Purpose : Thyroplasty type I and arytenoid adduction surgery are effective surgical treatments for dysphonic patients with unilateral vocal fold paralysis. Adduction of the vocal fold decreases the glottal gap during phonation and improves breathy voice. The decrease of glottal area during inspiration, however, may cause an increase in upper airway resistance. The purpose of this study is to quantify the glottal area during inspiration and to examine the relationship between glottal area and upper airway resistance in phonosurgical treatment. Materials and Methods : Eleven patients with unilateral vocal fold paralysis underwent multi-slice helical computerized tomography (MSHCT) before and after phonosurgical treatment. Seven of them underwent pulmonary function tests and FEV1.0/PEF ratio was calculated to evaluate upper airway obstruction. Six of them underwent body plethysmography to evaluate airway resistance. Image analysis software was developed to measure the glottal area during inspiration. Results : Glottal area during inspiration was significantly decreased after phonosurgical treatment. The mean glottal area decreased in size to 77.0% of that before phonosurgery. The FEV1.0/PEF ratio was not significantly increased after phonosurgery. The mean airway resistance was 114.4% of that before phonosurgery. A correlation between glottal area and airway resistance was not found. Conclusion : It is possible to measure glottal area by MSHCT, and upper airway resistance does not significantly increase after phonosurgical treatment.
After denervation of the recurrent laryngeal nerve (RLN), the innervated laryngeal muscles are atrophied. We have reported that functional electrical stimulation (FES) delivered to the thyroarytenoid (TA) muscle prevents muscle atrophy after denervation. The reason why FES prevents atrophy of the muscle is not yet clear. In this study, we tried investigating a hypothesis that the superior laryngeal nerve (SLN) might have a role in preventing muscle atrophy by FES. We used 23 adult rats in this study. Resections of the left SLN with the left RLN, or bilateral SLNs with the left RLN were performed. A pair of thin wire stimulation electrodes (50 u m) was placed in the left TA muscle. The animals were divided into two groups : a stimulated group and a non-stimulated group. In the stimulated group, FES, with 2 mA rectangular pulses of 0.2 ms duration at 2 Hz lasting for 1 hour, was delivered to the TA muscle once every 2 days. After the stimulation periods of 2 or 4 weeks, frontal sections of the larynx 8 pm in thickness were prepared. The differences in the area of the TA muscle, the area of the TA muscle fiber and the density of the TA muscle fiber were compared between the denervated (left) side and the non-denervated (right) side. Atrophy of the TA muscle was observed in spite of the ipsilateral and/or bilateral denervation of the SLN. The effect of FES to prevent muscle atrophy was also observed regardless of SLN resection. The results obtained from this study suggested that the information to the central nervous system through the SLN was not indispensable for preventing muscle atrophy after denervation of RLN.
Acute epiglottitis is a critical disease that causes rapid dyspnea and occasionally requires a tracheotomy to be performed. In this study, thirty-two patients (23 male and 9 female) with acute epiglottitis who had visited Kagoshima University Hospital between 1999 and 2002 were retrospectively investigated. Their ages ranged from 13 to 75 with a mean age of 47 years. The severity of epiglottis swelling was classified into three grades; mild, moderate, and severe. Two patients with severe swelling and one with moderate swelling underwent tracheotomy because of serious dyspnea. Scarification of the epiglottis was done in most patients classified as moderate or severe. There were no patients that had any complications or whose condition became worse after scarification. These findings suggest that a tracheotomy might be essential for severe grade case and scarification might be useful for the treatment of acute epiglottitis.
A total of 562 patients with recurrent laryngeal nerve paralysis (RLNP) who had visited our department of otolaryngology at the Kyoto Prefectural University of Medicine between 1988 and 2000 were examined and the results were compared with those from 436 patients with RLNP who had visited the same hospital between 1971 and 1987. Compared with the later mentioned group, the rate of infant patients affected had increased. Cases of RLNP caused by esophageal cancer, heart and aortic disease as well as post-endotracheal intubation had grown in number. Cases of RLNP from unknown causes had decreased. This was probably due to progress in diagnostic techniques utilizing imaging such as CT, MRI and ultrasonic examination. In some cases, the chest CT revealed causes which chest radiographs could not diagnose. A high rate of recovery was observed in patients with RLNP due to intubation as well as after common cold infections in both groups of patients.
In this study, we examined the advantages of hypopharyngeal fiberscopy. A hypopharyngeal fiberscope has the tip covered with plastic transparent hood that enables one to avoid the so-called red-ball phenomenon. This undesirable phenomenon occurs when observation becomes impossible due to the mucous membrane adhering to the tip of the scope. With the hypopharyngeal fiberscope, the esophageal inlet and the deep part of piriform sinus can be clearly observed much more readily than with a conventional laryngeal fiberscope. Hypopharyngeal fiberscopy was performed on 117 patients whose chief complaint was abnormal sensations in the laryngopharynx (ASL), particularly those who had no clinical findings from laryngeal fiberscopy. The patients were examined between June 2001 and December 2002. Details of the study are as follows : 1) Eighty-four males and thirty-three females were studied. Hypopharyngeal fiberscopy was often performed in the 6th and 5th decades of life for both genders. 2) Cancer was found in 6 of 117 patients studied by hypopharyngeal fiberscopic observation, a prevalence rate of 5%. Two of those had hypopharyngeal cancer and the remaining four had esophageal cancer. 3) Ectopic gastric mucosa was found in the esophagus of 19% of 117 patients who underwent hypopharyngeal fiberscopy. Compared to the incidence of ectopic gastric mucosa diagnosed by esophagogastroscopy in general, 19% was much higher. These findings support that abnormal sensa-tions in the laryngopharynx (ASL) may be caused by ectopic gastric mucosa.
The department of otorhinolaryngology in our hospital opened the Outpatient Clinic of Dysphagia in 1999, and has diagnosed and treated dysphagia caused by various diseases. At present, our hospital has an established system involving preparation and dissemination of a diagnostic flow chart to each department in order to evaluate dysphagia for patients with cerebrovascular disorders and who are at risk of dysphagia. Once identified, these patients are transferred to the Outpatient Clinic of Dysphagia at once so as to catch dysphagia at an early stage. First, an otorhinolaryngologist examines the movement and sensory perception of the oral cavity, pharynx and larynx in all patients using a laryngeal fiberscope. For some patients, the presence or absence of flow into the larynx is then examined by swallowing a solution under fiberscopic observation and while having videofluorography (VF) performed. The treatment includes training by a swallowing therapist (ST), and/or surgery to improve swallowing or to prevent accidental swallowing, on a case-by-case basis. The authors studied 120 patients who had consulted the Outpatient Clinic of Dysphagia of our hospital from April 2001 to March 2003. Fifty-four patients required training, surgery or other treatment, and 25 of them were treated with only by training. In combination with training, tracheotomies were performed on 10 patients, ; laryngeal elevation surgery/ cricopharyngeal myotomies with 3, ; tracheoesophageal diversions on 10, and laryngectomies in 6. Twenty-two patients could take food by mouth at the first visit. Oral feeding became possible in 96 out of 120 patients after the treatment, including those who were trained as well as treated by surgery.
Relapsing polychondritis (RP) is a rare inflammatory disease of unknown etiology characterized by recurrent inflammation and destruction of cartilaginous structures and connective tissue. We report a 55-year-old woman whose subglottic stenosis was successfully treated by removal of the granulation using KTP-laser and by the placement of retainer cannula in exchange for T-tube. At the age of 46, a tracheostomy and placement of T-tube treated the first onset of dyspnea due to RP. Her symptom was alleviated by medication of prednisolone. At the age of 54, she was admitted to our hospital because of recurrence of dyspnea caused by subglottic granulation. Despite laryngofissure, removal of the granulation using KTP-laser, mucosal graft, and placement of T-tube, subglottic granulation relapsed shortly. We removed T-tube and placed a retainer cannula while medicating immunosuppressant. Then subglottic granulation was gradually reduced, so she was stopped medication and now is under observation in outpatient clinic. The cause of RP is still unknown although current data provide increasing support for an autoimmune basis. Approximately 50% of the patients with RP contact laryngotracheaobronchial disease, which can be complicated by laryngeal, tracheal, and/or bronchial obstruction that may result in death. We reported removal of the granulation using KTP-laser and the use of retainer cannula for treatment of subglottic stenosis with RP was effective. Strict observation is still required.
A 22-years-old male complained of neck pain while using a lawn mower. He found a skin injury on the front of his neck. Computed tomography discovered a foreign body within the thyroid cartilage, which did not reach to the membrane of the larynx. He underwent a “thyrotomy” and a tracheostomy under general anesthesia. We found a foreign body that was burying under the thyroarytenoid muscle. It was made of metal and was 1 cm length. No functional disturbance was observed after the surgery.
The use of implanting titanium mesh for laryngotracheal reconstruction is explained in this report. A titanium mesh with a thickness of 0.4mm was used as a framework for full thickness defects of the larynx and trachea after resection of locally advanced thyroid carcinoma (T4). First, it was implanted next to the laryngotracheal stoma, which had been made during the initial treatment of the thyroid carcinoma. About three weeks after the implantation of the titanium mesh, a hinged flap including cervical skin and platysma was harvested and used for the closure of the stoma. The internal lining of the reconstructed airway was covered with cervical skin. The skin defect on the neck created from harvesting the hinged flap was covered with rotational flap advancement without requiring skin grafts. The diameter of the airway was sufficiently maintained. This method of reconstruction using titanium mesh and a hinged cervical skin flap had no major complications or difficulties, with an absence of exposure or rejection of the titanium mesh. This material has an affinity to the human body and is very easy to obtain and utilize safely for operations.
A case of a 57-year-old female suffering from adhesion of the vocal cords and esophageal stenosis was reported. In the course of treatment 40 years earlier for a papilloma in the larynx, she had received implantation of radon seeds. She had complained of aspiration difficulties and pneumonia several times. According to observations using a flexible fiberscope, both vocal cords were located in the lateral position, and the arytenoids were adhered to the posterior wall of the pharynx. Furthermore, both pyriform sinuses were completely closed. A small opening, less than 3mm, was detected between the postcricoid and pharynx, through which she could hardly ingest. An x-ray of the neck indicated that there were some radon seeds, each 3mm in length, located around the arytenoids. It was thought that the findings in the larynx and pharynx had been caused imperceptibly by inflammation and fibrosis following the implantation of the radon seeds. Surgery was performed to improve her dysphagia. First, incisions were made toward left pyriform sinus from a small opened-space located in the postcricoid via microsurgery. The hypopharynx was entered through the left pyriform sinus after the skin on the left side of the neck was incised vertically along the sternocleidmastoideus muscle. The adhesion at the level of the pyriform sinuses was cut sharply, and the left pyriform sinus was made by resuturing the mucous membrane of the hypopharynx so as to conceal the raw surface. Two years have passed since the surgery. The vocal cords have not moved and although she has suffered from hoarseness, she can now eat whatever she likes.
We reported on a case of parasitic laryngitis caused by Clinostomum complanatum, a small trematode. The patient was a 27-year-old man who complained of a sore throat and abnormal pharyngolaryngeal sensations that began 3 days after eating raw carp. By use of fiberscopic laryngoscopy, one of us discovered a crawing fluke attached to the left arytenoid mucosa. Laboratory examination results were within normal ranges. After removal of the fluke, the symptoms were relieved. The fluke was identified as Clinostomum complanatum. This trematode has been known to cause parasitic laryngopharyngitis as a result of eating raw freshwater fish. Parasitic laryngopharyngitis is not a common disease in Japan, however, in a global context, most human cases of Clinostomum infection have been reported in Japan. These cases occurred after having eaten raw freshwater fish. Those infected complained of pain or irritation of the pharynx, abnormal sensations which felt like a foreign body, coughing, and deglutitive pain. This is the 18th case recorded in Japan.
We initially report a 14-years old female case with chronic activity EB virus infection (CAEBV), suffered from dyspnea caused by proliferative granulation of bilateral vocal cords and supra glottic region. CAEBV is in the condition which the activity of EB virus infection maintains over several months or more, and the number of EB virus infected cell or the amount of EB virus genemes is increasing. In this case, EBERI positive and granzyme B positive cells were varified by in situ hybridization, and diagnosed as NK cell dominant CAEBV. CAEBV is the latest recognized EB virus related disease and doesn't established diagnostic standard. In cases of recurrent infectious mononucleosis and/or mosquito allergy, we need to consider to this disease.
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