Botulinum toxin (BT) injection into thyroarytenoid (TA) muscles is a very effective treatment for Spasmodic Dysphonia (SD). In this paper, we report on our experience of 1486 injections for 260 cases of SD in Japan over a 15-year period (1989-Jan. 2004). We made use of Type A neurotoxic BT, which blocks the release of acetylcholine at neuromuscular junctions, resulting in reversible paralysis of the TA muscles. We can identify TA muscles by using an injection needle as an electrode for electromyography (EMG). Several tasks (phonation, breath-holding, etc.) are necessary to identify TA muscles with EMG signals. There are basically four options for injection quantity : 2.5 units unilaterally, 2.5 bilaterally (5.0 in total), 5.0 unilaterally, and 5.0 bilaterally (10.0 in total). A BT injection for SD is effective for 17.3 weeks on average. The main side effects are breathy hoarseness and misdiglutition, which may last for less than two weeks. We have not observed antibody production. The possibility of antibody production is thought to be very low with such small quantities (2.5-10.0 units per injection) given over rather long intervals (once in 3-4 months). It is our hope that BT injections will be authorized by the medical insurance system in Japan, and that more institutes will perform this effective treatment for the benefit of SD patients.
Bilateral thyroarytenoid myectomies were performed on 14 patients with adductor spasmodic dysphonia. During the operation bleeding was controlled by use of a Laser. Fat tissue was removed from abdomen and inserted into vocal fold to fill in the defect after myectomy procedures and to prevent scarring. The patients' voices were restored to normal without recurrence of dysphonia. This operation is one of the most effective treatment for adductor spasmodic dysphonia.
Although botulinum toxin therapy is accepted worldwide as the treatment of choice for control of spasmodic dysphonia, the therapeutic usage of botulinum toxin is strictly limited to patients with blepharospasm or wryneck in Japan. It is problematic to treat spasmodic dysphonia, a relatively rare condition in Japan, without the use of botulinum toxin. Several surgical interventions were performed such as a partial removal of thyroarytenoid muscle under direct laryngoscope. The short-term outcomes were reported to be good, however, long-term results remain controversial since these procedures are categorized as destructive. Isshiki et al reported that type II thyroplasty was effective in treating patients with spasmodic dysphonia. In our hospital this procedure was modified and applied to 7 patients with spastic dysphonia. A horizontal skin incision was made at the mid-portion of thyroid cartilage under local anesthesia and the bilateral thyroid ala was separated at the midline keeping the anterior commissure intact. The anterior edges of the thyroid ala were retracted laterally until the spasticity of the patient's voice was relieved. Once the adequate glottal gap was determined, silicone block was inserted between the bilateral thyroid ala and then fixed in place by nylon thread. All patients noticed an improvement in their speech function during the surgery and were satisfied with their postoperative outcomes. This approach has the advantages of being a simple and reversible procedure, being open to the application of additional available techniques, and capable of revision surgery.
Laryngeal stenosis is a challenging problem for otolaryngologists. Laryngeal trauma and bilateral recurrent nerve palsy were the main causes of laryngeal stenosis in 60 adult cases treated in the Department of Otolaryngology at the University of Tokyo, from 1993 to 2002, although the series also included several cases with unknown causes. Three representative cases are discussed in this paper as well as therapeutic strategies for laryngeal stenosis in adult cases. For treatment of cicatricial stenosis of the larynx : 1) Framework structures of the larynx should be corrected appropriately, 2) The stenotic area and granulation should be excised, and 3) The raw surface of the mucosa should be covered with an appropriate graft. Options in applying treatment include endoscopic techniques (with or without use of a laser), and open surgical procedures. Among the discussed approaches, a staged procedure by the trough method is very useful for severe cicatricial stenosis of the larynx. For laryngeal stenosis of unknown cause, scar reformation often occurs, and prevention of restenosis is a target of treatment. Some new techniques, such as topical mitomycin application, are also discussed in this paper.
Laryngeal granuloma is a benign lesion of the posterior glottis with a tendency to recur. The optimal treatment of this disease remains controversial. In a series of 33 patients in our clinic, 24 had vocal hyperfunction, vocal abuse or habitual throat clearing. Fifteen patients underwent microlaryngoscopic removal of the granuloma. There was, however, a 73% recurrence rate after the surgery. Medical treatment for gastroesophageal ref lux was administered in 26 patients and it was effective in 42% of them. Voice therapy, which included lifestyle modification, was conducted for 17 patients, resulting in an improvement in 88% of them. Based on these results, we suggest that voice therapy should be a mainstay for management of laryngeal granuloma in combination with anti-reflux medication and lifestyle modification.
Papillomas and hemangiomas are benign but occasionally problematic tumor of the larynx. We described the treatment strategy of laryngeal papillomas and hemangiomas. While the goal of the treatment is to control the disease, treatment must be compatible with important laryngeal functions, such as respiration, swallowing and phonation.
In the study of voice function, measured averages from both young and middle aged adults have been used as standard values. Such standard values are not always adequate or applicable for elderly because voice function changes with age. In this report, the author has examined voice function tests of 148 human adults (74 male, 74 female) whose ages between 51 and 89, and investigated whether current standard values could be applied to elderly people. These elderly subjects were confirmed to be free from pathologic changes of the larynx. Several voice function tests including aerodynamic examinations (such as maximum phonation time (MPT), mean flow rate (MFRc)), as well as voice ranges or acoustic evaluations were measured, analyzed according to the age group and were compared to the standard value previously reported. The average data of MPT, MFRc, F0, F0range, amplitude perturbation quotient (APQ), obtained from high aged males as well as average data of sound pressure level (SPL) and APQ obtained from high aged females were considerably different from the standard values that have been used. These results indicate the necessity to establish standard value that can be applied to the elderly. It is also suggested that influence of the analyzing instrumentation on the more advanced high aged subjects, as well as factors such as hearing acuity, presence or absence of a smoking habit and breathing capacity should be taken into account.
CD9 is a member of the tetra-membrane-spanning glycoprotein family called tetraspanin. CD9 suppresses breeding and motion in some types of cancer cells. Until presently, the expression of CD9 in the larynx had not yet been elucidated. We examined the expression of CD9 not only in the normal larynx but also in the 25 cases of laryngeal cancer using immunohistochemical staining. CD9 was constantly detected in the normal larynx tissues (epithelium, muscle, cartilage, laryngeal gland and myelin). In contrast, squamous cell carcinoma of the larynx was various stained by antibody to CD9. The five year survival ratio of the CD9 positive group (9 examples) versus the weak positive/negative CD9 group (16 examples) was 88.9% to 82.1%. There was a tendency for immunostaining intensity of laryngeal carcinoma samples to be weak compared to intensities manifested by normal tissues.
The ideal injectable material for vocal fold medialization is biocompatible, not absorbable and non-migrating, and formulated for easy injection. In Japan, silicone, collagen, and autologous tissues such as fat and fascia are used as injectable materials. Silicone, however, causes foreign body reactions while collagen and autologous tissues have absorption problems. BIOPEX is calcium phosphate cement, widely used for treating bone defects in orthopedic, neurosurgical, craniofacial surgical procedures and has proved to be biocompatible. A BIOPEX kit consists of a powder and liquid that, after mixing, is self-hardening (recrystallized to hydroxyapatite). We performed a basic study using rabbits for investigating suitability of BIOPEX as an injectable material. The study revealed that it was biocompatible and unabosorbable. We then commenced clinical application and have since performed 10 cases of injection laryngoplasty using BIOPEX. BIOPEX was injected using 2.5cc syringe with either a 16G long needle for microlaryngeal surgery or an 18G short needle for transcutaneous injection. In all cases, the injection procedure was accomplished safely and no acute foreign body reaction was observed. Although the follow-up period for the earliest case is not much longer than one year, CT and laryngoscopic observation revealed that BIOPEX has not been absorbed nor has it migrated. BIOPEX appeared to be suitable as an injectable material and could be utilized instead of conventional injectable materials.
We investigated 107 patients who underwent total laryngectomies as treatments for T3 or T4 supraglottic carcinomas. The relationship between the clinicopathologic findings and distant metastases were examined. In postoperative follow-up, distant metastases were found in 19 patients without any evidence of locoregional recurrence. Other results were as follows : 1) There was no statistically significant correlation between varying TN categories and distant metastases. 2) There was no statistically significant correlation between the groups of carcinoma extension into the preepiglottic space. 3) In the analysis of paraglottic space (PGS) invasion, distant metastasis appeared in 15 of the 44 cases (32%) within the PGS invasion positive group and 4 of the 63 cases (6%) among the PGS invasion negative group. There was a statistically significant difference between the groups (p<1%). 4) Either an extension to the preepiglottic space or extra-capsular spread of the metastatic lymphnode resulted in 18 of 19 (95%) patients developing distant metastasis.
A case of laryngeal MALT lymphoma (marginal zone B cell lymphoma of MALT type) in a 62-year-old female was reported with a review of the literature. The surgeon happened to find an unusual mass with smooth surface located on the posterior commissure of the larynx during the gastrointestinal fiberoptic examination. We resected the mass under the direct laryngoscopy. Pathological examination revealed it as a MALT lymphoma of the larynx. She obtained disease free for one year after receiving three units of chemotherapy (CHOP).
Bilateral vocal cord abductor paralysis (VCAP) is frequently associated with multiple system atrophy (MSA). The early clinical manifestation of VCAP is nocturnal inspiratory stridor simulating heavy snoring that is observed in patients with obstructive sleep apnea syndrome. We have observed two cases of respiratory disturbance during sleep due to VCAP caused by MSA. Using laryngofibroptic examination, vocal cord movements were analyzed during wakefulness as well as during sleep induced by intravenous administration of diazepam. In case 1, VCAP was observed not only during wakefulness but also during sleep. In case 2, although VCAP was observed only during sleep, the vocal cords' movement in breathing at rest was normal in the course of wakefulness. As a treatment, continuous positive airway pressure (CPAP) was applied for the respiratory disturbance during sleep. In case 1, apnea-hypopnea index (AHI) as well as the sleep architecture completely recovered and daytime sleepiness improved. In case 2, the sleep architecture became worse despite improvement of the AHI; as a result, treatment by CPAP was given up. These results indicate that CPAP should initially be applied toward the respiratory disturbance during sleep in MSA.
This report presents two of our successful cases of laryngotracheal reconstructions that followed thyroid cancer operations. The reconstruction procedure was accomplished using a composite nasal septal cartilage graft. The advantages of this kind of graft for laryngotracheal reconstruction, in comparison with other cartilage grafts, are as follows : a) nasal septal cartilage is more easily harvested; b) the morbidity of the donor site is lower; and c) the ciliated columnar epithelium of the nasal mucosa is more suitable for the tracheal lining. The nasal septal cartilage with the unilateral mucoperichondrium appears to be one of the most compatible grafting materials for laryngotracheal reconstruction surgery in selected cases treated for thyroid carcinoma that required resection of the involved trachea (ranging from one-third to two-thirds of the circumferential trachea). We concluded that this technique should be considered for cases of laryngotracheal reconstruction made necessary due to tissue removal for treatment of thyroid carcinoma.
Recently attention is paid about the relationship between gastroesophageal reflux disease (GERD) and obstructive sleep apnea syndrome (OSAS). So we present an adult case considered to have developed respiratory insufficiency and dysphasia because of suffering from serious GERD and serious OSAS spontaneously. He was 52 years old man diagnosed at childhood as myopathy. He complained dyspnea on effort and sleep apnea from 2001. In May 2003 he hospitalized because of respiratory insufficiency and aspiration pneumonia. The tracheotomy was performed, and respiratory insufficiency was soon recovered. But he began to complain dysphasia after the tracheotomy. The gastric juice reflux to the pharynx was checked, and he was diagnosed GERD. Because dysphasia was not improved by conservative therapy taking proton pomp inhibitor, he was carried out with Nissen fundoplication operation. After the operation he was free from dysphasia, and his trachostoma was soon closed. In April, 2004 polysomnography was carried out to him, and he was diagnosed serious OSAS. At that time, swelling in the larynx and pharynx could not found. So when he was suffering from respiratory insufficiency before the tracheotomy, his OSAS was considered to have been more serious by pharyngeal stenosis caused by GERD.
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