It is difficult to determine the surgical indication of type 2 thyroplasty for spasmodic dysphonia because: 1) there is a great variety of symptoms among patients, 2) there is a high rate of changeability with time, and consequently 3) it is difficult to diagnose. There seems to be no objective criteria for making a diagnosis or for deciding the indication. Based on our surgical experience of over 300 cases, our principal policy for deciding is that the indication should be limited to those with an apparent excessively tight closure of the glottis during phonation; or those with severe anguish resulting from spasmodic dysphonia. While the deprivation of easy communication in itself isn’t an indication of surgery, the strong desire of a patient to get relief from this malady is an indication. If the decision is difficult to make, one should take into account: 1) the period of time of the past suffering, 2) the objective findings such as anterior foaming at the glottis on phonation, 3) the severity of speech distortion, 4) the strong desire of the patient for the operation, and 5) voice recordings under other circumstances such as on the phone. Full information regarding the operation should be made available to the patients.
Objective: This study evaluated whether functional magnetic resonance imaging (fMRI) could detect the brain activation sites during phonation and how findings could be applied clinically. Subjects and methods: The subjects were 29 right handed adults in good health. We analyzed the brain activation sites during vowel sound phonation. fMRI measurement was carried out using gradient echo-echo planar imaging (GE-EPI) in a 1.5T clinical setting MR instrument (Magnetom Vision, Siemens). We used the sparse sampling method during the phonation task to avoid artifacts from facial movement. The fMRI data was collected and analyzed using statistical parametric mapping a personal computer. Result: Both primary motor areas, premotor areas, kinetic speech areas, the supplementary motor area, the cerebellum, and the auditory area showed activation in the analysis performed on the subjects. These activation areas are consistent with previous reports using other fMRI protocols. Conclusion: We could detect brain activity during phonation using the specified design and can clinically apply this technique for treatment.
The clinical symptoms of laryngeal allergy are persistent cough, itching and irritation of throat. A clinical study focused on the diagnosis of laryngeal allergy was carried on 159 patients with nasal allergic symptoms from birch pollen (birch pollinosis). The diagnosis of birch pollinosis was confirmed by the clinical symptoms of seasonal rhinitis along with the presence of the specific anti-birch IgE antibody by CAP-RAST testing. Laryngeal allergy was diagnosed according to the criteria proposed by the Society of Study for Laryngeal Allergy in Japan (2005). Eighty-eight out of 159 (55.3%) birch pollinosis patients were diagnosed as having laryngeal allergy. Laryngeal allergy patients suffer from seasonal pharyngolaryngeal symptoms, such as persistent coughing (40.2%) and foreign-body sensation in the larynx (100%). It is well known that patients with birch pollinosis frequently have oral symptoms after fruit and vegetable ingestion, which has been termed oral allergy syndrome (OAS). Forty-eight out of 88 (54.5%) birch pollinosis patients with laryngeal allergy and 40 out of 71 (56.4%) patients without laryngeal allergy were diagnosed as OAS. It is considered that the new criteria would be effective for the diagnosis of laryngeal allergy for patients with birch pollinosis.
Early glottic caner is usually treated with radiotherapy. For untreated early laryngeal cancer, surgery including laser microsurgery can also be considered. The laser cordectomy procedure can be categorized into several types according to the depth of resection. One out of sixteen patients treated with type I (subepithelial) or type II (subligamental) laser cordectomy for untreated T1aN0M0 glottic cancer had a recurrence during the follow-up period. One in four patients treated with type III (transmuscular) laser cordectomy had a recurrence. Evaluation of postoperative voice with the voice handicap index-10 (VHI-10), voice-related quality of life questionnaire (V-RQOL) and visual analog scale (VAS) demonstrated comparable satisfaction between patients treated with type I or type II and patients treated with type III. These results suggest that type III laser cordectomy, in addition to type I and type II can be an optional treatment for T1a glottic cancer, providing satisfactory outcomes for control rate and postoperative voice quality.
Introduction: We examined post-total laryngectomy complications. By using PGE1 during the perioperative period, we made it possible to achieve complication-free laryngeal surgery for patients with radiation failure. We now present our evaluation of complication frequencies of patients with radiation failure and those without it. Patients and Methods: Our work was a retrospective chart review of 37 patients who underwent total laryngectomy in our hospital from 2001 to 2008. These included 24 patients who underwent surgery for primary treatment and 12 patients who underwent salvage surgery due to radiation failure. The remaining one patient had laryngo-pharyngeal stenosis after radiation therapy for hypopharyngeal cancer and underwent total laryngectomy as a salvage surgery. One T2, 9 T3 and 14 T4 cases underwent surgery for primary treatment and 2 T2, 5 T3 and 5 T4 cases underwent salvage surgery. Closure of the hypopharyngeal mucosa was performed using 4-0 silk and no other procedures were conducted to reinforce the wound. Results: As for 24 patients who underwent primary treatment, a minor leakage and a pharyngo-cutaneous fistula were observed in two patients who had active diabetes mellitus and their initiation of oral intake were on the 17th post-operative day (POD) and the 34th POD, respectively. Their days of discharge were also prolonged to the 30th POD and the 50th POD, respectively. One patient had a subcutaneous abscess around his tracheostoma and the commencement of his oral intake and day of discharge were prolonged to the 13th POD and the 28th POD. Another patient also had a subcutaneous abscess and his day of discharge was prolonged to the 36th POD. The average number of days to begin oral intake after surgery was 9.1 days and the average number of days until discharge after surgery were 23.3 days. However, with 13 patients who underwent salvage surgery and had no leakage or other wound complications the average number of days to discharge after surgery was 20.8 days. Discussion: According to our protocols for laryngectomies, the administration of PGE1 during the perioperative period, even for patients with radiation failure that had no wound complication, shortened the time to discharge from the hospital. Since diabetes mellitus seemed to be a key factor in wound complication after laryngectomies, even for patients undergoing primary treatment, we must consider new methods for treating them.
The Type 1 Thyroplasty or Medialization Thyroplasty was first reported in the 1970s by Isshiki et al for treating voice disorders resulting from vocal fold paralysis or atrophy. Since then, this therapeutic modality has gained world-wide popularity, and a number of modified methods were also reported with generally satisfactory results. Silicone block fabricated in situ had long been utilized to fix the window cartilage without any significant complication, however, containment failures from silicone bag breast implants and their resultant negative side-effect led to difficulties in obtaining silicone for any surgical treatment whatsoever. Gradually, Gore-tex, as used for correcting vascular problems, had replaced silicone, because of its ease in handling and of its excellent biocompatibility. However, it did not guarantee precision in the adjustment of medialization, especially when the window-cartilage was removed and/or when the Gore-tex sheet was packed in a wrong direction. In this respect, Titanium, well known for its excellent biocompatibility, seems better suited for precision and long-lasting effectiveness. Friedrich had already reported excellent results. Based on our abundant experience with Titanium Bridges in type 2 thyroplasty for spasmodic dysphonia, we utilized a simple thin and bendable Titanium plate so as to realize adequate medialization on site.
We surgically treated 117 patients with thyroid cancer between 2006 and 2009. The patients had had no preoperative recurrent laryngeal nerve palsy (RLNP). We could preserve recurrent nerve function in 106 cases. 16 patients developed RLNP after surgery. Of these 16, 12 ultimately improved from RLNP, 11 of which had done so within 6 months. Phonosurgery should be discussed with regard to patients whose RLNS after thyroid cancer surgery has not improved within 1 year according to their symptom.
A 73-year-old man with a supraglottic tumor was referred to our clinic by a gastroenterologist. A mass was found during a thorough medical checkup, and the gastroenterologist assumed that it would soon block the patient’s airway. The referring gastroenterologist therefore suggested performing emergency surgery. A laryngeal fiberscope inserted via the nasal cavity revealed a large mass within the left false vocal cord which almost completely blocked the glottis. We originally thought that the mass was adhering to the glottis. Although we asked the patient to assume numerous positions, the mass did not appear to be adhering to the glottis and stridor or dyspnea did not occur. After showing the video of his larynx to the patient, we removed the mass safely in phonomicrosurgery 5 days after his first visit. The mass was a 13×17-mm laryngeal neurinoma. This case illustrates that careful fiberscopic examination and consideration of the individual patient’s condition can avoid the need for emergency surgery, and that an airwayscope is a useful tool for inserting a tracheal tube in patients with large laryngeal masses to prevent airway obstruction.
A Case of Laryngeal Fungal Infection that required an urgent tracheotomy was reported. A 69-year-old male was referred to our hospital complaing of difficulty with breathing. A mass lesion was detected on his left false cord. Ground-glass opacity in the bilateral lower lobes showed up on a chest X-ray image. A biopsy utilizing a laryngeal fiberscope was performed. The histopathological diagnosis was revised to hyperkeratosis with a fungal infection. Therapy was initiated with polyconazole (400mg/day) for 16 days and the pulmonary mycosis disappeared completely, however, the fungal infection of the larynx remained unchanged. At day 27 after therapy with polyconazole, he had serious difficulty in breathing. Swelling of the larynx and an upper airway obstruction was found. An urgent tracheotomy was done. The patient was treated by intravenous drip of micafungin, and an almost complete remission was achieved within two months.