Transoral approach to laser thyroarytenoid myoneurectomy for treatment of adductor spasmodic dysphonia: short-term results.

OBJECTIVES: The surgical technique for the resection of the recurrent laryngeal nerve for adductor spasmodic dysphonia (ASD) has high late failure rates. During the past decade, botulinum toxin has emerged as the treatment of choice for ASD. Although effective, it also has significant disadvantages, including a temporary effect and an unpredictable dose-response relationship. In this study we investigated the effectiveness of a new transoral approach to laser thyroarytenoid myoneurectomy for treatment of ASD. METHODS: Fourteen patients with ASD underwent transoral laser myoneurectomy of bilateral thyroarytenoid muscles. Under general anesthesia, an operating microscope and a carbon dioxide laser were used to perform myectomy of the mid-posterior belly of bilateral thyroarytenoid muscles together with neurectomy of the terminal nerve fibers among the deep muscle bundles. Care was taken not to damage the vocalis ligaments, arytenoid cartilages, and lateral cricoarytenoid muscles. Preoperative and postoperative videolaryngostroboscopy and vocal assessments were studied. RESULTS: The 13 patients who completed more than 6 months follow-up were enrolled in this study. Moderate and marked vocal improvement was achieved in 92% of the patients (12 of 13) after laser surgery during an average follow-up period of 17 months (range, 6 to 31 months). No vocal fold atrophy or paralysis was observed in any patient. None of the patients had a recurrence during the follow-up period. CONCLUSIONS: Transoral laser myoneurectomy of bilateral thyroarytenoid muscles is a relatively simple, effective, and valuable technique for the treatment of ASD. The durability of outcome achieved with this procedure is encouraging.

Functional significance of arytenoid adduction with the suture attaching to cricoid cartilage versus to thyroid cartilage for unilateral paralytic dysphonia.

OBJECTIVE: In the treatment of unilateral paralytic dysphonia, traditional arytenoid adduction is designed to place suture through the muscular process of the arytenoid attaching anteriorly to the thyroid ala. In contrast with the suture direction of this technique, a new paramedian approach to arytenoid adduction anchors anteroinferiorly to the cricoid cartilage, mimicking the force action of the lateral cricoarytenoid muscle (the major adductor of the larynx). This study investigated the influence of these changes in suture direction on the vocal fold level as well as the vocal outcomes in these two techniques of arytenoid adduction. STUDY DESIGN: A prospective clinical series. METHODS: Thirty patients with unilateral paralytic dysphonia underwent medialization laryngoplasty with arytenoid adduction and strap muscle transposition. Under local anesthesia, the thyroid lamina on the involved side was paramedially separated. The inner perichondrium was carefully elevated away from the overlying thyroid cartilage, carrying the dissection posteriorly to the level of the superior and inferior cornua. The lamina was retracted laterally, the inner perichondrium was opened near the midpoint, and the lateral cricoarytenoid muscle identified. Tracing the muscle fibers posterosuperiorly, the muscular process of the arytenoid was identified. A 2-0 Prolene suture was placed through the muscular process and temporarily tied to the anterolateral aspect of the thyroid ala (AA-thyroid suture). Intraoperative acoustic and perceptual assessments were performed. After releasing the tie, the suture was anchored to the cricoid cartilage at the origin of the lateral cricoarytenoid muscle (AA-cricoid suture). Voice assessments were repeated, and the outcomes of the two tests were compared. The choice of the type of arytenoid adduction suture was made intraoperatively according to which condition provided better vocal performance. After securing the suture, a bipedicled strap muscle flap was transposed into the space between the lamina and inner perichondrium and the thyroid cartilages sutured back into place. RESULTS: The intraoperative acoustic and perceptual assessments revealed the vocal performance was significantly better with AA-cricoid suture than the AA-thyroid suture in this series. No major complications occurred in the study. CONCLUSION: This study suggests that arytenoid adduction with suture attachment along the longitudinal axis of the lateral cricoarytenoid muscle to the cricoid cartilage is more physiologic and effective than that attaching the suture to the thyroid ala. A paramedian approach to arytenoid adduction with or without strap muscle transposition is a safe and effective method for treatment of unilateral paralytic dysphonia.

Bone health status of the elderly in Taiwan by quantitative ultrasound.

Bone density of the elderly in Taiwan was assessed by quantitative ultrasound bone densitometry of the heel in the Elderly Nutrition and Health Survey in Taiwan (1999-2000). Broadband ultrasound attenuation (BUA) was measured, and the corresponding Z-score was calculated. Physical examination data of 1123 males and 1034 females were included in the current analysis, and data of 752 males and 721 females who also had complete questionnaire information were used for analysis of relationships between several risk factors and BUA status. The results show that in elderly Taiwanese males, higher BMI and intake of dietary calcium is positively associated with a higher BUA Z-score. Advancing age and living in the second stratum in the southern areas appeared to be negatively associated with BUA Z-score in elderly females. BMI, height, years of education, and intake of dietary calcium were positive predictors of BUA Z-score. Further analysis was performed by grouping subjects according to the gender-specific medians of intake levels of dietary calcium, protein, and sodium. The results revealed that for both genders, those in the "high calcium/high protein" group had a higher mean BUA Z-score. The results of the current analysis show that in Taiwan, BMI and dietary calcium intake are positive predictors of BUA Z-score in elderly males, whereas BMI, height, years of education, and dietary calcium intake are positively associated with BUA Z-score in elderly females. The effects of dietary calcium intake may be influenced by the intake of other nutrients such as sodium and protein.

Bipedicled strap muscle transposition for vocal fold deficit after laser cordectomy in early glottic cancer patients.

OBJECTIVE: In treating early glottic carcinomas, the outcomes of endoscopic laser cordectomy have been proven to be valuable in local control, survival, and vocal function preservation. In some extended cases, however, laser cordectomy may leave patients with poor vocal function because of vocal fold deficit. This work assesses the vocal outcome of medialization laryngoplasty with bipedicled strap muscle transposition for vocal fold deficit resulting from laser cordectomy in early glottic cancer patients. STUDY DESIGN: A prospective clinical series. METHODS: Thirteen early glottic cancer patients who had vocal fold deficit caused by previous laser cordectomy underwent medialization laryngoplasty with bipedicled strap muscle transposition. The thyroid lamina on the cordectomy side was paramedially separated. The inner perichondrium was circumspectly raised from the overlying thyroid cartilage. After separating the thyrohyoid and cricothyroid membranes, the lamina was retracted laterally. A bipedicled strap muscle flap was then transposed into the area between the lamina and the paraglottic soft tissue. The thyroid cartilages were carefully sutured back in position. All patients received pre- and postoperative voice assessments comprising laryngostroboscopy and vocal function studies. RESULTS: Vocal enhancement was present in 92% (12/13) of patients after medialization laryngoplasty with strap muscle transposition. The glottal closure and maximal phonation time were noticeably improved by surgery. No dyspnea or other significant complications were observed in any patients. CONCLUSION: The outcomes show that bipedicled strap muscle transposition is a prosthesis-free, safe, and valuable laryngoplastic technique for correcting glottal incompetence caused by endoscopic laser cordectomy in early glottic cancer patients.

Medialization laryngoplasty with strap muscle transposition for vocal fold atrophy with or without sulcus vocalis.

OBJECTIVE: Vocal fold atrophy with or without sulcus vocalis may result in a spindle-shaped glottal incompetence (SGI). Because of varying drawbacks with all existing materials (e.g., Silastic block, Teflon, fat, etc.) used for medialization or augmentation of the atrophic vocal folds, there is a need to supplant these materials with a more stable, autologous tissue to correct the SGI. STUDY DESIGN: Thirty-two patients with vocal fold atrophy underwent medialization laryngoplasty with strap muscle transposition. METHODS: Under local or general anesthesia, the thyroid lamina on the more affected side was vertically incised 5 mm off the midline. The inner perichondrium was carefully elevated from the overlying thyroid ala. Care was taken not to enter the laryngeal lumen. After dividing the thyrohyoid and cricothyroid membranes, the lamina was retracted laterally. To accommodate the muscle flap more easily, the caudal edge of the lamina was trimmed using a small burr. A bipedicled strap muscle flap was then transposed into the space between the lamina and the paraglottic soft tissue. The thyroid cartilages were carefully sutured back in place. All patients underwent pre- and postoperative voice evaluations including laryngostroboscopy, perceptual assessment, and acoustic and aerodynamic analyses. Patients who had been followed up for more than 3 months were enrolled in this study. RESULTS: A total of 27 of the 32 patients with complete pre- and postoperative voice function measurements were included in the analysis. Vocal improvement was demonstrated in 26 of these 27 (96%) patients. No dyspnea or other major complications were noted in any patients. CONCLUSION: The results indicate that medialization laryngoplasty with strap muscle transposition is a prosthesis-free, safe, and effective technique for correcting SGI caused by vocal fold atrophy.

A new paramedian approach to arytenoid adduction and strap muscle transposition for vocal fold medialization.

OBJECTIVE: To develop a prosthesis-free medialization laryngoplasty for the treatment of glottal incompetence. STUDY DESIGN: Twenty-two consecutive patients with glottal incompetence underwent vocal fold medialization using a new paramedian approach to arytenoid adduction and/or strap muscle transposition. METHODS: Under local anesthesia, the thyroid lamina on the involved side was parasagittally separated 5 mm off the midline. The inner perichondrium was carefully freed from the overlying thyroid cartilage. After dividing the thyrohyoid and cricothyroid membranes, the lamina was retracted laterally, the inner perichondrium was opened, and the lateral cricoarytenoid muscle identified. Tracing the muscle fibers posterosuperiorly, the muscular process of the arytenoid was identified. A 2-0 or 3-0 Prolene suture was placed through the muscular process and tied to the cricoid cartilage at the origin of the lateral cricoarytenoid muscle. A bipedicled strap muscle flap was then transposed into the space between the lamina and the inner perichondrium and the thyroid cartilages sutured back into place. Pre- and postoperative voice evaluations measured mean fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, and maximal phonation time, as well as assessments of voice quality. RESULTS: Vocal improvement was obtained in 95% (21 of 22) of patients. There was a significant improvement (P <.05) in all parameters except shimmer. No major complications were noted in any patient, except for dyspnea in one patient resulting from arytenoid overrotation. CONCLUSION: The results suggest that a paramedian approach to arytenoid adduction combined with strap muscle transposition is a safe and effective method for treating glottal incompetence, particularly in patients with unilateral paralytic dysphonia.