A case of arytenoid dislocation after ProSeal laryngeal mask airway insertion: A case report.

INTRODUCTION AND IMPORTANCE: Arytenoid dislocation, typically manifested as hoarseness and coughing when drinking, is a rare perioperative scenario, with an incidence rate of 0.009 %-0.097 % and endotracheal intubation under general anesthesia being the most common cause. However, arytenoid dislocation caused by a laryngeal mask airway (LMA) is extremely rare. CASE DESCRIPTION: Herein, a 53-year-old female patient was admitted for a "right breast lump" and scheduled for "unilateral mastectomy with ipsilateral axillary sentinel lymph node biopsy" under general anesthesia. During the surgery, the patient was noted to snore mildly, and rocuronium (15 mg) was immediately administered intravenously. The snoring ceased after adjusting the position of the LMA. Postoperatively, the patient was diagnosed with arytenoid dislocation by flexible nasal endoscopy after presenting with a sore throat accompanied by hoarseness and coughing when drinking. Thereafter, the patient underwent two cricoarytenoid joint reductions with a video laryngoscope under intravenous anesthesia, along with anti-inflammatory medication and voice therapy. The voice of the patient returned to normal after 1 month. CLINICAL DISCUSSION: Despite being a supraglottic airway device, the LMA can still cause arytenoid dislocation in clinical practice. Hence, anesthesiologists should analyze the potential causes and understand the diagnosis and treatment of arytenoid dislocation. Although closed reduction surgery typically requires two or three attempts, with a shorter disease duration leading to better outcomes, it can also aid in voice recovery for a longer disease course. In the presented case, the patient achieved a good prognosis after two closed reduction surgeries. CONCLUSION: Anesthesiologists should be vigilant for arytenoid dislocation in patients who present with persistent hoarseness and coughing while drinking after the insertion of the LMA, necessitating prompt treatment after diagnoses to achieve the best results.

The role of cricoarytenoid joint ankylosis in bilateral vocal cord immobility.

OBJECTIVES: To stratify the severity of cricoarytenoid joint fixation (CAJF) by surgery and understand the role of it played in the bilateral vocal fold immobility (BVFI). The second objective emphasizes on the significance of the preoperative differential diagnosis from neurogenic immobility with medical history and endoscopic findings. METHODS: A retrospective review was conducted of 74 patients between 2005 and 2022. Careful medical history inquiry, and videolaryngoscopy are conducted to recruit the appropriate surgical candidates. All patients underwent arytenoid remobilization (AR) followed by vocal fold medialization with arytenoid adduction (AA) or lateralization with suture lateralization (SL). The severity of CAJF is graded during the operation or inferred based on the period from operation to recurrence. RESULT: A total of 18 patients, aged between 18 and 76 years, were analyzed. Among them, 14 cases were classified as the adducted type with ventilation problems, with three presenting with dyspnea, and 11 requiring artificial airways. Additionally, four patients presented with the abducted type, characterized by aphonia. Meanwhile, two additional cases were considered for comparison but were not included in this cohort of 18 subjects due to incorrect diagnosis and inappropriate management. Using AR procedure, the AA procedure offered three aphonia subjects a voiced sound without airway impairment and the SL procedure decannulated 100% (11/11) of the artificial airways and improved the airway patency in 100% (3/3) of the non-tracheostomized subjects despite the severity of CAJF. The severity of joint ankylosis was distributed as follows: In the aphonia group, there were three subjects with grade I, one subject with grade II, and 0 subjects with grade III. In the ventilation group, there was one subject with grade I, seven subjects with grade II, and six subjects with grade III. In contrast, the two cases used for comparison experienced recurrent dyspnea and failed decannulation because the AR procedure was not performed. The follow-up period was averaged in 58 and 14 months at least. CONCLUSION: From this experience, it is the accurate preoperative diagnosis instead of the severity of CAJF that determines the successful rate in airway patency and voiced phonation if the AR procedure is utilized. Careful medical history inquiry and videolaryngoscopic examination can correctly differentiate the mechanical from neurogenic origin without the help of EMG. Evidence of level: 4.

Incidence and Risk Factors of Arytenoid Dislocation Following Endotracheal Intubation: A Systematic Review and Meta-Analysis.

Endotracheal intubation carries risks, including arytenoid dislocation (AD), a rare but severe complication. Due to small sample sizes, the incidence of AD varies considerably among studies. Proposed risk factors for AD include difficult intubation, prolonged intubation, certain surgeries, patient positioning, female sex, and BMI. This review aims to investigate the incidence of AD and explore the various predisposing risk factors. We retrieved relevant studies up to April 2024 from PubMed, Scopus, Web of Science, and the Cochrane Library. Using OpenMeta v5.26.14 software (Institute for Clinical Research and Health Policy Studies at Tufts Medical Center, Boston, USA), we pooled AD incidence rates from individual studies. Other outcomes, reported in fewer studies and thus not suitable for meta-analysis, were synthesized manually. Study selection yielded 16 eligible articles. A random-effects model analysis of nine studies found a significant AD incidence rate of 0.093% (confidence interval (CI): 0.045% to 0.14%), but the results were highly heterogeneous (I2 = 91%). Older age was associated with prolonged hoarseness, while younger age and female sex increased the risk of AD. Additionally, AD risk factors included taller stature, higher BMI, specific surgeries, esophageal instrumentation, prolonged procedure durations, head-neck movement, and inexperienced intubators. However, intubation with a stylet reduced the AD risk. AD post-endotracheal intubation is rare (incidence: 0.09%), with potential underdiagnosis in larger datasets. Many risk factors may contribute to the condition, but the small number of studies per risk factor limits the ability to draw robust conclusions. Subjective diagnoses and retrospective studies further restrict comprehensive understanding. Further research is needed to explore AD risk factors effectively.

Nasogastric tube syndrome: A case of vocal cord paralysis due to a nasogastric tube.

Insertion of a nasogastric tube is one of the most common methods of administering nutrition, but can cause vocal cord paralysis.

Fenestration Approach for Arytenoid Adduction in Unilateral Vocal Fold Paralysis.

OBJECTIVE: Several surgical techniques have been reported for the treatment of unilateral vocal fold paralysis (UVFP). Although the fenestration approach has recently been applied for arytenoid adduction (AA) in some cases, long-term large-cohort studies on its usefulness are lacking. Therefore, this study aimed to evaluate the long-term voice outcomes of this technique in patients with UVFP. STUDY DESIGN: Retrospective study. METHODS: A total of 168 patients with UVFP underwent laryngoplasty comprising AA performed through fenestration of the thyroid ala combined with a type I thyroplasty (TPI). The maximum phonation time (MPT) and mean airflow rate (MFR) were measured before and after surgery, and voice analysis included an estimation of shimmer and jitter. Anterior and posterior surgical windows were created in the lower thyroid ala and were used for typical TPI and AA, respectively. The window locations were determined based on three-dimensional computed tomography data. AA was performed by pulling the muscular process of the arytenoid cartilage toward the lateral cricoarytenoid muscle through the posterior window without releasing the cricothyroid joint. All surgeries were performed under local anesthesia, and medialization was endoscopically confirmed. RESULTS: Postoperative MPT >10 seconds was achieved in 156 of the 168 patients. Postoperatively, MFR improved to <250 mL/s in all but two patients, and MPT, MFR, jitter, and shimmer significantly improved in all patients. Furthermore, perceptual evaluation using the Grade, Roughness, Breathiness, Asthenia, and Strain scale revealed significant improvement in all patients. CONCLUSIONS: The fenestration approach preserves the cricothyroid joint and does not open the cricoarytenoid joint; therefore, the laryngeal cartilage is stabilized, and no distortion of the laryngeal framework occurs. Our results showed that combined AA and TPI via the fenestration approach provided stable long-term postoperative voice improvement in patients with UVFP. LEVEL OF EVIDENCE: Level 3.

Utility of Ultrahigh-Resolution Computed Tomography for Laryngeal Reconstructive Surgery.

OBJECTIVE: Unilateral vocal fold paralysis (UVFP) presents as incomplete glottal closure and leads to breathy hoarseness. Various treatments, including laryngeal framework surgery (type 1 thyroplasty [TP1] and arytenoid adduction [AA]), have been devised to correct this condition. Ultrahigh-resolution computed tomography (U-HRCT) allows detailed three-dimensional imaging of the larynx, which aids our understanding of vocal fold motion disorders. This study assessed whether U-HRCT is beneficial for correct diagnosis and surgical planning. METHODS: The participants were 26 UVFP patients who underwent laryngeal framework surgery (TP1 and/or AA). U-HRCT was used to measure the vocal fold volume (VFV) and level difference (LD). The need to combine AA with TP1 to obtain satisfactory surgical outcomes was evaluated by U-HRCT and various voice function tests. RESULTS: VFV was smaller in paralyzed folds than in unaffected folds. LD correlated strongly with voice parameters and showed high intra-rater and inter-rater reliability. The surgical outcome of the laryngeal framework surgery performed was judged to be excellent for improving voice function. Comparison of LD between the TP1 group and TP1 + AA group indicated that LD is an excellent parameter to determine the need to combine AA with TP1. CONCLUSION: These findings underscore the value of preoperative U-HRCT, especially LD, in surgical decision-making and afford insights for optimal phonosurgery and individualized intervention. Patients with LD >1.0 mm may benefit from thyroplasty with AA. LEVEL OF EVIDENCE: Level 3 (case-control study) Laryngoscope, 2024.

Phonosurgery training using Japanese deer larynx.

OBJECTIVE: To develop phonosurgery skills, surgical training of the actual larynx is essential. In our institution, the Japanese deer (Cervus Nippon aplodontids) larynx is used in phonosurgery training. This study aimed to examine the similarities and differences between the Japanese deer and human larynx and to demonstrate their utility in vocal surgery practice. METHODS: A comparative study was conducted using 30 Japanese deer larynges and 51 human donor larynges, evaluating the overall framework, dimensions, and angle of the thyroid cartilage, vocal cord length, and location of the arytenoid cartilage muscular process. The changes and movements of the vocal folds during contraction and relaxation of each internal laryngeal muscle were also visually analyzed. RESULTS: The larynx size of Japanese deer is intermediate between that of human males and females. The adduction and abduction of the vocal folds induced by contraction of the posterior and lateral cricoarytenoid muscles, as well as the extension of the vocal folds induced by contraction of the cricothyroid muscle, behaved in the same manner as in the human larynx. CONCLUSION: The morphology of the Japanese deer larynx is similar to that of the human larynx, making it suitable for use in dissection and surgical practice. Owing to the recent animal damage problem and the popularity of gibier cuisine, large quantities of Japanese deer larynx are available at low prices. We believe that the Japanese deer larynx is the most appropriate animal for phonosurgery training so far.

Investigation of the Position and Angle of the Vocal Fold Projected onto the Thyroid Cartilage.

OBJECTIVE: To perform laryngeal framework surgery for unilateral vocal fold paralysis and obtain favorable voice improvement, it is necessary to accurately determine the vocal fold and arytenoid cartilage positions. Thus, the position and angle of the paralyzed vocal folds and arytenoid cartilage projected onto the affected thyroid plate were measured using computed tomography (CT) before and after surgery. METHODS: Forty-six male patients with thyroid cartilage ossification observed on preoperative CT and vocal fold paralysis were included. Using Adobe Illustrator®, the thyroid plate on the affected side was reconstructed from the continuous images of the sagittal section of the CT examination during participant's quiet breathing (reconstructed affected thyroid plate [RATP]). RESULTS: The anterior commissure mean position was slightly cranial to the midpoint of the thyroid cartilage midline. The paralyzed vocal fold angle was not parallel to the baseline. The average unaffected vocal fold angle during vocalization projected onto the affected thyroid plate was 13.83°, which differed significantly from the average paralyzed vocal fold angle before surgery (19.05°). However, no significant difference was observed in comparison with the average angle of the paralyzed vocal fold after arytenoid adduction. The average distance from the inferior notch of the affected side thyroid cartilage to the affected arytenoid cartilage was 16.7 mm. CONCLUSION: By understanding the positional relationship between the thyroid cartilage plate and internal structure from preoperative CT images, more effective surgery can be performed according to individual differences. LEVEL OF EVIDENCE: IV Laryngoscope, 134:4088-4094, 2024.

Characteristic Laryngeal Findings in Patients with Pemphigus Vulgaris.

OBJECTIVE: Pemphigus Vulgaris (PV) is a rare autoimmune disease that could cause laryngeal lesions; however, only a few studies have described the localization of the laryngeal lesions associated with this disease owing to its rarity. Therefore, this study aimed to determine the localization of laryngeal lesions in patients with PV. METHODS: Fourteen patients with PV accompanied by laryngeal or pharyngeal lesions, who underwent flexible laryngeal endoscopy performed by laryngologists, were examined retrospectively. RESULTS: The arytenoid area was the most frequently affected site in the larynx, followed by the epiglottis and aryepiglottic folds. Vocal folds and ventricular bands were the least affected. CONCLUSION: Lesions in the arytenoid area were observed more frequently in this study than in previous studies. This result suggests that a more careful inspection of arytenoid lesions in patients with PV is required under laryngeal fiber observation. Moreover, we proposed a novel classification system for laryngeal findings in patients with PV and a systematic observation method. This novel classification and method would be useful not only for determining the lesions but also for careful inspection in this field. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3719-3725, 2024.

New strategy for intraoperative phonosurgical management of recurrent laryngeal nerve infiltrated by thyroid carcinoma.

PURPOSE: Treating an infiltration of the recurrent laryngeal nerve (RLN) by thyroid carcinoma remains a subject of ongoing debate. Therefore, this study aims to provide a novel strategy for intraoperative phenosurgical management of RLN infiltrated by thyroid carcinoma. METHODS: Forty-two patients with thyroid carcinoma infiltrating the RLN were recruited for this study and divided into three groups. Group A comprised six individuals with medullary thyroid cancer who underwent RLN resection and arytenoid adduction. Group B consisted of 29 differentiated thyroid cancer (DTC)patients who underwent RLN resection and ansa cervicalis (ACN)-to-RLN anastomosis. Group C included seven patients whose RLN was preserved. RESULTS: The videostroboscopic analysis and voice assessment collectively indicated substantial improvements in voice quality for patients in Groups A and B one year post-surgery. Additionally, the shaving technique maintained a normal or near-normal voice in Group C one year post-surgery. CONCLUSION: The new intraoperative phonosurgical strategy is as follows: Resection of the affected RLN and arytenoid adduction is required in cases of medullary or anaplastic carcinoma, regardless of preoperative RLN function. Suppose RLN is found infiltrated by well-differentiated thyroid cancer (WDTC) during surgery, and the RLN is preoperatively paralyzed, we recommend performing resection the involved RLN and ACN-to-RLN anastomosis immediately during surgery. If vocal folds exhibit normal mobility preoperatively, the MACIS scoring system is used to assess patient risk stratification. When the MACIS score > 6.99, resection of the involved RLN and immediate ACN-to-RLN anastomosis were performed. RLN preservation was limited to patients with MACIS scores ≤ 6.99.

How reliable is assessment of true vocal cord-arytenoid unit mobility in patients affected by laryngeal cancer? a multi-institutional study on 366 patients from the ARYFIX collaborative group.

PURPOSE: In clinical practice the assessment of the "vocal cord-arytenoid unit" (VCAU) mobility is crucial in the staging, prognosis, and choice of treatment of laryngeal squamous cell carcinoma (LSCC). The aim of the present study was to measure repeatability and reliability of clinical assessment of VCAU mobility and radiologic analysis of posterior laryngeal extension. METHODS: In this multi-institutional retrospective study, patients with LSCC-induced impairment of VCAU mobility who received curative treatment were included; pre-treatment endoscopy and contrast-enhanced imaging were collected and evaluated by raters. According to their evaluations, concordance, number of assigned categories, and inter- and intra-rater agreement were calculated. RESULTS: Twenty-two otorhinolaryngologists evaluated 366 videolaryngoscopies (total evaluations: 2170) and 6 radiologists evaluated 237 imaging studies (total evaluations: 477). The concordance of clinical rating was excellent in only 22.7% of cases. Overall, inter- and intra-rater agreement was weak. Supraglottic cancers and transoral endoscopy were associated with the lowest inter-observer reliability values. Radiologic inter-rater agreement was low and did not vary with imaging technique. Intra-rater reliability of radiologic evaluation was optimal. CONCLUSIONS: The current methods to assess VCAU mobility and posterior extension of LSCC are flawed by weak inter-observer agreement and reliability. Radiologic evaluation was characterized by very high intra-rater agreement, but weak inter-observer reliability. The relevance of VCAU mobility assessment in laryngeal oncology should be re-weighted. Patients affected by LSCC requiring imaging should be referred to dedicated radiologists with experience in head and neck oncology.

Voice outcome in medialisation thyroplasty with and without arytenoid adduction: a prospective comparison using intraoperative voice measurements.

PURPOSE: Arytenoid adduction as an addition to medialisation thyroplasty is highly advocated by some surgeons in selected cases but deemed less necessary by others in patients with unilateral vocal fold paralysis. This study aims to evaluate the additional benefits on voice outcome of arytenoid adduction in patients with unilateral vocal fold paralysis undergoing medialisation thyroplasty using intra-operative voice measurements. DESIGN/METHODS: A prospective study was conducted. Voice audio recordings were obtained at 4 moments; 1. direct prior to the start of surgery, 2. during surgery after medialisation thyroplasty, 3. during surgery after medialisation and arytenoid adduction, 3 months postoperative. At these same timepoints patients rated their own voice on a numeric rating scale between 0 and 10. The blinded recordings were rated by consensus in a team of experienced listeners, using the Grade of the GRBAS scale. Furthermore, the Voice Handicap Index was administered before and at 3 months after surgery. RESULTS: Ten patients who underwent medialisation and arytenoid adduction at our tertiary referral hospital between 2021 and 2022, were included. One patient was excluded after surgery. The intraoperative measurements showed a Grade score of 1.4 preoperatively, improving to 1.2 after medialisation, 1.2 after medialisation and arytenoid adduction, and further improving to 0.4 at 3 months postoperative, which was a not statistically significant improvement (p = 0.2). The intraoperative subjective numeric rating scale showed a statistically significant improvement from 3.9 preoperatively, to 6.1 after medialisation, 7.1 after medialisation and arytenoid adduction and a 7.6 at 3 months postoperative (p = 0.001). The Voice Handicap Index total score showed a statistically significant improvement from 71 points before surgery to 13 at 3 months after surgery (p = 0.008). CONCLUSIONS: Our study using intraoperative voice measurements indicate that the addition of arytenoid adduction to medialisation thyroplasty is a benefit in selected patients although more studies are needed due to the many limitations inherent to this field of investigation.

Arytenoid Cartilage Collapse During Inhalation in Awake Patients with Intermediate/High Risk of Obstructive Sleep Apnea: A Retrospective Analysis of Sixty-Four Patients.

OBJECTIVE: To assess the prevalence of arytenoid cartilage collapse (ACC) during deep inhalation in awake patients with intermediate/high risk of obstructive sleep apnea (OSA). STUDY DESIGN: Retrospective case-control study. METHODS: The medical records and video recordings of awake flexible endoscopic examination of patients with history of OSA who presented to the sleep apnea clinic in a tertiary referral medical center between June 2022 and December 2022, were reviewed. All patients had filled the STOP-BANG questionnaire and had intermediate/high risk of having OSA. A group of patients matched by age and gender and with no history of OSA were used as controls. RESULTS: A total of 95 patients, 64 with a history of OSA and 31 with no history of OSA, were included. Among the study group, 37.5% (n = 24) had a STOP-BANG score between 3 and 4 and were considered to be at an intermediate risk of OSA while the remaining had a score more than 5 and were considered to be at high risk of OSA. There was a significant difference in the prevalence of ACC between the study group and controls (32.8% vs 12.9%, respectively, P < 0.001). CONCLUSION: The prevalence of ACC was significantly higher in patients with intermediate/high risk of OSA in comparison to healthy controls with no history of OSA. When present, ACC should raise the physician's suspicion for OSA and probably prompt further investigation such as a sleep study.

A Novel Five-Step Reduction Technique of Arytenoid Dislocation.

The article reported a novel reduction device and standardized reduction technique for patients with arytenoid dislocation. The results showed that this reduction technique has been excellent in helping patients with arytenoid dislocation. Laryngoscope, 134:1744-1748, 2024.

Subtotal Submucosal Arytenoidectomy with Lateralization Sutures (SMALS) Covered by a Mucosal Flap.

OBJECTIVE: Glottic airway stenosis (GAWS) may result from bilateral paralysis (BVFP) or posterior glottic stenosis (PGS). Since the glottis is the principal airway sphincter, surgeons shift on the balance between airway, aspirations, and voice. We aim to describe our surgical technique and outcome of the SMALS procedure for GAWS correction. METHODS: A retrospective cohort of patients who underwent SMALS for PGS between 2018 and 2021. SMALS involves: endoscopic submucosal subtotal arytenoidectmy (preserving medial mucosal flap) and lateralization sutures. The sutures lateralize the mucosal flap to cover the arytenoidectomy bed without lateralization of the membranous vocal fold; expanding the posterior glottis, while preserving a relatively good voice. Covering the arytenoidectomy bed enhances healing. Medical and surgical data, airway, voice, and swallowing symptoms were collected. Relative glottic opening area (RGOA) and relative glottic insufficiency area (RGIA) were calculated. RESULTS: Eleven PGS patients who underwent 15 SMALS were included (4 bilateral), all patients had post-intubation PGS, 1 patient also had prior radiation to the larynx. All patients were tracheostomy-dependent. There were no major complications. No granulation or retracting scar was observed at follow-up. None had a persistent voice or swallowing disability. Successful outcome (decannulation) was achieved in 8 (73%); RGOA increased in all (Δ = 0.37; p = 0.003), while RGIA remained relatively stable (Δ = 0.02; p = 0.055). CONCLUSIONS: SMALS is a safe and effective, novel modification of the classic arytenoidectomy, for GAWS correction that can be easily applied and may expand the airway without significant glottic insufficiency symptoms. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:353-360, 2024.

History of Previous Surgical Resection Promotes the Sclerosis of the Arytenoid Cartilage in Patients With Laryngeal Contact Granuloma.

OBJECTIVES: To explore the relationship between arytenoid cartilage sclerosis and a history of previous surgical resection in patients with laryngeal contact granuloma. METHODS: 167 patients with laryngeal contact granuloma treated from March 2016 to December 2018 were studied. The high-resolution computed tomography (HRCT) data of the sclerosis of arytenoid cartilage is divided into asymmetric sclerosis, bilateral sclerosis, and no sclerosis according to the range of sclerosis. The proportions of various ranges of sclerosis in two subgroups of patients were compared to patients with and without a history of previous surgical resection. RESULTS: The arytenoid cartilage sclerosis rate of 167 patients was 69.46%. The exact probability method showed that P < 0.001, suggesting that the distribution of arytenoid cartilage sclerosis was different in patients with and without a history of previous surgical resection, and there was a moderate correlation between the extent of arytenoid sclerosis and history of previous surgical resection (Cramer's V = 0.436, P < 0.001). There were 18 cases of bilateral sclerosis in patients with a history of previous surgical resection, of which 50% had contralateral recurrence after combined therapy (proton pump inhibitor (PPI) and glucocorticoid injection into granuloma via the thyrohyoid membrane approach), accounting for 75% of recurrence after combined therapy. CONCLUSION: Surgery promotes the expansion of arytenoid sclerosis, Patients with bilateral arytenoid sclerosis are prone to recurrence of contralateral laryngeal contact granuloma.

Modified Laryngeal Forceps for Arytenoid Cartilage Dislocation Caused by Endotracheal Intubation: A Retrospective Case-Control Pilot Study.

Background: Arytenoid cartilage dislocation is considered as a rare laryngeal injury and closed reduction is commonly used as the first choice for the arytenoid dislocation. However, the tools of closed reduction vary, and there is no dedicated tool for closed reduction, and the treatment outcome varies from person to person. This study compared the treatment outcome of the modified laryngeal forceps and traditional laryngeal forceps. Material and Methods: This study conformed to the strengthening the reporting of observational studies in epidemiology guidelines regarding retrospective studies. From May 2021 to February 2023, the records of 28 patients with arytenoid cartilage dislocation caused by endotracheal intubation were reviewed. They were divided into the traditional group (n = 14) and the modified group (n = 14) by gender. Indirect or direct laryngoscopy, video stroboscopy, high-resolution computed tomography, and cricoarytenoid joint 3-dimensional reconstruction were used to evaluate arytenoid position and motion. Clinical characteristics, voice function, procedural skill, and treatment outcome for each case were recorded. Results: Each patient was diagnosed with arytenoid dislocation caused by endotracheal intubation. There was no significant difference in the treatment outcome between the traditional group and the modified group (P > .05). However, the median time interval between closed reduction and the return of normal voice in the traditional group was 31.08 ± 10.56 days, which was significantly longer than the median time of 17.92 ± 3.83 days in the modified group (P < .05). Conclusion: Closed reduction with the modified laryngeal forceps under local anesthesia is an effective and safe procedure. Compared with traditional laryngeal forceps, the modified laryngeal forceps can shorten the treatment duration.

Long-term voice evaluation after arytenoid adduction surgery in patients with unilateral vocal fold paralysis.

PURPOSE: Laryngeal framework surgery, including medialization laryngoplasty and arytenoid adduction (AA), is expected to have a lasting or permanent effect in patients with unilateral vocal fold paralysis (UVFP); however, there are few reports about the long-term outcomes of AA. This study aimed to evaluate the long-term postoperative effects of AA surgery and examine its stability and reliability. METHODS: This study collected the voice handicap index (VHI) questionnaire from patients with UVFP who underwent AA more than 2 years previously. The VHI values preoperatively and 3 months postoperatively (early postoperative evaluation) were retrospectively calculated, and VHI values more than 2 years after surgery (late postoperative evaluation) were collected by mailing a sheet to the patients and asking to fill and return it. Possible influenced subscales such as age, sex, causes of UVFP, affected side, and surgeons were also analyzed. RESULTS: A total of 77 patients with UVFP who underwent AA had significantly lower early and late postoperative evaluations than preoperative evaluations. In 38 patients with no missing values, there were no significant differences between early and late postoperative evaluations, measured at a median of approximately 5 years. There were also no significant differences between early and late postoperative evaluations in any of the subscale groups. CONCLUSION: Patients with UVFP who underwent AA surgery achieved stable voice improvement in the long term after surgery.

Effectiveness of vocal fold medialization surgery on the swallowing function of patients with unilateral vocal fold paralysis.

Objectives: Vocal fold medialization surgery is generally considered a phonosurgical procedure for improvement of vocal function in patients with glottic insufficiency. However, the literature describing this procedure for the management of dysphagia is limited. This study aims to assess the effects of medialization surgery on swallowing function in patients with unilateral vocal fold paralysis (UVFP). Methods: We enrolled 32 patients with UVFP undergoing vocal fold medialization surgery (medialization laryngoplasty combined with arytenoid adduction [ML + AA], 12 cases; injection laryngoplasty [IL], 20 cases). We assessed the aerodynamic vocal function including maximum phonation time and mean flow rate to evaluate glottal closure status. The Hyodo score determined by flexible endoscopic evaluation and Functional Oral Intake Scale (FOIS) were evaluated pre- and postoperatively. Results: Almost 60% of patients with UVFP had dysphagia, and one-third were at high risk for aspiration. Aerodynamic parameters effectively improved after IL and ML + AA. With regard to swallowing, both the FOIS and total Hyodo score were significantly improved postoperatively. We found a particularly significant improvement in pharyngeal clearance. However, patients with high vagal nerve paralysis and postoperative insufficient glottal closure showed poor swallowing benefits after the interventions. In patients with recurrent laryngeal nerve palsy, there were no significant differences in postoperative swallowing function between the ML + AA and IL groups. Conclusion: Vocal fold medialization surgery was effective in improving swallowing function in most cases with UVFP, except for those with high vagal paralysis and insufficient postoperative glottal closure. Both IL and ML + AA showed an equivalent effect on swallowing improvement. Level of evidence: 3b.

Acquired laryngomalacia as a cause of post-extubation stridor and extubation failure following craniotomy: a case report.

BACKGROUND: Laryngomalacia is a dynamic airway condition characterized by flaccid laryngeal tissue and inward collapse of supraglottic structures during inspiration. Although it may cause airway obstruction and requires careful management, there have been few reports regarding laryngomalacia after surgery. We report a case of adult-onset laryngomalacia occurred after craniotomy requiring reintubation. CASE PRESENTATION: A 21-year-old man was admitted to the ICU after craniotomy for a cerebellopontine angle tumor. He developed severe stridor immediately after extubation on the postoperative day 2 and required reintubation. On the postoperative day 5, similar episode occurred following re-extubation and fiberoptic laryngoscopy revealed a collapsed epiglottis and left arytenoid into the glottis. A diagnosis of laryngomalacia was made, and he underwent tracheostomy. Laryngomalacia had completely improved; however, bilateral vocal cord paralysis was detected 2 weeks later. CONCLUSIONS: Acquired laryngomalacia should be considered as a possible mechanism of the airway symptoms in a patient with neurological dysfunction.