This paper reviews the development and present status of modern laryngology and gives some prospects for future progress. The First International Voice Conference held in 1957 gave the initial impact upon the development of modern laryngology. Another impact was given by the establishment of the Voice Foundation in 1972. Over the past four decades, revolutionary progresses have taken place in the studies of structure and vibration of the vocal fold, muscular function and vocal fold adjustments, neurolaryngology, phonosurgery and evaluation of the vocal function. Major topics for future investigations are growth, aging and individual variations of the larynx and its function, neural mechanisms of the larynx, treatments of vocal fold scar, sulcus vocalis and spasmodic dysphonia, functional surgeries for the laryngectomized, and international standardization of clinical voice tests.

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Sixty-three patients with tracheoesophageal (T-E) shunt voice were analyzed. Their shunt methods consisted of 42 Komorn's modifications and 21 mucodermal direct methods. Mean maximum phonation time (MPT) of the former method was 18 sec, while that of the latter was 15 sec. Mean maximum sound pressure level (SPL) was 77 dB in the former and 84 dB in the latter. Protection against aspiration of the former was a stent tube, while that of the latter was three kinds of procedures, percutaneous digital pressure, collagen injection around the shunt, and insertion of voice prosthesis. Operation time of the former was about 60 min and the latter was only about 15 min. Success rates were 80% and 75% respectively, one year after the shunt operation. The mucodermal method was superior in simplicity than Komorn's modification.
Three out of four patients, who underwent tracheogastric (T-G) shunt operation, were also analyzed. Mean MPT was 11 sec and mean max. SPL was 70 dB. Air intake from the T-G shunt was weaker than that of the T-E shunt, however aspiration was not encountered in the cases with T-G shunt. Although the T-G shunt voice sounded strangely, this voice was useful for daily conversation.

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Sixty-five laryngectomees underwent voice rehabilitation using voice prosthesis for 11 years. A primary procedure for tracheoesophageal puncture at a total laryngectomy was performed in 57 patients, while a secondary procedure in patients who had previously undergone a laryngectomy was conducted in 8. There were no differences in success rate between the two groups, and the success rate with prosthetic voice restoration among all 65 patients was 86 %.A comparison was made between the initial group of patients performed from 1980 to 1985 and the group of patients done more recently from 1986 to 1990. The success rate of the latter was 94 % and improved in comparison with 73% of the former.
From the result of these experiences, this prosthetic method was thought to be an ideal one for voice restoration after total laryngectomy.

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We report 10 year's experience of our simplified version of Amatsu's TE shunt operation in 45 patients and the results of the operation are analysed. In our method, the ductal portion as an inlet of the air is constructed by small tracheal ring instead of the mucosal duct originally advocated by Amatsu. The shunt operation was successful in 34 patients which account for 75% of the all. The principal cause of failure in 11 patients was inappropriate setting of size of TE shunt that caused excess leakage of the fluid or closure of the shunt.
Preoperative irradiation appeared a possible risk factor but it was found that high dose of irradiation did not affect the success rate of voice production. The surgical intervention such as radical neck dissection did not interfare with the phonation. However, one should be careful in using PMMC-flap, as the massive flap may hinder mucosal vibration.

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During the past 14 years the tracheoesophageal (TE) shunt capability has been performed on 207 patients for primary voice restoration following total laryngectomy, and 172 patients (83%) retained fluent and intelligible speech with TE shunt. On the basis of successful results of postlaryngectomy speech with the TE shunt operation, the acquirement of both TE and esophageal speech, the primary tracheojejunal (TJ) shunt operation following pharyngolaryngoesophagectomy and the TE puncture operation for primary or secondary voice restoration reported by Singer and Blom were performed.
Out of 172 patients who had TE speech, 8 obtained voice capability with esophageal speech and the vibratory source during phonation with esophageal voice was located at the hypopharynx as well as with TE speech. These indicated that the TE speakers could acquire the esophageal voice.
The primary TJ shunt operation was performed on 6 patients for voice restoration following pharyngolaryngoesophagectomy with free jejunum reconstruction for advanced hypopharyngeal cancer. A fistula was created between the membraneous tracheal flap and the lower part of the transplanted jejunum. The membraneous part of the trachea was tubed to construct the TJ shunt. Out of 6 patients, 5 retained phonatory function. No leakage was seen at all during deglutition and a swallowing function was obtained in all 6 patients.
A total of 29 patients underwent the TE puncture operation. Seventeen and twelve were performed for primary and secondary voice restoration after total laryngectomy, respectively. Out of 29 patients, 24 acquired fluent speech with voice prosthesis.

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A technique for surgical voice restoration using a free ileocolic graft is presented. In this technique, a phonatory T-C (tracheocolic) shunt was fashioned from the terminal ileum. The sphincteric function of the ileocecal valve eliminated salivary leakage into the trachea. This valve mechanism was reinforced by the extrinsic compression produced by the “cecal application.” The intraluminal pressure before and after “cecal application” was studied experimentally in eight monkeys. The surgical procedure yielded a significant antireflex pressure in the animal model. Clinical experiences with six patients were satisfactory.

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The vocal fold vibration was basically studied using excised canine larynges and live canines. The vibratory pattern was observed and recorded by means of an X-ray stroboscope and an ultra-high speed camera. The frame by frame analysis of the motion pictures obtained revealed that only membranous part of the vocal fold vibrates while the muscle part does not move and the amplitude is the largest at the free edge. In addition, The trajectory of the movement was found almost circular only in the frontal plane. On the other hand, it was obseved to be almost linear in the superior and lateral planes.
The results mentioned above were obtained during the experimental phonation. Hereby, we newly designed a method by which we can obseve the wave motion even without vocalization. The wave motion can be induced extarnally by means of a vibrator.
Vibration (100/sec) was introduced into the larynx through the cervical skin and induced an external vibration on the vocal fold. Such a vibration was also analyzed and the same results as above mentioned was obtained. Observing the wave motion is very useful to estimate the physical property of the vocal fold. Even under general anesthesia, we perform surgical manipulations while estimating the stiffness of the vocal fold.

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The glottic incompetence caused by recurrent laryngeal paralysis results in not only voice problem but also occasional aspiration. Injections of silicon or collagen have been effectively used to improve the voice of paralysis cases. A transcutaneous intrafold injection technique in which the needle is inserted into the vocal fold through the thyroid lamina under fiberoptic monitoring has been employed in our clinic. There have been few reports on the effect of intrafold injection upon aspiration. In the present study, we measured the glottic closing pressure during swallowing in 12 normal cats and 19 cats with recurrent laryngeal nerve paralysis. In paralytic animals, measurements were conducted before and after silicon injection. A micro-tip catheter pressure transducer (Model PC-330, Micro-Tip, Miller Co. Ltd.) was employed. The results indicate that silicon injection can increase the glottic closing pressure up to the level enough to avoid aspiration.

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Although many attempts to remobilize paralyzed cords using, for example, nerve-to-nerve anastomosis or a nerve-muscle pedicle flap have been made, they have not gained wide acceptance in clinical use for the treatment of unilateral recurrent laryngeal nerve paralysis. The problem lies in the weakness of reinnervated muscle which is unavoidably caused by muscle atrophy or misdirection in the reinnervating process
Even in the presence of unilateral recurrent laryngeal nerve paralysis, normal cricothyroid muscle movement is preserved as long as external branch of superior laryngeal nerve remains intact. Therefore, we designed a new procedure using the cricothyroid-lateral cricoarytenoid muscle suturing as a dynamic reconstruction method for unilateral recurrent laryngeal nerve paralysis. This paper reports its clinical application in three patients with various degress of laryngeal paralysis.
Postoperative observations made during a period 2 to 6 months after the surgery revealed active movement to tense the paralysed cord during phonation in every case. Obvious remobilization was obtained in one case. The voice quality in every case was dramatically improved. Thus, we conclude that this method will be useful clinically as a new dynamic reconstruction method for selected cases of unilateral vocal cord paralysis.

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Cricopharyngeal myotomy is one of the most valuable surgical treatments for pharyngeal dysphagia. To improve surgical techniques of the myotomy, the authors investigated innervation pattern of the cricopharyngeal muscle through electromyographic and histochemical observations and measured the intraluminal pressure at the upper esophageal sphincter after various types of myotomy. The animals we used were dogs. Each half of the muscle was innervated by the ipsilateral pharyngo-esophageal branch of the vagal nerve. The muscular fibers arisen from the cricoid cartilage terminated on muscular fascia or mucous membrane around the posterior mid-line. In comparison with the unilateral myotomy, the bilateral myotomy decreased the resting pressure at the upper esophageal sphincter more effectively. From these findings, the bilateral myotomy at the lateral aspects of the cricopharyngeal muscle was recommended to obtain satisfactory and persistent surgical benefits.

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Histological and ultrastructural features of a pri-mary small cell carcinoma of the larynx were pre-sented. Lightmicroscopically, the tumor was compos-ed of small round cells with high nucleocytoplasm ratios. They were arranged in irregular sheats or nests. Immunohistochemically, most of the tumor cells were stained with antibodies to neuron specific enolase (NSE), and some were stained with antibo-dies to cytokeratin. Ultrastructurally, the tumor cells contained spherical dense core granules (neuro-secretary granules), approximately 100-500nm in dia-meter. The other cytoplasmic organellae were also well developed. Small cell carcinoma of the larynx must be differentiated from metastatic small cell carcinoma from other sites or undifferentiated squa-mous cell carcinoma. In our case there was no evi-dence of primary lesion in other regions. Further-more, immunohistochemical and ultrastructural exa-minations were useful for differential diagnosis.

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A 77-year-old male was seen with a chief complaint of dyspnea-like sensation. Mirror examination and fiberscopy revealed bulging at the anterior wall of the subglottic space. Laryngomicrosurgery was performed under general anesthesia. Operative finding revealed hard mass like ossification at the above mentioned area. X-ray CT examination and xerography demonstrated bony density area on the center of the inner side of the thyroid cartilage. This area corresponded to the location of the attachment of the median cricothyroid ligament to the thyroid cartilage. This case was suggested to be the ossification of the median cricothyroid ligament. There has been no report of the ossification of the median cricothyroid ligament in the literature.

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