Even when the glottal gap is improved by voice recovery surgery, wave-motion failure of the vocal mucosa persists in more than a few patients. In these patients, decreased wave-motion of the vocal mucosa and phase differences between the left and right cords are observed; therefore, it is necessary to evaluate the exact vibrations of the vocal cord in order to perform more precise surgery. The high-speed laryngeal imaging system introduced at our facility can accurately observe vocal cord vibrations even for patients with laryngeal paralysis exhibiting irregular basic frequencies. In this report, the method of image analysis of video obtained from a high-speed imaging system and its reliability are described. In addition, a patient who underwent atelocollagen injection is presented and the usefulness of the system as a clinical approach is discussed.
Bone marrow derived stromal cells (BSCs) which contain mesenchymal stem cells have great potential as therapeutic agents.Dezawa et al. reported a method for inducing skeletal muscle lineage cells from human and rat general adherent BSCs with 89% efficiency.Induced muscle progenitor cells (IMCs) were shown to differentiate into muscle fibers upon transplantation into degenerated muscles of rats and mdx-nude mice.However, the ability of regenerated muscle to restore skeletal muscle function in a large animal model such as canine has yet to be determined. In this study, we performed BSC⁄IMC transplantation into injured canine posterior cricoarytenoid muscles.We investigated the ability of BSC⁄IMC transplantation to promote functional regeneration of posterior cricoarytenoid muscles by fiberscopic analysis of vocal fold movement.As a control, a gelatin sponge scaffold without additional cells was transplanted into the injured area. Results indicated that auto-BSC⁄IMC transplantation effectively restored vocal fold movement, whereas scaffold alone or allo-BSC⁄IMC transplantation did not.Histological examination revealed that, in cases of good recovery, muscle regeneration occurred in the area of cell transplantation, while scar formation without muscle regeneration was observed under control conditions.
The purpose of this study was to evaluate the efficacy and safety of functional electrical stimulation in restoring glottal opening, ventilation, and exercise tolerance in case of bilateral laryngeal paralysis. A new generation stimulator, Genesis XP, and deep brain stimulation electrodes were surgically implanted into both posterior cricoarytenoid (PCA) muscles of canine, and the recurrent laryngeal nerves sectioned and repaired bilaterally. Vocal fold movement was measured endoscopically in the anesthetized animal during bimonthly sessions for over a year. The movement resulted from electrical stimulation of the PCA or from hypercapnia during spontaneous breathing. Exercise tolerance was measured on a treadmill using pulse oximetry and swallowing function was examined via videofluoroscopy. During the three months after surgery, there was minimal ventilatory compromise and near normal exercise tolerance in the stimulation-off state. PCA stimulation produced only nominal abduction. Beyond three months postoperatively, there was passive airway narrowing and further closure of the glottis during hypercapnia. The canine presented severe stridor and could walk for only 1 to 2 minutes on a treadmill. With the stimulation-on condition, the glottal area increased considerably, equaling that of a normally innervated animal. Exercise tolerance also returned to normal. There was no evidence of aspiration during deglutition. In conclusion, bilateral PCA stimulation offers a physiologic approach to rehabilitate ventilation to a normal level in the case of bilateral laryngeal paralysis.
We describe here not only the technical up-sides but also the pitfalls of the intracordal autologous fat injection technique. Buccal fat pads were used for the following reasons: 1) No blood was visible in the fat at the time of collection thereby eliminating the need for rinsing and consequent removal of excessive water. Without admixed blood, the amount of fat available for injection could be accurately determined. 2) Fat harvesting was not limited by physical characteristics of the patient. 3) There are relatively few variations in the size of fat cells. 4) Compared with subcutaneous fat tissues used in the past, it is expected that the post-injection effects will last relatively longer. The determination of intracordal autologous fat injection sites is dependent on the laryngeal condition of the patient. With cases of unilateral vocal cord paralysis, the needle should be set at the middle of vocal cord membranous region and the injection should be made in to the center of vocal cord muscle. In cases of sulcus vocalis and vocal cord atrophy, the injection should firstly be made into the muscle and then the needle should be slightly drawn out and the injection made further into the mucosa. The ideal attributes of means of injection are as follows: 1) An 18G needle with 28cm in length, designed for injection under direct laryngoscopy. 2) A Motor-driven injection instrument for consistent injection procedure with gradual and constant speed. Injection procedure should be stopped (at the time) when the edge of the injected of vocal cord crosses over the median line. If an excess quantity is injected, there may be undesired influences on the para-glottic space, and a part of mucosa may collapse, resulting in the leakage of the injected fat tissue.
Type I thyroplasty is well-established and one of the most popular surgical treatment for unilateral vocal fold palsy. We reviewed 207 cases of original and modified type I thyroplasty using a silicon block. As with all surgical procedures in type I thyroplasty, it is most important to avoid damaging the inner perichondrium during fenestration of the thyroid cartilage in order to obtain appropriate contact of vocal folds and have a good outcome of voice. With the elderly, however, we have found a pitfall in that the ossification of the cartilage presents an increased risk of damaging the perichondrium.
Type I thyroplasty and injection laryngoplasty are useful methods for patients suffering from breathy hoarseness due to unilateral vocal fold paralysis. These surgical methods have difficulty in correcting the level difference between bilateral vocal folds. The purpose of an arytenoid adduction is to place the arytenoid in the correct physiologic phonating position. Arytenoid adduction is effective to correct a wide vocal fold gap and is easily combined with type I thyroplasty during laryngeal framework surgery. We performed arytenoid adductions in combined with type I thyroplasties to improve phonation in the patients with a wide vocal fold gaps.
The injection of botulinum toxin into the thyroarytenoid muscle (BT injection) is the standard therapy used around the world in the treatment of adductor-type spasmodic dysphonia (ADSD) ; however, in Japan BT injection is not approved at all institutions. Thyroarytenoid muscle myectomy-Muta method (TAM) and type 2 thyroplasty (TP2) are the main surgical procedures currently undertaken for treatment of ADSD. The choice between the two procedures is difficult.We reviewed the operative methods of surgical treatment of ADSD. The voice was evaluated preoperatively and postoperatively using the Mora method. The spasmodic ratios (%) were calculated based on the Mora score and then compared. Both operative methods yielded satisfactory results in terms of treatment outcome and satisfaction level of the patients. In surgical therapy for ADSD, TAM and TP2 yield approximately equivalent treatment outcomes. When selecting between the two operative methods, the merits and demerits of each method for each individual patient should be considered.
Vascular tumors are divided histologically into vascular lesions on the surface of the body, i.e. hemangiomas, and vascular malformations which have normal endothelial cells but manifest structurally abnormal vascular proliferation. Vascular malformations are often encountered in the head and neck region. We studied patients who underwent laryngoscopic surgery in our department for vascular malformations of the larynx. Direct laryngoscopic surgery was performed under general anesthesia. The mucosa surrounding the vascular malformation was stripped and resected. The vasa vasorum were treated with an Ho:YAG laser. We reviewed five patients who had received laryngoscopic treatment in the larynx region during the past two years. Histopathologic examination of the removed tumor tissues revealed venous malformation in four cases and lymphatic malformation in one case. The postoperative course was uneventful with neither hemorrhaging nor other complications, and none of the cases showed any recurrent disease up to the present. Our experience suggests that the laryngoscopic surgery provides minimal surgical intervention and can be applied to a wide range of age.
Granular cell tumor (GCT) is a benign tumor that occurs in a systemic organ. The occurrence GCT is rare in the larynx, representing less than 2% of all cases. Two such cases, a 60-year-old male and a 36-year-old male were referred to our hospital complaining of dysphonia. Both patients underwent resection under laryngeal microsurgery, and had tumors in the posterior parts of the vocal folds, where laryngeal granulation commonly occurs. Differential diagnosis of GCT with laryngeal granuloma is important. A tumor occurring in the posterior sections of the vocal cords requires pathological diagnosis especially when laryngeal granuloma-like lesion is resistant to conservative treatment.
Spindle cell carcinoma is a rare malignant neoplasm in the larynx. We report a case of spindle cell carcinoma arising in the larynx. We recently treated a 73-year-old man with spindle cell carcinoma of the larynx who complained of dyspnea for rapid growth tumor in May 2009. We observed the tumor with a white moss on the bilateral vocal cords by laryngeal fiberscope. There was no lymphadenopathy palpable in the cervical region. A biopsy showed spindle cell carcinoma and it was a plan of the radiation therapy, but because the increased rapidly in June of the year and accepted dyspnea, I performed a tracheotomy in the general anesthesia bottom and performed total laryngectomy and neck dissencion. Although the patient had been observed without any recurrences or distant metastases for 29 months postopertively, he unfortunately died by unexpected accident.
Chondroma of the larynx is known to be very rare. Cartilaginous tumors respond to neither radiation therapy nor chemotherapy, therefore surgical excision is the general treatment. We present two follow up cases of chondroma of larynx originating in the cricoid cartilage. Case 1 was a 61-year-old man who was incidentally found to have a laryngeal tumor when he underwent surgery for an epiglottic cyst in 2001. A CT scan showed a mass at the cricoid cartilage level. We performed laryngeal microsurgery and found a submucosal mass in the subglottic area. We biopsied the mass and the pathological diagnosis was chondroma. We followed up on him and there has been no evidence of enlargement. Case 2 was a 68-year-old woman who presented with a one-year history of increasing hoarseness. CT and MRI imaging showed a mass involving 2⁄3 of the cricoid cartilage. An open biopsy was performed and the tumor was pathologically identified as a cartilaginous tumor. It was difficult to distinguish between chondroma and condrosarcoma. We explained that if the tumor was chondrosarcoma, there was the possibility of metastasis during an observation period and if she choose immediate radical resection her QOL would decrease considerably. Based on this information she selected to hold off surgery and accept a period of observation. There has been no evidence of enlargement but we need to continue following her closely.
Relapsing polychyondritis (RP) is a comparatively rare systemic diseases that is manifested by relapses of painful inflammation to the cartilage tissue of the whole body, especially pinna, the nose and the trachea. It is suspected to be an autoimmune disease because various autologous such as type 2 collagen are admitted although details of the etiology are uncertain. We report a case of 26-year-old woman who had severe subglottic stenosis due to relapsing polychondritis. The stenosis was getting so severe that we had to perform a tracheostomy. At the time of inflammation exacerbation, we had to increase the steroid dosage. It was considered that we should be able to reduce the increase in steroid dosage by treating the RP with colchine.