Bilateral vocal cord paralysis associated with laryngeal myxedema.

For managing dyspnea caused by bilateral vocal cord paralysis as a complication of thyroidectomy in the acute postoperative period, reversible vocal cord lateralisation is performed at the authors' departments. However, in the later postoperative period of thyroidectomy when there is no chance for recovery of the recurrent laryngeal nerves, they perform irreversible procedure. Applying these operative techniques satisfactory breathing can be achieved in about 95% of cases avoiding tracheostomy. In 5% of cases there are other comorbidities in the background of unsuccessful operative results which can cause potential dyspnea as well. From these complications the authors emphasize the role of laryngeal obstruction and myxedema as a consequence of hypothyroidism developed after thyroidectomy. Management of severe dyspnea caused by association of these two complications of thyroidectomy means a great therapeutic challenge. Between 01 Jan 1989 and 30 Nov 2008 the authors performed 161 reversible and 135 irreversible vocal cord lateralisations to manage dyspnea caused by bilateral vocal cord paralysis as a complication of thyroidectomy. From these cases four patients had further obstruction due to laryngeal myxedema. By performing endoscopic laryngeal surgeries and applying levothyroxine replacement therapy sufficiently wide glottic chink has been achieved in all the cases. According to the experience of the authors dyspnea caused by bilateral vocal cord paralysis after thyroidectomy needs complex, interdisciplinary therapeutic approach beside glottis widening operations.

Diagnosis of myiasis by fine needle aspiration cytology: a case report.

BACKGROUND: Myiasis is the infestation of tissues and organs by dipteran larvae and is endemic in tropical areas. Diagnosis usually is made by demonstration of a larva or larvae in infected tissue, generally recognizable to the naked eye. In our case, diagnosis was based on fine needle aspiration cytology (FNAC). CASE: A 59-year-old female patient with a painful neck mass was examined at an otorhinolaryngologic department after symptoms for several weeks. The lesion was found to be an absceding lymphadenitis, based on clinical symptoms, palpation and imaging (ultrasound and computed tomography). The lesion did not improve with repeated courses of antibiotics, so surgery was performed. Pus cultures collected after incision were negative, leaving origin of the inflammation undetermined. Smears from FNA of the residual mass demonstrated a worm-like pathogen alien to most European pathologists' experience. The pathogen was identified as a dipteran larva, leading to accurate etiologic diagnosis of myiasis. More scrupulous examination of the patient's history revealed she had spent her vacation in Australia, where she probably acquired the infection. CONCLUSION: Our case demonstrates the growing importance of the pathology of infectious diseases. One reason for this may be the ever-increasing possibility, frequency and distance of travel.

Surgery of adult bilateral vocal fold paralysis in adduction: history and trends.

Bilateral vocal fold paralysis (BVFP) in adduction is characterised by inspiratory dyspnea, due to the paramedian position of the vocal folds with narrowing of the airway at the glottic level. The condition is often life threatening and therefore requires surgical intervention to prevent acute asphyxiation or pulmonary consequences of chronic airway obstruction. Aside from corticosteroid administration and intubation, which are only temporary measures, the standard approach for improving respiration is to perform a tracheotomy. Over the past century, a vast majority of surgical interventions have been developed and applied to restore the patency of the airway and achieve decannulation. Surgeons can generally choose for every individual patient from various well-established treatment options, which have a predictable outcome. An overview of the surgical techniques for laryngeal airway enlargement in BVFP is presented. Included are operative techniques, which have found application in clinical practice, and only to a small extent in purely anatomic or animal studies. The focus is on two major groups of interventions--for temporary and for definitive glottic enlargement. The major types of interventions include the following: (1) resection of anatomical structures; (2) retailoring and displacing the existing structures, with minimal tissue removal; (3) displacing existing structures, without tissue resection; (4) restoration or substitution of the missing innervation of the laryngeal musculature. The single interventions of these four major types have always followed the development of the medical equipment and anaesthesia. At the beginning of the twentieth century, when medicine was unable to counteract surgical infection, endoscopic or extramucosal surgical techniques were dominant. In the 1950s, the microscopic endoscopic laryngeal surgery boomed. At the end of the twentieth century many of the classical endoscopic operations were performed either with the help of surgical lasers alone, or in combination with other interventions.

[Prevention of bilateral vocal cord paralysis due to thyroid surgery and microsurgical management of the developed paralysis]. / A kétoldali hangszalagbénulás megelôzése pajzsmirigymûtétek során, illetve a kialakult hangszalagbénulás mikrosebészi kezelése.

INTRODUCTION: Following the great tradition established in the St.Rókus Hospital and Institutions by author's predecessor Prof. Aurel Réthi, there have been more than 300 patients operated on for treatment of laryngotracheal stenosis. The vast majority of the cases admitted to the department suffering from bilateral vocal cord paralysis were the consequences of thyroid surgery and its complications, which may develop even after operation by the best surgeon. OBJECTIVES: Confronted with this challenging clinical scenario, the author became determined to focus not only on reconstruction but also on prevention. METHODS: A new method, the neuromonitoring has been introduced first time in Hungary in the St.Rókus Hospital for thyroidectomies to simplify the identification and preservation of the recurrent nerves. As the author's department is a center for laryngotracheal reconstruction, patients from different institutions and countries were treated with larynx dilating operations, benefiting the newly developed additional techniques. With the goal of refined alternatives to previous glottis dilating operations, new methods have been worked out for the management of bilateral vocal cord paralysis based on the author's endo-extralaryngeal suture technique, mostly without tracheostomy. RESULTS: They introduced in the last 5 years the neuromonitoring by performing thyroidectomies in 57 cases mostly for the management of malignant thyroid diseases. The recently popularized methods of the author for the management of bilateral vocal cord paralysis they were performed in the last 20 years consist of two operations, a reversible one and an irreversible one. The first operation was the reversible endo-extralaryngeal lateralization, which was carried out in 63 patients, 61 of which were successful. In the reversible technique the sutures were not removed if the cords remained paralyzed. If there was evidence of return of vocal cord function, the sutures were removed, thus eliminating the need for further dilating operations. The second operation is performed on patients whose vocal cords are paralyzed. This irreversible operation can be performed with and without arytenoidectomy. These operations were successful in 94 out of 99 patients. CONCLUSIONS: The author feels that these two operations are quite successful because the medial mucous membrane of the vocal cord is preserved, avoiding scar and granuloma formation. The operations may be performed without any kind of tracheostomy. These are significant advantages over most other glottic dilating operations.

Development of a new method and device for adaptation and suture of tissues during transoral surgery: in vitro and cadaver experiments.

OBJECTIVE: The objective of this study was to present cadaver and model experiments of a technique using an instrument that may overcome the problems of achieving adaptation and suture of mucous membrane and other tissues during transoral surgery in narrow anatomical circumstances. STUDY DESIGN: The following interventions were carried out on cadavers: adaptation and suture of mucous membrane by uvulopalatopharyngoplasty (UPPP); release and anteroposition of the epiglottis and fixation to the vallecula or to the base of the tongue; denudation and closing the lumen of the larynx; release and retroposition and fixation of the epiglottis to the posterior part of the larynx; creation, adaptation, and suturing of mucosal flaps in the posterior part of the larynx; craniolateral mobilization and fixation of the vocal cord; submucous excision of excess tissues; and adaptation and suture of the edges of the mucosa. RESULTS: The safety and reduced need for microclips in surgeries in these areas can be accomplished by introducing the Ligature-Suture device, which makes it possible to pass a suture under the tissues with a single movement. CONCLUSIONS: This new technique and instrument for the Ligature-Suture device has the potential to be applied successfully in other fields of surgery. The main advantages of this technique are its simplicity and safety.

Prevention and management of bilateral vocal cord paralysis by and after thyroid surgery.

Following the great tradition established in the Szent Rókus Hospital and Institutions by author's predecessor Prof. Aurel Réthi, there have been more than 300 patients operated on for treatment of laryngotracheal stenosis. The vast majority of the cases referred to the department suffering from bilateral vocal cord paralysis were the consequences of thyroid surgery and its complications. Confronted with this challenging clinical scenario, the author became determined to focus not only on reconstruction but also on prevention. For example, all thyreoidectomies are performed with identification and preservation of the recurrent nerves. As the author's department is a center for laryngotracheal reconstruction, patients from different institutions were treated with larynx dilating operations, benefiting from the newly developed additional techniques. With the goal of refining alternatives to previous glottis dilating operations, new methods have been worked out for the management of bilateral vocal cord paralysis based on our endo-extralaryngeal suture technique. These recently popularized approaches consist of two operations, an irreversible one and a reversible one. The first operation is performed on patients whose vocal cords are paralyzed. This irreversible operation can be performed with and without arytenoidectomy. These operations were successful in 94 out of 99 patients. The second operation was the reversible endo-extralaryngeal lateralization, which was carried out in 63 patients, 61 of which were successful. In the reversible technique the suture was not removed if the cords remained paralyzed. If there was evidence of return of vocal cord function, the suture was removed, thus eliminating the need for further dilating operations. The author feels that these two operations are quite successful because the medial mucous membrane of the vocal cord is preserved, avoiding scar and granuloma formation. The operations may be performed without any kind of tracheostomy. These are significant advantages over most other glottic dilating operations.

Development of a new method and device for securing haemostasis during transoral surgery: in vitro and cadaver experiments.

The objective of this study is to present cadaver and model experiments of an instrument and technique that may overcome the problems of achieving hemostasis after tonsillectomy and surgery of the tongue base. The safety and the reduced need for microclips in surgeries in these areas can be accomplished by introducing the "ligature" device, which makes it possible to pass a suture under a blood vessel or other diffuse areas of bleeding with a single movement. This technique may also be applied to operations on the supraglottic larynx, oropharynx and hypopharynx. Utilization in the larynx may be more limited. This new instrument and technique for the ligature device has the potential to be applied successfully in other fields of surgery. The main advantages of this technique are its simplicity and safety.

Simple and safe puncture technique for voice prosthesis implantation.

OBJECTIVE: A simplified esophagotracheal (ET) puncture technique is described for use instead of the Blom-Singer method for voice prosthesis implantation, with the aim to offer an easier alternative for the same purpose. Study population Of 68 study patients, there were 10 women and 58 men (age range, 46 to 80 years) who had been operated on during a 5-year period with use of this technique. Of the 68 patients, 57 were able to learn to speak in a fluent voice acceptable for everyday communication after the implantation. Seven of the 57 patients had a spasm in the cricopharyngeus muscles and were able to speak only after myotomy. METHODS: Sixty-eight patients were implanted with voice prosthesis using the ET puncture technique as follows: through the laryngoscope, the distal bent blunt end of the endoextralaryngeal needle carrier is led into the esophagus. The needle with the leading thread (2-0 Prolene) is pushed through in the upper third of the tracheostoma from inside out. Afterward, the cone-trocar catheter is pulled through the stitching canal in the upper third of the tracheostoma. Using the ET puncture technique, the puncture site is the same as with the use of the Blom-Singer method, 5 to 8 mm below the mucocutaneous junction. Then the cone-trocar is cut off from the 18 charrier catheter and the guide wire is pushed inside the catheter through the esophagus, pharynx, and mouth. The voice prosthesis will be fixed on the guide wire and then pulled back in the opening of the fistula. RESULTS: There were no problems or complications with this technique. In 4 cases, the ET puncture could be performed on patients in whom it was not previously possible with the Blom-Singer technique. CONCLUSION: This management approach offers an alternative to the Blom-Singer technique. The advantage of the ET puncture is that it is simple and safe and that the back wall of the pharynx or esophagus cannot be damaged. Using the ET puncture technique, the possibility of complications is eliminated.

Reversible lateralization of the paralyzed vocal cord without tracheostomy.

The initial management of bilateral abductor vocal cord paralysis is usually tracheostomy. It is proposed that a reversible endoscopic vocal cord lateral fixation would avoid this morbid procedure. The operation is performed by laryngoscopy utilizing the endo-extralaryngeal suture technique of Lichtenberger. Two polypropylene sutures are looped over one of the paralyzed vocal cords and brought out through the neck skin. A small incision is made, and the sutures are secured in the sternohyoid muscle. If movement of one or both vocal cords returns, the sutures are removed. Sixty-one of 63 cases were successful. In 53 cases, the airway became stable, without return of function. In 8 cases, one or both of the vocal cords became mobile 3 to 4 months after the operation. The reversible endo-extralaryngeal lateralization of the vocal cord using the above suture technique ensures a stable airway immediately. This technique avoids the need for tracheostomy in cases of bilateral abductor vocal cord paralysis.