simultaneously displayed with bony densities, may help in evaluating the effects of phonosurgical treatment of the paralyzed vocal fold.

We produced high-quality three-dimensional (3D) endoscopic images of the larynx using helical scanning computed tomography. Subjects included two normal volunteers and 10 patients: five with laryngeal cancer, four with unilateral recurrent laryngeal nerve (RLN) palsy, and one with atrophied vocal folds. Two vertically split hemilaryngeal images were displayed together with the oral and tracheal views. Although motion artifacts were seen in four patients, laryngeal structures including the vocal fold, ventricular fold, and ventricle were clearly identified in all subjects. In the patients with cancer, axial images showing the extent of the tumor in each patient provided more information than 3D endoscopic images. In the patients with RLN palsy and atrophied vocal fold, combination of 3D endoscopic and cross-sectional images offered more diagnostic information than axial images alone.