[Vertebral artery dissection due to the C6 transverse process and laryngeal cartilage associated with vertebral artery anomaly].

A 52-year-old woman complained of the sudden onset of a left temporal headache, left neck stiffness and dizziness. Brain magnetic resonance imaging showed a high-intensity lesion in the right medial medulla. Dynamic cerebral angiography revealed vertebral artery dissection and compression at the C6 level due to a transverse process at the C6 level associated with rightward head rotation. Removal of bone and decompression of the vertebral artery were performed from the C5 to C6 levels. Intraoperasively, obstruction of blood flow due to a laryngeal cartilage that rotated with the passive rotation of the patient's head to the right was found. To the best of our knowledge this is the first reported case of vertebral artery occlusion due to a laryngeal cartilage associated with head rotation.

Clinical analysis of 15 patients with relapsing auricular polychondritis.

Relapsing polychondritis (RP) is a rare autoimmune disorder of unknown etiology. The disease is characterized by episodic inflammation and destruction of cartilaginous and connective tissue structures, including the ear, eye, nose, larynx, trachea, bronchi, joints, skin, heart valves, and aorta. As the symptoms of RP are diverse and complex, it is easily misdiagnosed. The aim of this paper was to improve the understanding of the clinical features of RP, thereby facilitating its early diagnosis. Fifteen patients with RP were analyzed retrospectively and the relevant literature reviewed. The number of patients presenting with auricular chondritis was 13, while two presented with polyarthritis. Among them, the treatment of 2 RP patients with respiratory tract involvement failed and 1 patient died. Eleven patients with RP (73 %) were initially misdiagnosed. RP involves cartilage and connective tissue. The prognosis for patients with respiratory tract involvement is poor. RP causes episodic and progressive inflammation of cartilage throughout the body and is associated with a variety of clinical manifestations. Early diagnosis of RP depends on a thorough understanding of its clinical features.

Computer-based analysis with three-dimensional imaging constructed from fine-slice computed tomography scan of supracricoid laryngectomy with cricohyoidoepiglottopexy: report of two cases.

OBJECTIVE: Supracricoid laryngectomy with cricohyoidoepiglottopexy is an organ-preserving surgical technique used to treat laryngeal cancer. This procedure resects the vocal folds; however, it is unclear how the sound source and airway morphology are involved in phonation through the post-operative neoglottis. METHOD: Multidetector helical computed tomography scanning was performed on two patients who had undergone supracricoid laryngectomy with cricohyoidoepiglottopexy. The cricoid and arytenoid cartilages and the airway were visualised using three-dimensional images. RESULTS: The mobility of the arytenoid cartilages was well preserved in the one patient with bilateral arytenoids, and in the other patient with only one arytenoid remaining. Two types of airway configuration were observed during phonation: one patient had a single stream airway, while the other had a combination of several streams. CONCLUSION: In the patient with only one arytenoid remaining, the preserved arytenoid tended to be rotated excessively inward. Therefore, phonation may have also occurred in various airways followed by mucosal vibration, which may be a sound source.

Role of subglottal shape in turbulence reduction.

OBJECTIVES: In previous work, we found that airflow at the superior edge of the vocal folds, in the excised canine larynx, can be laminar even when the tracheal airflow is predominantly turbulent. Turbulent flow directly above the folds may lead to an irregular or "rough" voice. Thus, it is important to determine the mechanism of turbulence reduction. From fluid mechanics, it is known that a smoothly converging duct will reduce turbulence. In this study, we tested the hypothesis that the majority of the turbulence reduction is due to the smooth converging shape of the subglottis. METHODS: In 3 excised canine larynges, hot-wire anemometry was used to measure the turbulence intensity (TI) below the cricoid cartilage and 2 to 3 mm above the superior edge of the vocal folds. Laminar flow was seen when the TI was approximately less than 2%. For our measurements, flow into the subglottis had an average TI of more than 20% (high turbulence) in the shear layer and a TI of more than 15% in the center of the jet. The larynges were tested under steady conditions (folds not phonating) with the vocal processes approximated. RESULTS: For the center of the jet, there is moderate turbulence below the cricoid cartilage and laminar flow 2 to 3 mm above the folds. For the shear layer, there is very high turbulence below the cricoid cartilage and low turbulence 2 to 3 mm above the folds. CONCLUSIONS: The smooth converging shape of the subglottis can produce a significant reduction in turbulence. These findings may have important voice implications for operations that may change the subglottal shape (such as vocal fold medialization or airway reconstruction).

Pulmonary arterial pressure in infants with laryngomalacia.

OBJECTIVE: Persistent upper airway obstruction may lead to increased pulmonary arterial pressure in childhood. Laryngomalacia is one of the most common causes of transient upper airway obstruction by laryngeal blockage in infants. The aim of the study is to evaluate the pulmonary arterial pressures in infants with laryngomalacia during infancy period. METHODS: Fifteen infants with laryngomalacia and 30 healthy controls were enrolled into this study. The pulmonary arterial pressures were measured by using Doppler echocardiography. Infants were also evaluated by clinical investigations, telecardiography and electrocardiography. RESULTS: Our results showed that infants with laryngomalacia may have significantly higher pulmonary arterial pressure than healthy subjects. Pressures of patient group were significantly decreased at the end of infancy period. CONCLUSIONS: Increased pulmonary arterial pressure levels due to laryngomalacia are reversible by during developmental process. Therefore, in symptomatic period, evaluation of infants with laryngomalacia by using Doppler echocardiography may be useful for monitoring pulmonary arterial pressure and following up the clinical outcome.

Findings of multiple muscle involvement in a study of 214 patients with laryngeal dystonia using fine-wire electromyography.

Although perceptual and stroboscopic data help in diagnosing and classifying laryngeal dystonia, these measures do not aid the voice clinician in targeting which specific muscles to treat with botulinum toxin. Most patients achieve smoother, less effortful voicing with standard injection regimens. However, there is a notable failure rate. We performed fine-wire electromyography on 214 consecutive patients with laryngeal dystonia. We correlated voice ratings, stroboscopy data, and fine-wire electromyography data. Videostroboscopy was successful in visually demonstrating most of the audible findings in isolated vocal tremor, but it was much less successful in identifying breaks alone or a combination of breaks and tremor. Fine-wire electromyography revealed that the thyroarytenoid muscle was significantly more likely than the lateral cricoarytenoid muscle to be the predominant muscle associated with adductor spasmodic dysphonia, and that the thyroarytenoid and lateral cricoarytenoid muscles were equally likely to be predominantly involved in tremor spasmodic dysphonia. In addition, several patients in both the adductor spasmodic dysphonia and the tremor spasmodic dysphonia groups presented with interarytenoid muscle predominance. All of the intrinsic laryngeal muscles are capable of being the predominant muscle in laryngeal dystonia, and there are patterns of muscle abnormalities that differ between adductor spasmodic dysphonia and tremor spasmodic dysphonia. Some of the failures in treating adductor spasmodic dysphonia with botulinum toxin, and the greater difficulty with success in treating patients with tremor spasmodic dysphonia, are due to failure to deliver toxin to the appropriate muscles.

Postcricoid hemangioma: an overlooked cause of dysphagia in infants?-a case report.

Feeding and swallowing disorders in children remain a major challenge owing to a wide differential diagnosis. Hemangioma of the upper aerodigestive tract represents one of the numerous non-neoplastic causes of dysphagia. We report two cases of postcricoid hemangioma causing inhalation and recurrent respiratory infections, treated successfully with systemic corticotherapy alone. To our knowledge, these are the second and third cases described in the literature. After a short review of the literature, the diagnostic procedures are discussed and a management strategy is proposed for this clinical entity, by far underestimated.

Swallowing disorders in the elderly.

Changes that occur as a natural part of senescence in the complex action of deglutition predispose us to dysphagia and aspiration. As the "baby-boomers" begin to age, the onset of swallowing difficulties will begin to manifest in a greater number of our population. Recent advances in the evaluation of normal and abnormal swallowing make possible more precise anatomical and physiological diagnoses. Coupled with an understanding of swallowing physiology, such detailed evaluation allows greater opportunity to safely manage dysphagia with directed therapy and appropriate surgical intervention. The current study is a discussion of the changes that occur in deglutition with normal aging, contemporary evaluation of swallowing function, and some of the common causes of dysphagia in elderly patients.

Attempts to restore abduction of the paralyzed equine arytenoid cartilage. I. Nerve-muscle pedicle transplants.

The purpose of this project was to adapt a surgical technique from humans and dogs to horses in which a portion of an accessory muscle of respiration and its nerve supply is transplanted to a denervated dorsal cricoarytenoid muscle. Anatomical dissections in seven horses revealed two possible donor nerve-pedicle grafts: the omohyoid and the sternothyrohyoid, both innervated by a branch of the first and second cervical nerves. Histochemical evaluations in two ponies of the dorsal cricoarytenoid, omohyoid and sternothyrohyoid muscles revealed similar proportions of fiber types 1 and 2 in all three muscles. Electromyographic studies in these two ponies revealed that the omohyoid and sternothyrohyoid muscles contract synchronously with respirations during forced inspiration under general anesthesia. Based on surgical ease of access, a 1 cm2 portion of the omohyoid muscle at the point of penetration of the second cervical nerve was used as a nerve-muscle pedicle graft in an attempt to reinnervate the left dorsal cricoarytenoid muscle in four ponies. These four ponies (as well as three others which served as controls) had previously undergone left recurrent laryngeal nerve transection. All seven ponies endoscopically showed signs of complete left laryngeal hemiplegia immediately postoperatively. Animals were monitored endoscopically for 30 weeks after surgery. The three control ponies showed no abduction of the arytenoid cartilage. In addition, in these three ponies, histological and histochemical expected changes of muscle fiber atrophy and fibrosis were present in the dorsal cricoarytenoid muscle.(ABSTRACT TRUNCATED AT 250 WORDS)

Attempts to restore abduction of the paralyzed equine arytenoid cartilage. II. Nerve implantation (pilot study).

The purpose of this project was to attempt restoration of abduction of a recently experimentally denervated left dorsal cricoarytenoid muscle by implanting a transected nerve-end into the paralyzed muscle. In six ponies the cut end of the second cervical nerve was implanted into a slit made in the left dorsal cricoarytenoid muscle. The nerve end was secured in place with one 5-0 polypropylene suture connecting the epineurium to the epimysium. The left recurrent laryngeal nerve was transected during this procedure. All six ponies showed signs of complete left laryngeal hemiplegia immediately after surgery. Postoperatively all ponies were evaluated qualitatively on a monthly basis by subjective examination for evidence of abduction of the arytenoid cartilages on endoscopy and quantitatively by measurement of the cross sectional area of the left and right half of the rima glottidis. Subjective endoscopic evidence of partial abduction was seen in four of the six ponies six months postoperatively. Measurement of the cross sectional area of the rima glottidis revealed a total loss of 38% of the area immediately postoperatively. There were no significant changes in cross sectional areas of the rima glottidis between the immediate postoperative evaluation to the six months postoperative evaluation. Gross postmortem examination revealed partial dorsal cricoarytenoid muscle atrophy as evidenced by a 24-55% decrease in muscle mass compared to the right dorsal cricoarytenoid muscle. Histopathological studies revealed regions with clusters of large muscle fibers.(ABSTRACT TRUNCATED AT 250 WORDS)

[Differential diagnosis of vocal cord immobility after intubation]. / Differentialdiagnose des Stimmlippenstillstandes nach Intubation.

Vocal cord paralysis as cause of an immobility of the vocal cord following endotracheal intubation is often a misdiagnosis. The differential diagnosis is pointed out to distinguish between paresis and ankylosis of the cricoarytaenoid joint, interarytaenoid fibrosis or luxation of the arytaenoid. The development of these disturbances following endotracheal intubation and their therapy are presented.

Cricopharyngeal dysfunction in childhood: treatment by dilatations.

A 3-year-old child with cricopharyngeal dysfunction is reported. Swallowing difficulties, nasal regurgitation, and gagging developed at 2 months of age. Repeated aspirations and over 40 episodes of pneumonia necessitating multiple hospitalizations occurred up to 2 years of age, along with pharyngeal pooling of saliva and inability to swallow solid food. Barium was held up at the cricopharyngeal level, and a prominent esophageal impression was seen at the same level. Symptoms were completely alleviated after two esophageal dilatations by mercury dilators, and the relief persisted for the 6 months of follow-up. The diagnosis of cricopharyngeal dysfunction is discussed, and the necessity for manometric studies, in the face of often misleading radiologic appearance, is emphasized. It is suggested that early use of esophageal dilatations might prevent prolonged morbidity and afford long-term symptomatic relief.

[Laryngeal immobility after intubation]. / Les immobilités laryngées après intubation.

Based on findings in 14 cases of post-intubation laryngeal immobility simulating a paralysis, it is demonstrated that a mechanical cause bringing into play the arytenoids exists in every case. The origin may be from a synechia between the vocal cords, crico-arytenoid ankylosis, inter-arytenoid and plate of the cricoid fibrosis, or a combination of these lesions. Conclusive evidence of the type of lesion involved is rarely apparent from clinical or paraclinical examinations, an exact diagnosis requiring a median thyrotomy. This emphasizes the need for pathologic investigation of the arytenoidectomy surgical specimens. These findings suggest that neurogenic theories concerning the etiopathogenicity of post-intubation laryngeal immobility be revised.