Laryngomicrosurgery has been successfully employed in japan for pathological diagnosis and for treatment of laryngeal lesions during last 30 years. Recently, microsurgery in the larynx become more important meanings not only for removal of vocal lesions but also for recovery of vocal movements as one of the phonosurgery.
In this presentation, 2493 patients with laryngeal lesions were examined under the endlaryngeal microsurgery. They were mainly performed this operation under modified N. L. A. (80%), others under endtracheal anesthesia (20%) including the children.
Pathological findings of laryngeal lesions were classified into inflammatory changes of 3228 tissues, begin tumors of 182, and carcinomas of 467 cases respectively. These patients were tested their phonatory function by the use of PS-77 Phonatory equipment pre and post operation. As the parameters, maximum phonation time, mean flow rate, air flow rate at easy phonation for several seconds. and vocal velocity index were compared with pre and post operative function on the viewpoint of surgical techniques shown on the TV.
From this result, important points for phonosurgery are to keep clear operative fields and to check the vocal vibrations during operation and never remove the excess mass especially in lower lip of the cords.

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Sixty-four human larynges were investigated histologically. Their age ranged from 70 to 104 years. The following tendencies were observed in aged larynges : (1) The keratinized layer of the squamous epithelium thickens; (2) Edema develops in the superficial layer of the lamina propria in females; (3) Collagenous fibers in the superficial layer of the lamina propria become denser and fibrotic in males; (4) Elastic fibers in the superficial layer become less dense; (5) Elastic fibers in the intermediate layer of the lamina propria become less dense and atrophic in males; (6) Collagenous fibers in the deep layer of the lamina propria become denser and fibrotic in males; (7) The vocalis muscle becomes atrophic in both sexes; (8) The laryngeal glands become atrophic in both sexes; (9) The surface of the cricoid and arytenoid cartilages at the cricoarytenoid joints becomes irregular and ossified; (10) The laryngeal cartilages become ossified; (11) An evident bowing of the membranous portion of the vocal folds takes place in males.

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In order to evaluate the phonatory function causing by senescence of the larynx, normal adult subjects (52 males and 45 females) were examined the aerodynamic aspects and acoustic analysis for their sustained vowel phonation, and also we measured their pulmonary function test at the same time. The parameters for phonatory function were applied the Maximum sustained phonation time (M.P.T), Mean flow rate (M.F.R), Air flow rate (A.F.R) and Vocal velocity index (V.V.I) by the use of PS-77 phonatory equipment. Acoustic analysis for their voices were investigated the fundamental frequency and PPQ and APQ using the Voice Evaluation System SH-10, made by the RION Co.. In some cases, we measured the subglottic pressure to obtained the laryngeal resistance and efficiency. In this study, chronologically, subjects were classified into three age groups such 20-45, 45-65, and more than 65 years old, and each age groups divided the two groups by the values of VVI less than 50, and of more than 50.
With increasing ages, they revealed a tendency of decrease of MPT values, and increase the MFR and AFR with phonatory tests, and also, decreasing of VC and FEV1 with pulmonary test. These data showed a significant difference between the young age groups and the groups more 65 years old. In acoustic analysis, fundamental frequencies in old persons showed to become more higher pitch in males, but lower in females voices. In older female subjects with VVI more than 50, weakness and lower pitch of voices were caused by reduction of subglottic pressure and glottal resistance at phonation.
Results were summarized as follows :
(1) Over 65 years old subjects may have a tendency to the hypotensive mode of phonation and closely be related to the reduced pulmonary power.
(2) Senescent voices were become the lower pitch and weakness of voices in female, and the higher pitch in males. This might be affected with reduced subglottic pressure and pulmonary power for phonatory modality such as degenerative changes of laryngeal and pulmonary muscles.
(3) Increasing values of PPQ, and APQ by aging, more detailed laryngeal senescence information may be obtained from the analysis for air flow fluctuation during phonation, and pitch perturbations and amplitude modulations for their voice.

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The aging of the vocal cords as well as changes in the vocal tract and in articulatory movements are responsible for the unique characteristics of speech of aged persons. In order to carry out a detailed investigation of articulation in aged persons, acoustic, optic, and aerodynamic analyses were performed on running speech samples from both young and aged persons.
The VCV syllable [aka] was extracted from a sample of Japanese speech [yabunonakakara usagiga pyokonto detekimashita] and subjected to acoustic analysis. The results for 40 aged persons were compared to those obtained for 20 young persons. In aged persons, the power of the leading vowel [a] significantly influenced and relatively weakened the plosive [k] that followed.
Fiberoptic examination of laryngeal movement during the articulation of the plosive [k] showed poor glottal opening in the aged group.
The intrapharyngeal pressures were also measured at the same time point in ten aged persons and compared with those obtained from ten young persons. The mean intrapharyngeal pressure in the aged group was significantly lower.
The results indicate that aging affects the mobility of the tongue, pharyngeal wall and soft palate, causing low intrapharyngeal pressure and poor glottal opening. As a result, the speech of aged persons tends to be less clear.

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The larynx has very important roles, as the organ for respiration, phonation and protection of the lower air tract. A total resection of the larynx, therefore, affects the quality of life of the patient after the operation. Hereby, we emphasize that it is very important to preserve the laryngeal function as much as possible. For this purpose, every laryngologist makes a pains-taking effort to find the cancer of the larynx as early as possible. Recently, an endoscopic videostroboscopy using a flexible fiberscope has been greatly developed and applied for daily clinical use. As the laryngeal cancer is found at so early stage, surgeons come to have a better opinion for a functional surgery. The functional surgeries we have performed in our clinic are as follows;
- laser surgery under microlaryngoscopy
- cordectomy through laryngofissure
- vertical partial laryngectomy.
The indication for each was investigated in retrospect. We have summarized up as follows;
1. The laser surgery should be done for the case with carcinoma confined to the membranous part of the vocal fold without invasion to the anterior commissure.
2. The cordectomy through laryngofissure should be done for the case with a small invasion to the ventricle (without invasion to the false vocal fold).
3. The partial laryngectomy should be done for the case with an apparent invasion to the ventricle (without invasion to the false vocal fold).

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The laryngeal function was evaluated in 14 patients following frontlateral laryngectomy and in 2 patients after hemilaryngectomy. The patients were all male, aged 48 to 80 years. A set of phonatory function tests were conducted for each patient. The swallowing function was investigated with the use of a cinefluorography. Vertical movements of the larynx during deglutition and the swallowing pressure were also examined. After frontolateral laryngectomy, the muscle flap employed for glottic reconstruction became atrophic in many cases. It seemed to be difficult to keep the glottis in an adequate size consistently. Phonatory function tests revealed an incomplete glottal closure manifested by a large DC flow and small AC/DC ratio. In a perceptual evaluation, however, the voice was fairly good.
Cinefluorographic study frequently showed an asymmetrical barium passage in the pharynx, piece meal deglutition, aspiration into the trachea, and intrapharyngeal stasis. An abnormal elevation of the swallowing pressure in the hypopharynx was demonstrated in five cases. The results indicate, unexpectedly, that frontolateral laryngectomy can often cause aspiration.
The two patients following hemilaryngectomy had a relatively good voice and no aspiration. The swallowing pressure at the level of the hypopharynx was reduced. They were, however, not able to breathe through the larynx. They had to have a permanent tracheostoma for respiration.

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During the period of 19 years from 1973 to 1991, 33 patients, 30 males and 3 females, with glottic cancer were treated with vertical partial laryngectomy followed by a laryngeal reconstruction in our clinic. Their age ranged from 35 to 75 years, with an average of 56.2. Of the 33, 8 cases had a T1 ; 23 cases, a T2 ; and 2 cases, a T3 lesion. Two patients developed local recurrence two and 8 years, respectively, after vertical partial laryngectomy. In order to make a glottic bulge, a pedicled thyrohyoid muscle and sternohyoid muscle flaps were employed. The surface of the muscle flaps was covered with a hypopharyngeal mucosal flap or a cervical skin flap. The phonatory function after glottal reconstruction did not differ significantly among the materials used for the reconstructed glottis.

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72 cases of hemilaryngectomy operated in Kurume University Hospital from 1971 to 1990 were investigated. The following results were obtained.
1. The cumulative 5 year survival rate of hemilaryngectomy for laryngeal cancer was 80%, and determined 5 year survival rate was 93%.
2. The local recurrence occured in 5 out of 8 cases with supraglottic carcinoma, and in 7 of 64 cases with glottic carcinoma. The best candidates for hemilaryngectomy were glottic T2 cases and early glottic T3 cases.
3. Cases with poor vocal function were most frequent in the skin flap group and least frequent in the lip mucosa group.
4. The post-hemilaryngectomy vocal function is inferior to normal voice but close to the lower border of the normal voice.

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A pharyngolaryngectomy for hypopharyngeal cancer precludes esophageal voice rehabilitation for postsurgical speech communication. Partial laryngectomy combined with a curative surgical removal of hypopharyngeal cancer is a modality to restore postsurgical vocal function for carefully selected patients. During the 18 years between 1974 and 1992, 64 patients received surgical treatments for hypopharyngeal cancer at the Chiba Cancer Center Hospital. Of the 64, 32 patients underwent voice restoration surgery. The oncological results were superior for the voice restoration surgeries to those for total pharyngolaryngectomy in terms of disease free survival. Surgical modalities including partial laryngectomy were indicated on the bases of anatomical sites of the tumor and its local extension. This paper describes three surgical modalities : (1) extended hemilaryngectomy (a modified Pearson technique), (2) posterior frontal partial laryngectomy and (3) supraglottis-saving subtotal laryngectomy. The indication and postoperative functional results of these techniques were presented.

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Dual motor innervation by the bilateral recurrent laryngeal nerves (RLNs) has been described in the human arytenoid muscle (AR). It has been thought that AR has single motor innervation at the level of muscle fibers. Following unilateral denervation, however, AR presents no morphological evidences of denervation including muscular degeneration and atrophy. The purpose of this study was to investigate the reason why unilateral denervation did not cause evidences of denervation in AR.
The location of the neuromuscular junctions (NMJ) in AR of guinea pigs was determined with the use of acetylcholine esterase stain by Karnovsky. Guinea pigs have unpaired type of AR, like human beings do. In guinea pigs NMJs of AR were located near the midline. Following unilateral denervation, both NMJ and terminal axons were investigated by means of silver-cholinesterase immunocytochemistry stain by Pestronk. The investigation was conducted three days and five weeks after section of a unilateral vagus nerve. The distal cut end of the nerve was placed far away from the proximal end. Three days after denervation, approximately one half of the NMJs had no terminal axon. Five weeks following denervation approximately 80 percent of NMJs had a terminal axon. The terminal axons for the denervated NMJs should have come from sprouting of the contralateral recurrent laryngeal nerve.

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Vocal fold vibration has been considered to be a transmission of mucosal waves which move upward from the mucosal upheaval. The mechanism of the occurrence of the mucosal upheaval has not been known yet. The purpose of this study was to relate the pliability of the mucosa to the occurrence of the mucosal upheaval. In addition, a histological basis for the occurrence of the mucosal upheaval was investigated. Five mongrel dogs were used in the experiment. After administration of an intramuscular Ketaral injection, the larynx was excised and divided vertically into two segments (hemilarynges). Pliability of the vocal fold mucosa was measured at 5-7 points ranging from the free edge to 8 mm below the edge at the middle, anterior forth and posterior forth of the membranous portion. Following the pliability measurements, each hemilarynx was fixed in formalin, sectioned in the frontal plane and stained for histologic examination. Results were summarized as follows :
1) The free edge showed the greatest pliability. The pliability of the mucosa became smaller as the edge became further. The mucosa at 3 mm below the free edge showed the least pliability.
2) The mucosa at the middle of the membranous portion had a greater pliability than that at the anterior and the posterior forth.
3) The lamina propria of the mucosa was thinnest at 3-4 mm below the free edge. At this thinnest point, the muscle layer was closest to the epithelial layer.

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A case of palato-pharyngo-laryngeal myoclonus in a 53-year-old male was presented. An otherwise healthy patient suffered from involuntary movement of the anterior part of the neck. The movement stopped only during phonation and swallowing. All examinations including MRI failed to reveal any etiology, and no treatment was really effective. It was noted, however, that an anxiety often worsened the symptom. Although the cause of this disorder is unknown, psychogenic factors appear to be related to manifestation of the symptom.

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