Search

Spasmodic dysphonia (SD) is considered a rare focal laryngeal dystonia characterized by task-specific voice dysfluency resulting from selective intrinsic laryngeal musculature hyperfunction. Symptoms may be attenuated by a sensory trick. Although SD can be seen at times in generalized dystonia syndrome, it is typically a sporadic phenomenon, and the involvement of the laryngeal adductor muscles is more common than that of the abductor muscles. This research reviews the literature for the pathogenesis, clinical characteristics, treatment options, and current management methods of SD. Technological advances have enabled clinicians to better understand the connection between laryngeal function and dysfunction. Refinements in imaging and genetic investigation techniques have helped better understand the underlying mechanisms of this neurolaryngology disorder. Currently, the standard of care for SD is the symptomatic management of botulinum toxin (BT) chemodenervation. This is supported by a large body of literature attesting to its efficacy in many different research studies, particularly in the uncomplicated adductor form of the disorder. Efforts towards surgical treatment predate the development of BT treatment by a decade, but the long-term efficacy has not been proven and, further research is expected. Symptom relief in patients with abductor SD and dystonia with tremors after surgical and BT treatments and those in patients remains suboptimal.

OBJECTIVE Titanium bridges are used to separate the thyroid ala during type 2 thyroplasty for adductor spasmodic dysphonia. Revision surgeries have adventitiously indicated that bridge wing failure occurs in the area of the medial hole in some cases. This study investigated the rate and cause of device malfunctions and developed an improved device. METHODS We conducted a questionnaire survey to determine the number of surgeries performed in Japan up to the end of 2014, and to obtain information about revision cases. In addition, damage analyses were performed on the fracture surfaces of recovered titanium bridges through use of scanning electron microscopy (SEM). RESULTS Between 2002 and 2014, titanium bridges were used in 385 patients. Revision surgery was performed in 19 cases. Revision surgeries revealed that in 11 cases breakage occurred in the wings of the device in the region of the medial hole. However, such fractures were not associated with any signs of recurrence or any adverse events. SEM analyses of fracture surfaces confirmed that fatigue fractures were caused by repeated bending stress in the area of the medial hole. Based on these results, the shape of the hole was changed from round to oval and the wing thickness was increased to prevent breakage. CONCLUSIONS The wings of titanium bridges may break without any associated signs, symptoms or tissue damage. Based on the malfunctions detected and analyses of the devices recovered following malfunction, changes to the specification were made for commercial development of the titanium bridge.

Endoscopic endonasal skull base surgery has become popular due to its minimally invasive nature to the patient and the development of various medical devices. The reason why it is considered less invasive is that it is possible to reach the anterior skull base lesion using the corridor of the nasal cavity and paranasal sinuses. The roles of the nasal sinuses include acting as breathing pathways, warming, humidifying, and filtering of inhaled air, olfaction, and being a resonant cavity, all of which are important for a comfortable life, and the loss of these functions reduces the quality of life. Therefore, to perform endoscopic endonasal skull base surgery in a minimally invasive and safe manner, it is necessary to understand the anatomy of the nasal sinuses to reach anterior skull base lesions while preserving nasal structures as much as possible. This article describes the normal local anatomy of the nasal cavity and the paranasal sinuses, as well as the surgical techniques, especially the anterior skull base approach and the pterygopalatine fossa approach, for endoscopic endonasal skull base surgery.

Background and purpose Botulinum toxin (BT) injection into the laryngeal muscles has been a standard treatment for spasmodic dysphonia (SD). However, few high‐quality clinical studies have appeared, and BT is used off‐label in most countries. Methods We performed a multicenter, placebo‐controlled, randomized, double‐blinded, parallel‐group comparison/open‐label clinical trial to obtain approval for BT (Botox) therapy in Japan. Twenty‐four patients (22 with adductor SD and two with abductor SD) were enrolled. The primary end point was the change in the number of aberrant morae (phonemes) at 4 weeks after drug injection. The secondary end points included the change in the number of aberrant morae, GRBAS scale, Voice Handicap Index (VHI), and visual analog scale (VAS) over the entire study period. Results In the adductor SD group, the number of aberrant morae at 4 weeks after injection was reduced by 7.0 ± 2.30 (mean ± SE) in the BT group and 0.2 ± 0.46 in the placebo group (p = 0.0148). The improvement persisted for 12 weeks following BT injections. The strain element in GRBAS scale significantly reduced at 2 weeks after BT treatment. The VHI and VAS scores as subjective parameters also improved. In the abductor SD group, one patient responded to treatment. Adverse events included breathy hoarseness (77.3%) and aspiration when drinking (40.9%) but were mild and resolved in 4 weeks. Conclusions Botulinum toxin injection was safe and efficacious for the treatment of SD. Based on these results, BT injection therapy was approved as an SD treatment in Japan., The number of aberrant morae (phonemes) decreased significantly at 2 to 12 weeks after botulinum toxin injection into the thyroarytenoid muscle in patients with adductor spasmodic dysphonia, whereas the placebo group showed insignificant change. This study showed the significant effectiveness of botulinum toxin therapy for spasmodic dysphonia.

To evaluate whether vocal function exercises (VFE) could be an adjunct treatment for patients with unilateral vocal fold paralysis (UVFP) who were not satisfied with their postoperative voices after reinnervation surgeries.Retrospective.Medical records of the patients with UVFP who underwent laryngeal reinnervation between October 2011 and October 2014 were reviewed. Patients were classified into two groups: one received VFE according to patients' desire (VFE group) and the other did not have voice therapy (control group). Effects of VFE were assessed by vocal fold vibration (regularity, amplitude and glottal gap), aerodynamic measurements (maximum phonation time (MPT) and mean airflow rate (MFR)), GRBAS scale, acoustic parameters (pitch range, pitch perturbation and amplitude perturbation quotients (PPQ, APQ), and noise-to-harmonics ratio (NHR)) and subjective evaluation by patients (Voice Handicap Index-10 (VHI-10)). Phonatory function was also compared between the two groups at three time points: before reinnervation surgery, before VFE, and after VFE.Thirty patients were enrolled (11 men, 19 women). The VFE group included eight patients, and 22 patients served as controls. In the VFE group, several parameters (amplitude, MPT, MFR, pitch range, APQ, and NHR) did not improve significantly after surgery, while all parameters examined improved significantly in the control group. After VFE, amplitude, glottal gap, MFR, B score, pitch range, and PPQ showed significant improvement, while the control group did not show a significant improvement except in VHI-10, during the corresponding period. Significant differences in G and B scores and VHI-10 between the two groups were observed at the third time point.VFE may be used as an adjunct treatment for patients with UVFP who are not satisfied with their voices after reinnervation surgery. However, phonatory function after VFE may not reach the same level as for those who are satisfied with their voices after reinnervation surgery.

Adductor spasmodic dysphonia (AdSD) is caused by hyperadduction of the vocal folds during phonation, resulting in a strained voice. Animal models are not yet used to elucidate this intractable disease because AdSD has a difficult pathology without a definitive origin. For the first step, we established an animal model with vocal fold hyperadduction and evaluated its validity by assessing laryngeal function.In this experimental animal study, three adult Japanese 20-week-old rabbits were used. The models were created using a combination of cricothyroid approximation, forced airflow, and electrical stimulation of the recurrent laryngeal nerves (RLNs). Cricothyroid approximation was added to produce a glottal slit. Thereafter, both RLNs were electrically stimulated to induce vocal fold hyperadduction. Finally, the left RLN was transected to relieve hyperadduction. The sound, endoscopic images, and subglottal pressure were recorded, and acoustic analysis was performed.Subglottal pressure increased significantly, and the strained sound was produced after the electrical stimulation of the RLNs. After transecting the left RLN, the subglottal pressure decreased significantly, and the strained sound decreased. Acoustic analysis revealed an elevation of the standard deviation of F0 (SDF0) and degree of voice breaks (DVB) through stimulation of the RLNs, and degradation of SDF0 and DVB through RLN transection. Formant bands in the sound spectrogram were interrupted by the stimulation and appeared again after the RLN section.This study developed a rabbit model with vocal fold hyperadduction . The subglottal pressure and acoustic analysis of this model resembled the characteristics of patients with AdSD. This model could be helpful to elucidate the pathology of the larynx caused by hyperadduction, and evaluate and compare the treatments for strained phonation.

Objectives Laryngeal and voice findings of adductor spasmodic dysphonia (AdSD) and muscle tension dysphonia (MTD) are similar, and it is difficult to distinguish between both disorders. The purpose of this study is to ascertain the effect of voice therapy on MTD and AdSD and clarify their difference. Methods A total of 49 patients, including 22 patients with MTD (MTD group) and 27 patients with AdSD (SD group), were included in the study. The MTD scores were evaluated, and aerodynamic analysis (maximum phonation time [MPT], mean airflow rate [MFR], highest pitch, lowest pitch, and pitch range), perceptual evaluation (Strangulation, Interruption, and Tremor), acoustic analysis (PPQ, APQ, NHR, and DVB), and subjective assessment (voice handicap index-10 [VHI-10]) were performed before and after voice therapy. Results The MTD score, highest pitch, pitch range, strangulation, PPQ, APQ, NHR, and VHI-10 showed significant improvement after treatment in the MTD groups. On the other hand, the effect of voice treatment on AdSD was poor despite the improvement in the MTD score. Conclusions This study could serve as a basis for conducting prospective studies to verify the effects of voice therapy on MTD and AdSD.

Spasmodic dysphonia (SD) is characterized by an involuntary laryngeal muscle spasm during vocalization. Previous studies measured brain activation during voice production and suggested that SD arises from abnormal sensorimotor integration involving the sensorimotor cortex. However, it remains unclear whether this abnormal sensorimotor activation merely reflects neural activation produced by abnormal vocalization. To identify the specific neural correlates of SD, we used a sound discrimination task without overt vocalization to compare neural activation between 11 patients with SD and healthy participants. Participants underwent functional MRI during a two-alternative judgment task for auditory stimuli, which could be modal or falsetto voice. Since vocalization in falsetto is intact in SD, we predicted that neural activation during speech perception would differ between the two groups only for modal voice and not for falsetto voice. Group-by-stimulus interaction was observed in the left sensorimotor cortex and thalamus, suggesting that voice perception activates different neural systems between the two groups. Moreover, the sensorimotor signals positively correlated with disease severity of SD, and classified the two groups with 73% accuracy in linear discriminant analysis. Thus, the sensorimotor cortex and thalamus play a central role in SD pathophysiology and sensorimotor signals can be a new biomarker for SD diagnosis.

Objectives Spasmodic dysphonia (SD) is a rare disease and its epidemiological status is unclear. This review aimed to explore the current prevalence and clinical features of SD in Japan. Methods We reviewed Japanese surveys of SD and compared them to surveys reported from other countries. We focused on SD prevalence, clinical features (SD type, sex and age), and treatment modalities. Results The SD prevalence in Japan was 3.5–7.0/100,000, similar to that in Rochester (NY, USA) and Iceland. Adductor SD predominated (90–95%) and females were four-fold more likely to be affected than males. Mean age at onset was approximately 30 years in Japan. Several years elapsed from onset to diagnosis. The most frequent treatment was botulinum toxin injection, and surgical intervention, particularly type 2 thyroplasty is becoming more popular. Conclusions Our review demonstrated some differences of clinical features of SD in Japan compared with other countries, such as a greater female predominance and younger age of onset. Many physicians and patients may be unfamiliar with the clinical features of SD leading to delayed of diagnosis. Therefore, we proposed diagnostic criteria to facilitate early diagnosis and an appropriate choice of treatment modalities.

Objective Adductor spasmodic dysphonia is a rare voice disorder characterized by strained and strangled voice quality with intermittent phonatory breaks and adductory vocal fold spasms. Type II thyroplasty differs from previous treatments in that this surgery does not involve any surgical intervention into the laryngeal muscle, nerve or vocal folds. Type II thyroplasty intervenes in the thyroid cartilage, which is unrelated to the lesion. This procedure, conducted with the aim of achieving lateralization of the vocal folds, requires utmost surgical caution due to the extreme delicacy of the surgical site, critically sensitive adjustment, and difficult procedures to maintain the incised cartilages at a correct position. During surgery, the correct separation of the incised cartilage edges with voice monitoring is the most important factor determining surgical success and patient satisfaction. Methods We designed new surgical instruments: a thyroid cartilage elevator for undermining the thyroid cartilage, and spacer devices to gauge width while performing voice monitoring. These devices were designed to prevent surgical complications, and to aid in selecting the optimal size of titanium bridges while temporally maintaining a separation during voice monitoring. Results We designed new surgical instruments, including a thyroid cartilage elevator and spacer devices. Precise surgical procedures and performing voice tuning during surgery with the optimal separation width of the thyroid cartilage are key points for surgical success. Conclusion We introduce the technique of voice tuning using these surgical tools in order to achieve a better outcome with minimal surgical complications.

Intervento di adduzione aritenoidea sec. Isshiki modificata, senza separazione cricotiroidea e cricoaritenoidea.Gli interventi modificati di adduzione aritenoidea (AA) sono finalizzati a preservare l’integrità dell’articolazione cricotiroidea. Non ci sono tuttavia studi comparativi che confrontino tali metodiche con interventi in cui vi sia la separazione cricotiroidea in termini di edema laringeo postoperatorio e funzione fonatoria a lungo termine. In questo studio si valuta un intervento di AA con allestimento di lembo peduncolato neuromuscolare (+ NMP) e preservazione dell’articolazione cricotiroidea. Sono stati valutati otto pazienti con paresi cordale monolaterale sottoposti a tale procedura (Gruppo 1). È stato valutato l’edema post operatorio a livello delle corde vocali, cappucci aritenoidei e seni piriformi con una scala, da 0 a 3 (0: nessun edema - 3: edema grave). Il gruppo controllo (Gruppo 2) è rappresentato da 19 pazienti sottoposti a AA con separazione dell’articolazione cricotiroidea. Il tempo massimo di fonazione (MPT), il jitter e il voice hadicap index (VHI) sono stati misurati prima e 1 anno dopo la chirurgia. I risultati funzionali fonatori del Gruppo 1 sono stati comparati con quelli di un gruppo controllo formato da 58 pazienti sottoposti a AA + NMP (Gruppo 3). L’edema a livello delle corde vocali, cappucci aritenoidei e seni piriformi del Gruppo 1 è risultato relativamente stabile dal primo al sesto giorno post operatorio. L’edema a livello delle corde vocali e seni piriformi nel Gruppo 1, a 3 e 4 giorni dalla chirurgia è risultato inferiore rispetto al Gruppo 2. Ad un anno dopo la chirurgia, non sono risultate differenze in termini di MPT, Jitter e VHI fra il Gruppo 1 e il Gruppo 3. La preservazione dell’articolazione cricotiroidea può risultare vantaggiosa nel ridurre l’edema laringeo post operatorio dopo AA. La funzione vocale dopo AA + NMP con preservazione o separazione dell’articolazione cricotiroidea sono comparabili.Modified methods of arytenoid adduction (AA) have been reported to keep the cricothyroid (CT) joint intact. However, postoperative laryngeal oedema and long-term vocal function have not been compared with those after AA with CT joint separation. We refined AA to combine it with nerve-muscle pedicle (NMP) flap transfer for preservation of the CT joint. Eight patients with unilateral laryngeal paralysis underwent the procedure (Group 1). Postoperative oedema at membranous vocal fold (MVF), arytenoid mound (AM) and pyriform sinus (PS) was assessed using a 4-point ordinal scale: none (0) to severe (3). Laryngeal oedema in Group 1 was compared with that of 19 patients who had AA with CT joint separation (Group 2). Maximum phonation time (MPT), jitter and voice handicap index-10 (VHI-10) were measured before surgery and one year postoperatively. Vocal function in Group 1 was compared with 58 patients who underwent AA + NMP flap transfer with CT joint separation (Group 3). The degree of oedema from postoperative days 1 to 6 in Group 1 was relatively invariable: 1.2~1.6 at MVF, 1.3~1.7 at AM, and 1.4~1.7 at PS. The scores at 3 and 4 days postoperatively at MVF and PS in Group 1 were significantly lower than in Group 2 (P = 0.0032 and 0.0317 at day 3, and 0.0224 and 0.0182, at day 4, respectively). The degree of oedema at day 3 at AM in Group 1 was significantly less than in Group 2 (P = 0.0260). One year after surgery, there were no significant differences in MPT, jitter and VHI-10 between Groups 1 and 3 (P = 0.660, 0.111 and 0.556, respectively). Preservation of the CT joint might be beneficial in reducing the maximum degree of laryngeal oedema after AA. Vocal function after AA + NMP flap transfer with CT joint preservation is comparable to that after AA + NMP flap transfer with CT joint separation.

Objectives/Hypothesis To evaluate vocal function after refined nerve-muscle pedicle (NMP) flap implantation with arytenoid adduction (AA) compared with type I thyroplasty with AA for patients with unilateral vocal fold paralysis (UVFP) and to evaluate the degree of patient satisfaction following the refined NMP with AA. Study Design A retrospective review of clinical records of 52 patients with UVFP who received AA + NMP (NMP group, n = 40) or AA + type I thyroplasty (type I group, n = 12) as a single-stage operation between April 1999 and December 2011. Methods Evaluation of vocal fold vibration, aerodynamic analysis, perceptual evaluation, acoustic analysis, and subjective assessment were performed preoperatively and at two different postoperative periods (short term: within 3 months and long term: >12 months). Results All parameters except for glottal gap of the vocal fold vibration, maximum phonation time (MPT), and mean airflow rate revealed significant improvement between the short- and long-term assessments in the NMP group. On the contrary, the type I group did not show significant change of any parameters during postoperative periods. In the NMP group, the measurements for regularity of the vocal fold vibration and MPT at the long-term assessment were significantly favorable compared with the type I group. In the NMP group, subjective assessment (Voice Handicap Index-10 and Voice-Related Quality of Life) revealed significant improvement between the short- and long-term assessments. Conclusions In comparison with the type I group, significant improvement of vocal function patient satisfaction during the long-term follow-up period after AA combined with the refined NMP was confirmed. Level of Evidence 4. Laryngoscope, 2016

Objective The aim of the present study was to illustrate the safety and utility of the endoscopic endonasal approach (EEA) for the treatment of esthesioneuroblastomas (ENB). Methods We retrospectively reviewed patients with a diagnosis of ENB between March 2008 and February 2016 at 10 tertiary referral hospitals in Japan, and assessed demographic data, stage of disease, surgical approach, outcomes and postoperative complications. Results A total of 22 patients (10 males and 12 females; mean age at presentation, 49.0 years) underwent endoscopic endonasal resection of newly diagnosed ENBs. Dulguerov staging at presentation was T1, 6 patients; T2, 9 patients; T3, 5 patients; and T4, 2 patients. As surgical procedures, unilateral resection via EEA was performed in 12 patients aiming preservation of the contralateral olfactory system, and bilateral resection via EEA was done in 10 patients. Post-operative radiotherapy was done in 20 patients. Pathological margin studies revealed margin-free resections in 21 patients (95.5%). The mean period of follow-up was 44 months. Local recurrence was observed in one T2 patient 12 months after bilateral resection. All patients were alive at the last follow-up, and 21 patients showed no evidence of disease. No post-operative complications including bleeding, CSF leak and meningitis were identified. Preservation of olfactory function was achieved in 11 patients (91.7%). Conclusion The results of the present study indicate the safety and utility of multilayer resection using EEA for treatment of ENBs.

Objectives/Hypothesis 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. Study Design Quantitative real-time polymerase chain reaction qPCR and histologic assessment of the TA muscle following RLN transection and anastomosis. Methods 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. Results The expression levels of messenger RNAs (mRNAs) encoding M-cadherin and MyoD in the TA muscle of the DNV group were significantly higher (P

The objective of this study is to evaluate long-term efficacy of refined nerve-muscle pedicle (NMP) flap implantation combined with arytenoid adduction (AA) for treatment of unilateral vocal fold paralysis (UVFP). The authors retrospectively reviewed 33 patients with UVFP who received refined NMP flap implantation with AA and were followed up over a 1-year period. Evaluation of vocal fold vibration (regularity, amplitude, and glottal gap), aerodynamic analysis (maximum phonation time [MPT] and mean airflow rate [MFR]), and perceptual evaluation (Grade and Breathiness) were performed preoperatively and at five different time points (1, 3, 6, 12, and 24 months) postoperatively. All voice parameters improved significantly postoperatively. All parameters except MFR also continued to improve over the course of 24 months. In the videostroboscopic analysis, the parameter for regularity 24 months after surgery was significantly improved compared with that at 1, 3, and 6 months after surgery. There were also significant improvements in amplitude and the glottal gap 24 months after surgery in comparison with values at 3 and 6 months after surgery and 3 months after surgery, respectively. Significant improvement in aerodynamic and perceptual measurements during the follow-up period together with near-normal vocal fold vibration was achieved by delayed reinnervation with refined NMP flap implantation and AA. The combined surgical technique is effective in the treatment of severe breathy dysphonia due to UVFP. Level of evidence 4.

Objectives Standard treatments of adductor spasmodic dysphonia (AdSD) provide temporary relief of symptoms. Type 2 thyroplasty offers a long-term solution; however, long-term voice outcome data are lacking. The objective of this study was to assess the long-term voice outcomes of type 2 thyroplasty with titanium bridges through use of a validated voice questionnaire. Study Design Case series with chart review. Setting University hospital. Subjects and Methods Forty-seven consecutively enrolled patients with AdSD underwent type 2 thyroplasty with titanium bridges between August 2006 and November 2014. Questionnaires were completed during regularly scheduled follow-ups and, in some cases, were sent to patients who missed follow-up appointments. In 2015, questionnaires were mailed to all 47 patients and included a Voice Handicap Index-10 evaluation, as well as questions on postoperative vocal symptoms, surgical site, and status of the implanted titanium bridges. Results Of 47 patients with AdSD, 31 (66%) completed the questionnaires. The average follow-up interval was 41.3 months. No patient reported experiencing an adverse event around the surgical site, and almost all were satisfied with their voices postoperatively. The mean postoperative (>3 years) Voice Handicap Index-10 score improved significantly, from 26.3 to 9.4 (n = 17, P = .0009). Conclusions Type 2 thyroplasty for AdSD significantly improved patient quality of life and voice symptoms and continued to do so long after the surgery. The results of this study suggest that type 2 thyroplasty provides relief from vocal symptoms in patients with AdSD for >3 years.

Objectives To determine the long-term functional outcomes of type II thyroplasty using titanium bridges for adductor spasmodic dysphonia (AdSD) by perceptual analysis using the Voice Handicap Index-10 (VHI-10) and by acoustic analysis. Methods Fifteen patients with AdSD underwent type II thyroplasty using titanium brides between August 2006 and February 2011. VHI-10 scores, a patient-based survey that quantifies a patient's perception of his or her vocal handicap, were determined before and at least 2 years after surgery. Concurrent with theVHI-10 evaluation, acoustic parameters were assessed, including jitter, shimmer, harmonic-to-noise ratio (HNR), standard deviation of F0 (SDF0), and degree of voice breaks (DVB). Results The average follow-up interval was 30.1 months. No patient had strangulation of the voice, and all were satisfied with the voice postoperatively. In the perceptual analysis, the mean VHI-10 score improved significantly, from 26.7 to 4.1 two years after surgery. All patients had significantly improved each score of three different aspects of VHI-10, representing improved functional, physical, and emotional well-being. All acoustic parameters improved significantly 2 years after surgery. Conclusions The treatment of AdSD with type II thyroplasty significantly improved the voice-related quality of life and acoustic parameters 2 years after surgery. The results of the study suggest that type II thyroplasty using titanium bridges provides long-term relief of vocal symptoms in patients with AdSD.

Objectives/Hypothesis: To evaluate the impact of nimodipineon reinnervation of the long-term denervated rat thyroarytenoid (TA) muscle following nerve-muscle pedicle flap (NMP) implantation. Study design: Quantitative histologic and physiologic assessments. Methods: 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. Results: 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 (P < 0.05, each). In the 0-week and 32-week interval subgroups, the muscle fiber subtype changed significantly, from IIA to IIB (P < 0.01 and P < 0.05, 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. Conclusions: Nimodipine expedited the effects of NMP implantation on reinnervation of the long-term denervated TA muscle. Laryngoscope, 2012

Objectives/Hypothesis: Arytenoid adduction (AA) as surgical treatment for unilateral vocal fold paralysis (UVFP) is associated with higher morbidity from airway complications due to postoperative laryngeal edema compared with other laryngeal framework surgeries. The aim of this study was to evaluate postoperative laryngeal edema after AA using a new videolaryngoscopic (VL) scoring assessment. Study Design: Prospective case series. Methods: Nineteen patients with UVFP (14 males and five females; mean age, 56 years) who were treated with AA alone or combined with ansa cervicalis (AA/AC) nerve anastomosis or nerve-muscle pedicle (AA/NMP) flap implantation were evaluated. Laryngeal edema was assessed by VL scoring for 10 days postoperatively. Degree of edema was scored in three subsites: the membranous vocal fold, arytenoid mound, and pyriform sinus on the operated side. Statistical significance was defined as P < .05. Results: No patient experienced postoperative airway compromise. Interexaminer reliability was generally high (Spearman r > 0.75). The mean degree of edema increased steadily from postoperative day (POD) 1 to 3, peaking on POD 3 at all subsites. It then declined significantly from POD 3 to 7 (P < .05) and gradually through POD 10. The maximum degree of edema, maximum edema time, and operative time were not correlated significantly at any subsite. Maximum edema time and surgery type (AA vs. AA/AC or AA/NMP) were not correlated at any subsite. Conclusions: Inter-rater reliability for the proposed VL scoring was significant at all subsites. The VL findings suggest that AA alone or AA combined with reinnervation showed maximum laryngeal edema on POD 3 but added no significant morbidity.

Objectives/Hypothesis: 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. Study Design: Prospective study. Methods: 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. Results: 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). Conclusions: 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.

片側声帯麻痺の嗄声に対する治療として, 披裂軟骨内転術 (以下, 内転術) はよく知られた術式であり, 一般的に他の術式と併用して行われることが多い. これまで併用術式の術後発声機能を経時的に検討した報告はない. 今回, 内転術を単独で行った症例 (内転群) , 内転術に甲状軟骨形成術I型 (以下, I型) を加えた症例 (内転+I型群) , 内転術に頸神経ワナ－反回神経吻合術 (以下, Ansa吻合術) を加えた症例 (内転+Ansa吻合群) について治療前後の発声機能を, 空気力学的検査, 音響分析, 声域を用いて検討した. 内転+I型群, 内転+Ansa吻合群でMPT, MFR, Jitter, HNRが正常域まで改善した. 内転+Ansa吻合群では, 術後1ヵ月以降持続的に有意な改善を認め, 術後12ヵ月で他の2群と比較し有意に声域が拡大していた. 症例に応じて内転術に加え, I型やAnsa吻合術を併用することで良好な音声が得られ, 特にAnsa吻合術を併用することで, 他の2群と比較して声域が広がり, より一層正常な音声に近づけることができると考えた.

Use of the titanium bridge, both at the top and bottom corners of the incised thyroid cartilage, is essential for success. Most importantly, these procedures should be done with minimal damage to the tissues involved, using fine instruments.Type II thyroplasty that aims at lateralization of the vocal folds for spasmodic dysphonia is a type of surgery that requires utmost surgical caution, because of the extremely delicate site for surgical intervention, critically sensitive adjustment, and difficult procedures to maintain the incised cartilages in a correct position.By means of a postoperative questionnaire and examinations, analyses were made of the relation in each case between the detailed surgical records and the outcomes in terms of subjective complaints, vocal features, and laryngeal as well as aerodynamic findings.It was found that surgical failures or unsatisfactory results arise most frequently from certain clear mechanical faults. The critical procedures that most affected the results included: (1) incision and separation of the thyroid cartilage at the midline; (2) adjustment of separation width for optimal voice; (3) cartilage-perichondrium separation for holding an appropriate titanium bridge; and (4) installation and fixation of titanium bridges.

Scarring of the vocal folds can result from blunt laryngeal trauma or more commonly due to surgical iatrogenic injury after the removal of vocal fold lesions. The scarring results from the replacement of healthy tissue with stiff fibrous tissue that can irrevocably alter vocal function, leading to a decreased or absence of the vocal fold mucosal wave. Current treatments for this complex condition are inconsistent and often produce suboptimal results. This study reviews the outcomes of 13 patients who, in an office setting, underwent transcutaneous chordal steroid injections with curved needles for vocal fold scarring. This injection technique was performed under local anesthesia. Results were evaluated by videostroboscopy, perceptual evaluation of the GRBAS scale, and acoustic analysis before and after the injections. Injections were given from 2 to 5 times. These steroid injections did not completely clear scar lesions in all patients, although videostroboscopic observations revealed improvement in 11 patients. In perceptual evaluations, all cases experienced a progressive improvement of voice quality with the passage of time after the injections. With the acoustic findings, all parameters showed significant improvement after the injections. Our experience showed a positive response of scars to steroid injection therapy. Repeated transcutaneous chordal steroid injections using curved needles offer significant improvement in the management of vocal fold scars.

披裂軟骨内転術は，一側声帯麻痺患者の嗄声を改善させる有用な手術の一つである．しかし，披裂軟骨筋突起周囲を操作するため，術後に披裂部を中心とした腫脹を起こす．腫脹が高度の場合には気管切開が必要となることがあり，術後早期の経過観察については注意を要する．しかし，術後の咽喉頭粘膜の腫脹を詳細に検討した報告は見られない．今回，われわれは，当科で披裂軟骨内転術を施行した一側声帯麻痺患者8例について，術後の咽喉頭を鼻咽喉ビデオスコープを用いて経時的に観察し，粘膜の腫脹を評価した．評価項目を1)患側声帯膜様部の腫脹，2)患側披裂部の腫脹，3)患側梨状陥凹の腫脹とし，術後咽喉頭粘膜腫脹の変化と，腫脹が最大となる時期に影響する因子，評価方法の妥当性について検討した．結果，術後咽喉頭粘膜腫脹は術後2日目以降に強くなり，腫脹が最大となるのは術後3日目から4日目であった．また，本評価方法の結果は，検者間で差がなかった．