Koutou (THE LARYNX JAPAN) Vol. 26(2014) No. 1

When Type II thyroplasty is performed, surgical management of the dihedral angle of the midline of the thyroid cartilage is very important. Clinical histoanatomy around the anterior commissure was investigated using whole organ serial sections of the human larynx to make Type II thyroplasty successful.
An inner perichondrium did not exist at the dihedral angle in the upper three-forths of the midline of the thyroid cartilage. On the other hand, the inner perichondrium was present at the lower one-forth of the midline of the posterior surface of the thyroid cartilage.
The attachment of the collagenous fiber (anterior commissure tendon, Broyles, 1943) extends from the upper portion of the thyroid notch caudalward for approximately upper three-forths of the midline of posterior surface of the thyroid cartilage.
The midline of the posterior surface of the thyroid cartilage is only covered with thin mucosa at the laryngeal ventricle level. It is important not to perforate the mucosa when the laryngofissure is performed.
In order to make the anterior commissure the proper width, it is important to split the anterior commissure tendon at the mid-line and to spread the glottis while making sure the tendons remain attached to the bilateral thyroid cartilage.

We reviewed the clinical dissection of anterior commissure, and Type II thyroplasty operative procedures. The handling of the anterior commissure is the most important point in this surgery. An inner perichondrium does not exist in the dorsal midline part of the thyroid cartilage, and the collagenous fiber of the anterior commissure tendon combines with the cartilage matrix of the thyroid cartilage at the vocal cord level. At the supraglottic level, the thyroepiglottic ligament connects with the thyroid cartilage through the collagenous fiber of the anterior commissure tendon which extends to the supraglottics. In order to maintain a moderate glottis split with certainty and permanence, don’t exfoliate this tendon from the thyroid cartilage. It is necessary to split the tendon and to spread the glottis while the tendon is joined with the cartilage. For this purpose, a special spreader was made.

The clinical symptoms of laryngeal allergy are persistent cough, itching and irritation of the throat. We endeavored to shed light on features of antigens and laryngeal findings of laryngeal allergy. A clinical study focusing on the diagnosis of laryngeal allergy was carried out on 32 patients exhibiting a persistent cough, itching and irritation of the throat. The diagnosis of laryngeal allergy was confirmed by the effectiveness on H1-blockers along with the presence of specific IgE antibodies by RAST testing. Laryngeal allergy was diagnosed according to the criteria proposed by the Society of Study for Laryngeal Allergy in Japan (2005).
Eighteen of the 32 patients were diagnosed as having laryngeal allergy. A major positive perennial antigen in laryngeal allergy is house dust mite. In comparison to nasal allergy, moth and cockroach antigens has a higher positive frequency with laryngeal allergy.
The sensitivity and specificity of nasopharyngeal smears for laryngeal allergy were 67% and 79%, respectively. H1-blocker was significantly effective with positive nasopharyngeal smears.
There were no typical laryngeal features in laryngeal allergy cases but patients with a higher effect of antihistamines exhibited pale laryngeal mucosa.

Angiolytic laser such as KTP ⁄ 532nm, green laser/532nm, or pulse dye laser (PDL) ⁄ 585nm have proven useful for the treatment of various vocal fold lesions including hemorrhagic lesions, papilloma, leukoplakia, and Reinke’s edema. Since the laser causes minimal bleeding during the procedure, office based out-patient surgery is well indicated. It has also been confirmed that laser treatment causes negligible heat damage to the underlying tissues because of low lasing power and good absorption of the energy into oxyhemoglobin. The present case series provided safety and vocal outcome of angiolytic laser surgery for 16 cases with hemorrhagic ⁄ non-hemorrhagic vocal polyps. The results showed significant improvement of vocal function postoperatively with no scarring effects on the vocal folds.

We investigate the excisional limitations of larynx preservation by the technique of extended supracricoid laryngectomy (ESCL) with regard to postoperative swallowing function. Twenty-three patients with advanced or recurrent laryngeal squamous cell carcinoma underwent supracricoid laryngectomy from 2005 to 2012. Extended resection (ESCL) was performed on seven of them. We observed CTCAE v4.0 defined Grade 1 dysphagia in 3 patients, Grade 2 in 2 patients, Grade 3 in 1 patient and had no assessment for 1 patient because of an earlier salvage operation by total laryngectomy. We obtained a good outcome in patients with additional resection of only unidirectional excision of hyoid bone, cricoid arch or arytenoid cartilage, and only in patients in their early sixties or younger. Dysphagia after ESCL is a common result, but we suggest that ESCL is an effective surgical procedure for functional larynx preservation to deal with advanced or recurrent laryngeal cancer if properly performed.

The incidence of the non-recurrent inferior laryngeal nerve is reported to be approximately 1% of the population. The rare nerve condition was exclusively observed on the right side. The reason for laterality is a congenital abnormality of the right subclavian artery. It is important for surgeons to be vigilant for non-recurrent inferior laryngeal nerve before thyroid and parathyroid surgery.
The patient was a 34-year-old male suffering from thyroid papillary carcinoma. He underwent right lobe dissection and D2 dissection. During surgery, we noted a non-recurrent inferior laryngeal nerve emanating directly from the right vagus nerve. The patient didn`t complain of post-operative voice change as the non-recurrent laryngeal nerve was preserved. Post-surgically, we checked the pre-operative cervico-thoracic computed tomography scan again and noticed abnormality of right subclavian artery, branching from the descending aorta and passing behind esophagus.

Arytenoid cartilage dislocation is sometimes caused by endotracheal intubation or external neck trauma. Arytenoid cartilage dislocation is divided into anterior and posterior types according to the direction of dislocation. In this study, we reported on two patients with arytenoid dislocation treated by several methods of repositioning and surgery.
Case1: A 69-year-old female complained of hoarseness after aortic valve replacement. Endoscopic examination revealed the deviation of the left arytenoid toward the posterolateral position and hypokinesia of the left vocal cord during phonation. Endoscopic manual reduction and balloon-reduction were performed and arytenoid cartilage movement improved one month later.
Case2: A 68-year-old male who had the habit of self-induced vomiting after consuming alcohol. One day, he complained of a sore throat after self-vomiting, and hoarseness emerged three days later. The local otolaryngologist found immobility of the right vocal fold and referred him to our hospital. His maximum phonation time (MPT) was 1.7 seconds at first visit. Endoscopic examination suggested dislocation of the left posterior arytenoid cartilage. Computed tomography (CT) imaging was helpful in the evaluation of patients. Electromyography revealed reduced electrical activity in the thyroarytenoid muscle during phonation. We diagnosed right posterior arytenoid dislocation. Neither endoscopic balloon-reduction nor manual-reduction could improve arytenoid movement. We applied the surgical system of Transoral videolaryngoscopic surgery (TOVS) for the arytenoid reduction which was effective for evaluation of arytenoid movement during the surgery. His arytenoid seemed to be re-dislocated. A right arytenoid adduction and Type I thyroplasty was performed. The hoarseness improved immediately. MPT improved remarkably from 1.7 to 32 seconds 17 days after surgery. (254 words)

Patients who suffer serious laryngotracheal stenosis due to a laryngeal trauma need to have framework and airway surface reconstruction ; therefore, they require several more surgeries and protracted treatments in many cases. Patients’own tissues such as costochondral, nasal septal cartilage and conchal cartilage, as well as artificial materials such as hydroxylation apatite, titanium mesh and artificial airways developed by advances in regenerative therapy, have been used for the reconstruction framework. We reported on a traumatic laryngeal case, an 18-years-old man, with whom we obtained good result using a spacing device and a plate specially manufactured from titanium for airway reconstruction. Results from this case suggest that using instruments made from titanium for reconstruction of laryngotracheal stenosis minimizes invasive tissue harvesting and shortens the treatment period.

Mucosa-associated lymphoid tissue (MALT) lymphoma in the larynx is rare. Its treatment has not been standardized and radiation therapy or radiochemotherapy are often selected for stage I E. We report on a case of surgical treatment for stage I E laryngeal MALT lymphoma which occurred in the false vocal cord. The patient was 44-year-old woman exhibiting hoarseness. Fiberscopic examination revealed a tumorous lesion of the right false vocal fold’s surface smooth. The lesion was treated by excisional biopsy under general anesthesia using a CO₂ laser. Histological diagnosis was stage I E MALT lymphoma in the larynx. Her voice has improved after surgery. Recurrence has not been observed to the present. Excisional biopsy for localized lesions increases the certainty of diagnosis. And, it can be a radical surgery. Observation is one of the choice for patients of Stage I E MALT lymphoma in the larynx after excisional biopsy.

It is very important to prevent secondary infections of tuberculosis. If a case of tuberculosis infection is found in a hospital, we need to expend much time and labor on a follow-up survey. We experienced two cases of laryngeal tuberculosis. In the first case, we found germ discharge of tuberculosis in the hospital. As a result, we needed to follow up on potential secondary infections for patients who were in the same room as the tuberculosis patient. With the second case, we investigated the germ discharge in the outpatient department. We studied the prevention of secondary infections of laryngeal tuberculosis.

A 59-year-old woman with supraglottic T3 cancer was reported. Her right vocal cord lost movement and a tumor was suspected of having invaded the cricoarytenoid joint. She had a history of concurrent chemo-radiotherapy for esophageal cancer and preferred to undergo surgery. We resected a part of the cricoid cartilage beyond the joint and more than a half of thyroid cartilage beyond the midline and reconstructed the larynx by using a forearm free flap. She was discharged 55 days after the surgery and the tracheal stoma closed about a year after the surgery. Five years have passed with no recurrence. She was capable of taking on a normal diet for 30 minutes without aspiration. Although it took a long time to heal, her laryngeal function was ultimately preserved.

The Sato curved laryngoscope permits a wide view of the hypopharynx by suspending the larynx. As a result, both the examination of the hypopharynx and hypopharyngeal surgery become easier when compared to conventional laryngoscopy.
In this study, we report on two cases of hypopharyngeal foreign bodies (fish bones) which were difficult to locate with an upper gastrointestinal endoscope but were readily found and removed safely utilizing the Sato curved laryngoscope.