Vocal Rehabilitation Following Laryngectomy.Rationales and Techniques. The techniques for vocal rehabilitation after total laryngectomy currently in use have been based on one of the following two rationales.
(1) Since the respiratory and articulatory functions are preserved following laryngectomy, the clients can produce speech sounds if any source sound is introduced into the articulatory organ.
(2) From a phonatory point of view, the larynx in normal subjects can be regarded as a vibrating tube which is located between the trachea and the pharynx. When the pulmonary expiratory air blows the larynx, source sounds are produced. If a vibratory tube is reconstructed between the trachea and the pharynx following laryngectomy the clients should be able to produce speech sounds (Asai, 1966).
The following three modalities are based on the first rationale : (1) pneumatic artificial larynx, (2) electric larynx including oral type and submandibular type, and (3) esophageal speech. Two groups of techniques, on the other hand, are based on the second rationale : tracheo-esophageal shunt and laryngoplasty or glottoplasty. This paper discusses each technique, in particular, the laryngoplasty developed by the present author.

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A marked difference in the incidence of laryngeal carcinoma between male and female has been widely unknown. The reason to this, however, has been unknown. In this connection, the affinity of the laryngeal tissue for androgen hormone was investigated in the present study. An auto radio-graphic study was conducted with the tissue of normal laryngeal mucosa and that of moderately differentiated squamous cell carcinoma of the larynx. ³H-T and its metabolites were found in the nuclei of epithelial cells of male vocal folds and some parts of male laryngeal carcinoma tissues. This suggest the existence of some effect of testosterone on the cell nuclei of these tissues. Quantitative analyses of the intracellular distribution of radioactivity conducted by means of the silver grain counting method showed that approximately 60-70% of ³H-T were located in the nuclear compartment of cancer cells of small size and the epithelium of the vocal fold near the basement membrane. The ABC method demonstrated a positive reaction in the nuclei of laryngeal carcinoma cells and the laryngeal muscle in males.
These findings suggest that human laryngeal tissue, especially the vocal fold tissue, and laryngeal carcinoma cells may be one of the target organs for androgenic steroids and that androgen plays an important role in the carcinogenetic process of normal laryngeal tissue.

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By using an image analyzing system, we evaluated the pattern of glandular tissue appearance in developing human infant larynges. The distribution of serous type glandular tissues was detected by staining with antiserum to S-100 protein and analyzed using an image binarization procedure (SPICCA II). The area occupied by glandular acini in the mucosa increased dramatically in older babies compared to the findings in younger neonates. The ratio of serous-type glands to mucous type glands was also determined by analyzing the binary image. The use of this new procedure is expected to facilitate immunopathologic studies of diseases of human infant larynx.

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The lamina propria of the human vocal fold consists of three morphologically different layers. Previous investigations have revealed age-related changes in the histological structure of this apparatus. The authors tried to define the role of the lamina propria in vocal fold vibration. Using an enzyme-immunohistochemical method, the distribution of three different collagens, type I, type III and type IV in the lamina propria was examined. Type III collagen was found in all lamina propria layers. The majority of type I collagen was found in the deep layer, especially in the anterior and posterior parts of the vocal fold. The localization of each type of collagen was related to the degree of vibratory movements during phonation.

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We reported previously that when the internal branch of the superior laryngeal nerve (ISLN) of generally anesthetized cats was electrically stimulated, short latency response (early response, ER) and long latency response (late response, LR) emerged in the thyroarytenoid muscle (TA). Vibratory stimulation, applied to the contralateral subglottic mucosa as a conditioning stimulation, enhanced LR, particularly in phase I (the transitional phase from inspiration to expiration). When the vibratory frequency was elevated from 100 Hz to 350 Hz at 50 Hz interval in phase I, vibration effect was observed in all frequencies investigated. Maximum effect was obtained at 300 Hz. Following denervation of ISLN, the vibration effect was minimized, and it did not depend on the vibratory frequency.
In the present study, the data processing technique was partly modified : the sampling time of integrated EMG of LR was shortened. As a result, LR was occasionally divided into two responses L₁R and L₂R. The effect of vibratory stimulation on the subglottic mucosa differed for L₁R and L₂R.
The effect of subglottic vibration upon LR as a function of vibratory frequency may reflect frequency characteristics of the mechanoreceptors to vibration in the subglottic mucosa. If this is the case, the aforementioned results indicate that there are two groups of mechanoreceptors having different frequency characteristics against vibration. The mechanoreceptors in the laryngeal mucosa play an important part in auto monitoring systems of vibration.

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Vocalization was induced by repetitive electrical stimulation (0.2ms, 25 to 80 μ A, 60 to 100Hz, lasting for 5 to 30 s) delivered to the brainstem (Horsley Clarke coordinates : A 1.5 to P 5.0, L or R 1.5 to 5.5, H -3.0 to -9.0) in unanesthetized pre-collicular-postmammilary decerebrate cats. During induced vocalization, the activities of both inspiratory (diaphragm) and expiratory (rectus abdominis) muscles were augmented. The stimulation also bilaterally augmented the activities of the abductor (posterior cricoarytenoid) and adductor (thyroarytenoid) muscles of the vocal folds during inspiration and expiration, respectively. The stimulation initiated in either inspiratory or expiratory phase reset the spontaneous respiratory rhythm. Following inspiration due to the activation of the diaphragm and abductor muscle of the vocal cords, expiration with vocalization and inspiration were alternately induced with a newly developed rhythm. This suggested that the tonic electrical stimulation delivered to the higher brainstem can alter rhythm generation of spontaneous respiration. Persistent opening of a T-tube inserted into the trachea decreased respiratory cycle. Although opening of the T-tube during vocalization decreased subglottic pressure, the expiratory phase did not abruptly terminated. It was suggested that the feedback input from the mechanoreceptors in the laryngeal mucosa was less important than the vagal feedback from the alveolar stretch receptors to maintain respiratory cycle during the induced vocalization.

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Vocalization was induced by repetitive electrical stimulation (0.2 ms, 60-200Hz, 30-300μA, 5-10 s) of the midbrain and pons using a tungsten microelectrode under light Ketamine anesthesia (40mg/Kg i.m.) in cats. Effective sites were localized in the ventrolateral part of the periaqueductal gray (PAG), the midbrain reticular formation (RF) near PAG from the level of the rostral superior colliculus (SC) to the middle SC, and in the ventrolateral pontine RF near the pyramidal tract, and the medial lemniscus from the level of the middle SC to the inferior colliculus (IC). Furthermore, from the level of the middle SC to the caudal SC, the effective sites were localized in the lateral part of the pontine RF. The acoustic characteristics of the induced vocalization were analyzed by means of FFT with 20 Hz resolution every 50 ms for 3 s. Acoustic analysis by FFT revealed that there were no significant differences in the fundamental frequency and formant components between the spontaneous and induced vocalization. When stimulus frequency was changed, the harmonic structure of the power spectrum varied slightly, although there were no significant differences in the fundamental frequency. When the stimulation site was changed from the rostral to the caudal position, no significant difference was found in fundamental frequency of the induced vocalization.

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Cholera toxin B-Gold, a new retrograde tracer, allows simultaneous observations of the retrograded tracer and immunoreactivity of calcitonin gene-related peptide (CGRP) in a single cell on a single section. Application of this tracer revealed the distinct ratio of the CGRP containing motoneurons innervating the canine intrinsic laryngeal muscles. The ratios of the CGRP containing motoneurons innervating the cricothyroid muscle, thyroarytenoid muscle and posterior cricoarytenoid muscle were 93.0%, 71.9% and 85.5%, respectively. These differences may reflect the special property of each muscle.

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The difference in peak intraoral pressures between the consonants /p/ and /b/ (abbreviated as Pr./p-b/) showed a significant correlation with the transglottal pressure during consonant /b/ production. The values of Pr./p-b/ in the subjects with vocal fold palsy were smaller than those of the subjects with cancer or polyp. The values of Pr./p-b/ divided by the subglottal pressure in the subjects with cancer showed different distributions from those in the patients with palsy and in normal population. We concluded that these two parameters showed potential benefits for evaluation of pathological conditions of the glottis, especially for insufficient closure of the glottis and stiffness of the vocal folds.

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A perceptual study of whisper uttered by patients with bilateral recurrent nerve palsy (BRNP) revealed that, frequently, five vowels were perceived as syllables /hV/ and voiced fricative consonants were perceived as voiceless ones. Sound spectrographic analysis of the uttered samples showed that vowels uttered by BRNP had noise at the initial portion of the utterances like in a breathy voice onset and that voiced consonants uttered by BRNP had no formant transitions. On the other hand, the airflow rate in BRNP was very high during phonation and it was difficult for the patients to control the airflow. It was suggested that this difficulty of airflow control caused the decrease of the articulatory adjustments in BRNP.

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Proliferating activity of biopsied specimens from 27 cases of laryngeal carcinoma was studied immunohistochemically using anti proliferating cell nuclear antigen (PCNA) antibody. PCNA labeling index was defined as percentage of the labeled cells in tumor tissue. PCNA labeling index was measured and related to histological and clinical findings. Results :
1) A positive correlation (p<0.01) was found between the PCNA labeling index and the mitotic index.
2) The PCNA labeling index was significantly different between T1, 2 group and T3, 4 group (p<0.01).
3) Many cases of poor prognosis were found in the cases showing a high PCNA labeling index.
4) In laryngeal carcinoma, the PCNA labeling index may be useful as an adjuvant diagnostic parameter for objective evaluation of the biological malignancy referred to as the proliferating activity.

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Injection of steroid into the vocal cord was performed by means of the fiberoptic laryngosurgery technique under local anesthesia. In this method, injection can be done precisely and easily, because the surgeon can use both hands.
The operation was performed in 9 patients with very small nodules and 12 patients with chronic inflammatory vocal cords, all of them being resistant to conservative treatments. Satisfactory result was obtained in most of the patients. Intracordal steroid injection may serve as an effective therapy for inflammatory vocal cord diseases and very small nodules, which did not respond to conservative therapy, such as anti-inflammatory drugs, laryngeal nebulizer and voice rest therapy.

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A 75-year-old man developed severe hoarseness following laser cordectomy for glottic cancer. The left vocal cord was deficient and scar formation was found at the anterior commissure extending to the subglottis. The right vocal cord was atrophic. His voice was quite breathy because of these laryngeal deformities.
We employed two surgical procedures. First, we applied the omohyoid muscle flap for the reconstruction of the vocal cord bulging on the left. In the second step, thyroplasty type I was performed on both sides. After the surgeries, the maximum phonation time was prolonged from 3 sec to 10 sec and the breathy voice was remarkably improved.
For the treatment of glottic insufficiency after cordectomy, it is most important to examine the laryngeal findings carefully and choose a suitable surgical method.

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A 41-year-old female patient with thyroid carcinoma involving the right recurrent laryngeal nerve (RLN) underwent total thyroidectomy and neck dissection. The right RLN was partially removed because of the carcinomatous invasion. A resection of the posterior cricoarytenoid muscle (PCA) and a nerve graft for RLN were conducted immediately after removal of the thyroid gland. An improvement of voice was noted soon after the operation. Further improvements of voice took place 8 months later. A set of vocal function tests including the maximal phonation time, airflow rate, sound spectrogram and perceptual evaluation showed marked improvements. The voice improvement noted soon after the operation was supposed to result from median fixation of the paralyzed vocal fold by the PCA resection. The later voice improvement was presumably caused by a reduction of vocal fold atrophy by the nerve graft.

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Protein anabolic steroid produces a side effect of lowering vocal pitch in some women, i. e. virilization of voice. Virilization causes an increase in size and mass of the vocal folds, resulting in lowered voice pitch, hoarseness, and/or inability to sing higher notes. The voice disorder is often long lasting and the prognosis is unfavorable. Saito and Kokawa devised a surgical technique to raise the vocal pitch. Their technique employed an anteroposterior incision in the bilateral thyroarytenoid muscle. Immediate results were reported to be satisfactory. Long term results of this method, however, have not been reported. This paper reports a case who underwent the thyroarytenoid muscle incision for voice virilization and was followed up for two years. Following the surgery, the vocal pitch was raised and the effect continued for two years.

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This paper presents a case of spindle cell lipoma of the larynx which is a very rare condition. The patient was a 68-year-old man who had been suffering from progressive hoarseness. A flexible fiber-scopic examination demonstrated a spherical protrusion covered by intact mucosa at the right vestibular fold. CT scan examination showed a large, low density mass medial to the thyroid cartilage. The mass was surgically removed by means of the laryngofissure technique. A light micro-scopic examination of the surgical specimen revealed mature lipocytes and spindle cells. Under electron micro-scopic observations the spindle cells contained a prominent rough endoplasmic reticulum and they lacked a typical basal lamina. The histological diagnosis was spindle cell lipoma. This condition occurs most frequently in the subcutaneous tissue of the shoulder and the posterior aspect of the neck. To the best of our knowledge, this case is the first reported case of spindle cell lipoma of the larynx.

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A 61-year-old woman with adenoid cystic carcinoma of the larynx was reported. The tumor was originated from the laryngeal surface of the epiglottis. The true vocal fold was not involved. A supraglottic horizontal laryngectomy using contact Nd-YAG laser was successfully performed. Radiation and chemotherapy were not employed. The patient has been disease free for six months following surgery.
According to previous literature, the first choice of the treatment for this disease is a radical resection of the tumor. Evaluation of radiation therapy and chemotherapy has not been confirmed. A long term follow-up has been recommended, because local recurrence and distant metastasis at an interval of ten years or longer after operation is not very rare for this condition.

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