Laryngeal framework surgery: a proposal for classification and nomenclature by the Phonosurgery Committee of the European Laryngological Society.

Laryngeal framework surgery, developed by Isshiki in the 1970s, is one of the most dynamic areas of phonosurgery and these procedures have served to considerably widen our spectrum and options for surgical improvement and/or changing of voice. As these techniques became more accepted and became common throughout the world, several new surgical modifications and different terms have been introduced. These new developments have lead to a confusion regarding terminology and types which make it difficult to communicate between and to compare the results of different authors. In an effort to create a more precise and descriptive list of definitions and terms, the Phonosurgery Committee of the European Laryngological Society has developed a new terminology for laryngeal framework surgery. In accordance with the concept of Isshiki, four types can be separated according to the intended purpose of the surgery: -Approximation laryngoplasty: medialization thyroplasty, arytenoid adduction. -Expansion laryngoplasty: lateralization thyroplasty, vocal fold abduction. -Relaxation laryngoplasty: shortening thyroplasty -Tensioning laryngoplasty: cricothyroid approximation, elongation thyroplasty. The proposed terms are functionally oriented and related closely to the intended purpose of the procedure or related to the underlying pathogenesis of the dysphonia. This new classification should provide a general framework suited not only to classify the current techniques but also to easily apply and adapt to include new procedures and future developments as necessary.

Thyroplasty for adductor spasmodic dysphonia: further experiences.

OBJECTIVES: Two different surgical techniques for midline lateralization thyroplasty (type 2 thyroplasty) for adductor spasmodic dysphonia (SD) have been described, one using a composite graft and the other without. Indications and results for each method among different types of SD were compared, together with the theoretical background for the surgery. STUDY DESIGN: Retrospective. METHODS: The medical records of six patients with SD together with the fiberscopic video recording of laryngeal findings before, during, and after surgery were reviewed. The intraoperative video recordings of the surgical procedures were compared with the postoperative findings. RESULTS: The vocal features of SD, diverse preoperatively, disappeared postoperatively and a normal, or almost normal, voice was attained in 5 of 6 cases. The failure in one patient was attributed to combined focal dystonia of the neck muscles and difficulty in lateralization. Type 2 thyroplasty without a graft, which causes bowing of both vocal folds, is simple to perform and effective enough for most SD cases. No recurrence has been noted so far over postoperative periods ranging from 6 months to more than 3 years. CONCLUSION: The results suggest that thyroplasty is an effective therapeutic approach for SD.

Three-dimensional reconstruction by scanning electron microscopy from serial epoxy resin semi-thin sections after ion-etching.

Three-dimensional reconstruction was performed using scanning electron micrographs of serial semi-thin sections of Epon embedded specimens. Connective tissue in a rabbit ear chamber was fixed in glutaraldehyde and osmium tetroxide, and then embedded in Epon. One-microm-thick serial sections were cut with a diamond knife, mounted on glass slides and stained with toluidine blue. After observation with a light microscope, the sections were ion-etched with an ion-spatter coater. Following double staining with uranyl acetate and lead citrate, the consecutive sections were ion-coated with platinum. Each serial section was photographed with a scanning electron microscope. Profiles of a blood vessel and fibroblasts were digitized with a computer and computer reconstruction of the blood vessel was performed. Three-dimensional reconstructions showed that the newly formed blood vessel was a cylinder-like, bare endothelial tube with a rather smooth outer surface. Fibroblasts were situated around the endothelial tube. Several openings were found in the endothelial tube, suggesting the morphological feature of high permeability and fragility in newly formed blood vessels. The availability of three-dimensional reconstruction from scanning electron micrographs of serial semi-thin epoxy resin sections was discussed; structures of interest can be reconstructed (1) quickly and easily, (2) without skilful techniques, and (3) almost at the level of ultrastructure.

Mechanical and dynamic aspects of voice production as related to voice therapy and phonosurgery.

Laryngeal framework surgery can change the position and tension of the vocal folds safely without direct surgical intervention in the vocal fold proper. Some 23 years of experience with phonosurgery have proved its usefulness in treating dysphonia related to unilateral vocal fold paralysis, vocal fold atrophy, and pitch-related dysphonias. Meanwhile, much information about the mechanism of voice production has been obtained through intraoperative findings of voice and fiberscopic examination of the larynx. Based on such knowledge together with information obtained through model experiments, the human vocal organ was reconsidered mainly from the mechanical view point, and the roles of voice therapy and singing pedagogy were discussed in relation to phonosurgery. The vocal organ may not be an ideal musical organ and is rather vulnerable, but its potential is enormous.

Midline lateralization thyroplasty for adductor spasmodic dysphonia.

Midline lateralization thyroplasty was successfully performed on a patient with adductor spasmodic dysphonia. The thyroid cartilage was incised at the midline, and a 3 x 2-mm perforation was made at the anterior commissure to widen it. The perforation was closed with a free composite graft taken from the upper edge of the thyroid ala, and the incised thyroid cartilage edges were kept separated 4 mm apart with silicone wedges. A part of the sternohyoid muscle was rotated to seal any leak from the perforation. The postoperative course was uneventful. The voice has been restored to normal, and there is no sign of recurrence of the symptom so far, as of 1 year 5 months postoperative. Although a longer follow-up is needed, this case indicates that midline type II thyroplasty could be a useful treatment for adductor spasmodic dysphonia.

Progress in laryngeal framework surgery.

This paper reviews progress in laryngeal framework surgery since it was first reported about 25 years ago. The success of this type of surgery requires both a basic knowledge of the physiology of phonation, in order to make decisions about the surgical procedure, and surgical skill, in order to accomplish the intended procedure successfully. The main reason for hoarseness is imperfect closure of the glottis, but the second most important reason for hoarseness, increased stiffness of the vocal fold, cannot be corrected by mere medialization of the vocal fold. Laryngeal framework surgery is different in concept from conventional surgery, which is intended to remove the lesion. Controversial points discussed here regarding type I thyroplasty include: (i) whether the cartilage window should be removed; (ii) materials for fixation of the window; and (iii) comparison of type I thyroplasty with arytenoid adduction. A new surgical treatment for spasmodic dysphonia and its results in three patients are described briefly. Surgery for raising the vocal pitch requires further improvement. In the future, laryngeal framework surgery will have wider application in treatment of dysphonias, such as asthenic voice due to atrophy in professional singers or aging, pitch problems in females and gender identity disorder and spasmodic dysphonia.

A new method for detecting and localizing cell markers endocytosed by fibroblasts in epoxy resin semi-thin sections using scanning electron microscopy combined with energy dispersive X-ray microanalysis after ion-etching.

Cell marking is widely used to examine cell development and differentiation in developmental biology. We developed a new method for localizing cell markers in a semi-thin epoxy section with scanning electron microscopy. Cultured fibroblasts ingesting carbon particles were autologously transplanted into a rabbit transparent ear chamber, 6 mm in diameter and 100 microm in depth. Eight days after the transplantation, tissues in the chamber were fixed and embedded in epoxy resin. Semi-thin sections were cut and stained with toluidine blue. Fibroblasts in connective tissues which contained black spots were observed with a light microscope. These sections were subsequently ion-etched with an ion-coater and coated with platinum. The same fibroblasts were then visualized by secondary electron imaging using a scanning electron microscope. A nucleus with nuclear envelope, nuclear pores, a nucleolus and heterochromatin, mitochondria with cristae and rough endoplasmic reticulum were observed in the fibroblasts. The black spots in the fibroblasts were identified as bright bodies with the scanning electron microscope. The bright bodies were found to be a lump of tiny particles less than 100 nm in diameter. In order to analyse such particles with energy dispersive X-ray microanalysis, ion-etched sections were coated with carbon. X-ray energy spectrometry clearly demonstrated that these were carbon particles, which had been endocytosed by the fibroblast. This suggests that scanning electron microscopy combined with energy dispersive X-ray microanalysis is useful for detecting carbon particles in the cytoplasm at an ultrastructural level in semi-thin epoxy sections subsequent to ion etching and that this method may be applicable to other cell markers, such as gold particles to track cells in the field of cell development and cell differentiation.

Anatomic study for posterior medialization thyroplasty.

To attain posterior medialization by thyroplasty type I, we simulated the surgery using 3 cadaveric larynges. Two approaches were applied to adduct the arytenoid cartilage: one involved compression of the vocal process, and the other, compression of the muscular process inward. The inner perichondrium was incised to reach the arytenoid cartilage from the framework. To compress the vocal process, a large silicone plug was required. In this method, there was some difficulty in compressing the vocal process precisely, and there was the risk of postoperative extrusion of the large plug. In contrast, the muscular process was more superficial relative to the framework, and it could be precisely compressed, resulting in sufficient posterior glottal closure. The silicone plug required for this procedure has a shallow depth that may provide the advantage of preventing postoperative extrusion. In conclusion, the compression of the muscular process is preferable for safely achieving posterior glottal closure.

Virtual reality in a children's hospital.

We used virtual reality technology to improve the quality of life and amenity of in-patients in a children's hospital. Children in the hospital could enjoy a zoo, amusement park, and aquarium, in virtual. They played soccer, skiing and horse riding in virtual. They could communicate with persons who were out of the hospital and attend the school which they had gone to before entering hospital. They played music with children who had been admitted to other children's hospitals. By using this virtual technology, the quality of life of children who suffered from psychological and physiological stress in the hospital greatly improved. It is not only useful for their QOL but also for the healing of illness. However, these methods are very rare. Our systemic in our children's hospital is the first to be reported in Japan both software and hardware of virtual reality technology to increase the QOL of sick children need further development.

Vocal mechanics as the basis for phonosurgery.

OBJECTIVE: A number of modifications in laryngoplastic phonosurgery have recently been proposed. This report is intended to clarify the concept on which the surgery should be based, vocal mechanics, for further rational development of the surgery. STUDY DESIGN: The results of various previous surgeries were compared. In an attempt to elucidate what makes the difference in the results, simulation of voice production was conducted with the use of excised larynges. METHODS: Excised larynges were mounted on a tube so as to be blown from below. Experimental variables in the model included the glottal area initially set, stiffness of the vocal folds, and subglottal pressure. The conditions under which the voice became hoarse were examined. RESULTS: The voice became hoarse under the following major conditions: 1) the initial glottal area exceeded a certain value, 2) stiffness was too high, and 3) the glottis was too tightly closed. Clinical representation for each condition was made, particularly for excessively tight glottal closure such as in spasmodic dysphonia. A new type of surgical treatment for spasmodic dysphonia, lateralization thyroplasty, was briefly reported, which restored the voice to normal without recurrence for 1 year at the time of this writing. CONCLUSIONS: A potential new type of laryngoplastic phonosurgery should be conformed to the mechanics of voice production. In treating dysphonia, it is often necessary to switch from etiologic or radical treatment, if infertile, to symptomatic treatment instead, at the level of mechanics.

Mechanical and dynamic aspects of voice production as related to voice therapy and phonosurgery.

Laryngeal framework surgery can change the position and tension of the vocal folds safely without direct surgical intervention in the vocal fold proper. Some 23 years of experience with phonosurgery have proved its usefulness in treating dysphonia related to unilateral vocal fold paralysis, vocal fold atrophy, and pitch-related dysphonias . Meanwhile, much information about the mechanism of voice production has been obtained through intraoperative findings of voice and fiberscopic examination of the larynx . Based on such knowledge together with information obtained through model experiments, the human vocal organ was reconsidered mainly from the mechanical view point, and the roles of voice therapy and singing pedagogy were discussed in relation to phonosurgery. The vocal organ may not be an ideal musical organ and is rather vulnerable, but its potential is enormous.

Recent progress in treating patients with cleft palate.

Over the last 4 decades remarkable progress has been made in the treatment of cleft palate: the rate of attaining normal or nearly normal speech after surgery has risen from about 65% 40 years ago to nearly 90% or more nowadays. One of the main factors is intratracheal intubation anesthesia that has made the surgery much safer and easier. Improved surgical technique and speech therapy also played a great role. This paper deals with two problems: (1) Slight velopharyngeal incompetence: The combined use of fiberscopy and fluorovideoscopy can provide useful information as to: (a) the exact place of the faulty articulation, (b) the detailed pattern of inconsistent velopharyngeal function, (c) changes in articulation induced by speech therapy, and (d) the relation between velopharyngeal function and faulty articulation. All the above information greatly facilitates speech therapy for cleft palate speech. It should be done with utmost care though due to possible adverse effects of radiation. (2) Analysis of faulty articulation. It was revealed that faulty articulations such as laryngeal fricative and affricates, pharyngeal stop, and glottal stop in cleft palate speech, secondary to velopharyngeal incompetence, were produced by articulation in the larynx at various sites such as the epiglottis, arytenoids, aryepiglottic folds and vocal folds. These faulty articulation points were located lower than supposed on the basis of auditory perception.

Familial occurrence of electrocardiographic abnormalities of the Brugada-type.

Electrocardiographic abnormalities were pointed out in a 51-year-old Japanese male whose major complaint was dizziness. His electrocardiogram showed a complete right bundle branch block, and a prolonged His bundle-ventricle (HV) interval of 100 msec. Two members of his family died of heart disease and 3 members, including a case of sudden death, presented an abnormal electrocardiogram of the Brugada-type with persistent ST segment elevation in the right precordial leads and right bundle branch block. The signal-averaged examination was made in the children of cases that died with the diagnosis of sudden death. Four cases showed a tendency of delay in the HV interval and a positive finding in the late potential. Further studies are necessary to clarify the relationship between electrocardiographic abnormalities of the Brugada-type and atrioventricular conduction disorder as well as to clarify the genetic basis of this disorder.

Vocal fold atrophy and its surgical treatment.

The effectiveness of surgical treatment for vocal fold atrophy of various causes was examined. Type I thyroplasty was performed on 31 patients with vocal fold atrophy, often bilaterally and occasionally combined with type III thyroplasty. Of these 31 patients, 3 patients underwent the operation twice, for a total of 34 operations. The surgery was found to be effective in improving the voice quality and the ease of phonation. When a scar or sulcus was present, the results were not as satisfactory. The intraoperative decision-making process as to which procedure to perform is extremely important for achieving an optimal voice, and should be based on the intraoperative voice quality, fiberoptic findings, and manual tests. In operations for vocal fold atrophy in which the vocal folds are mobile, a silicone shim should be firmly fixed to prevent migration. Overcorrection is generally recommended. No complications were encountered. It was often the increased ease of phonation rather than the improved voice quality that patients appreciated after surgery.

Increase in length of experimental skin flaps that survive with dibutyryl cyclic AMP.

One of the most important research topics in plastic surgery is the extension of the length of skin flaps that survive. We have investigated the increase in the length of skin flaps that can be achieved by giving dibutyryl cyclic AMP (DB-cAMP) to rabbits with experimental skin flaps and compared the results with those in animals not given DB-cAMP. Three variables, the arrival of DB-cAMP in the critical area of circulation of the flap (n = 6), changes in the blood flow in the flap (n = 10), and increase in the length of skin flap that survived (n = 30) were investigated by high performance liquid chromatography and laser Doppler flowmetry. DB-cAMP reached the critical area of circulation in the skin flap (dye distance), increased the blood flow within this area (mean (SEM) peak value 30 minutes after operation 1.24 (0.06) ml/min/kg compared with 1.06 (0.02) in control flaps), and extended the length of the flap that survived (mean (SEM) length seven days after operation 66.1 (3.0) mm compared with 60.8 (1.8) mm in the control group). We conclude that DB-cAMP improved the blood flow in skin flaps in rabbits with a consequent increase in the length of skin flap that survived.

In vivo chondrogenesis in collagen sponge sandwiched by perichondrium.

In order to increase the cartilage synthesis of the perichondrium, we combined auricular perichondrium with a collagen sponge as a template (perichondrium-sandwiched collagen sponge) and implanted the assembly as an autograft into the back of rabbits. Microscopic examination revealed that cartilaginous tissue was produced in the collagen sponge and chondrosynthesis was accelerated in the collagen sponge implants in comparison with that in materials containing perichondrium alone.

Involvement of lipid peroxidation in necrosis of skin flaps and its suppression by ellagic acid.

To evaluate the pathogenesis of lipid peroxidation in skin-flap necrosis and to select a novel herbal antioxidant to suppress lipid peroxidation and salvage the flaps, in vitro and in vivo experiments were instituted. In vitro studies revealed (1) the potentiality of the cutaneous microsomal system (vesicular fragment of endoplasmic reticulum) to generate oxyradicals by FeCl3 (oxidative agent), since NADPH-dependent lipid peroxidation was elevated time-dependently, (2) suppression of microsomal lipid peroxidation by herbal antioxidants (dose- and time-dependently), further supporting the theory of oxyradical-induced lipid peroxidation in the skin, and (3) that ellagic acid showed the strongest response, with curcumin, chlorogenic acid, and alpha-tocopherol (tocopherol) being moderate, and ferulic acid and gallic acid remaining weakest. Thus ellagic acid, curcumin, chlorogenic acid, and tocopherol at doses of 10, 60, 80 and 100 microM (twice I50, the dose which could inhibit lipid peroxidation by 50 percent) were chosen for in vivo assessments, respectively. In vivo studies were performed using rat back skin random flaps (70 x 15 mm and based anteriorly) and circular island flaps (20 mm in diameter and raised on superficial epigastric vessels). Control flaps were painted with a Tris-ethanol solution, and test flaps were painted with either ellagic acid, curcumin, chlorogenic acid, or tocopherol (above-mentioned doses per 250 microliters of Tris-ethanol per 300 mm2 of flap surface 1 hour before the operation and once a day for 3 postoperative days). Doses, frequency, and period of drug application were based on in vitro and in vivo pilot experiments. The results were as follows: (1) a direct and time-dependent relation was noticed between lipid peroxide levels and the rate of necrosis in both types of flap; (2) time-dependent elevation of lipid peroxide levels of skin, subcutaneous fat, and exudate of island flaps during ischemia and those of skin and subdermal fat after reperfusion indicated pre- and post-reflow states of lipid peroxidation rather than the original conception of merely reperfusion state; and (3) in good agreement with the results of in vitro experiments, ellagic acid exerted the strongest effect to suppress lipid peroxide levels of skin and to augment the viability of random flaps more than that of island flaps.(ABSTRACT TRUNCATED AT 400 WORDS)

The use of microsurgical planing to treat traumatic tattoos.

A traumatic tattoo results from an abrasion in which dirt, carbon, tar, asphalt, or other particles have become embedded beneath the superficial layer of the dermis. These embedded particles are difficult to remove completely. Under a microscope, rectangular epidermal and upper dermal grids including these pigments are made, and each section of the grid is removed. The microsurgical planing technique has the following advantages: it saves the maximum possible amount of normal skin, and the particles are completely removed. Twenty patients have been treated with this technique and have obtained excellent results.

Tissue transfer with a distal to proximal arteriovenous anastomosis for venous drainage: microcirculatory analysis on the rabbit ear model.

An experimental study was conducted to find out the survival mechanism of tissue transfers drained by distal to proximal arteriovenous fistulas in 22 rabbit ear chambers using a videorecording system. In the first experiment (n = 12) the rabbit earlobe was cut at the base to eliminate blood and lymphatic flow. The central artery was reanastomosed and an anterior marginal distal to proximal arteriovenous anastomosis was created. In the second experiment (n = 10) the anterior marginal artery was reanastomosed, and a central distal to proximal arteriovenous fistula was created. In the first experiment, constant blood flow was observed postoperatively in arterioles, venules, capillaries and arteriovenous shunts, while in the second experiment, no blood was observed in any vessels. In conclusion, capillary blood circulation was experimentally confirmed in a tissue transfer with distal to proximal arteriovenous anastomosis, and selection of arteries, one for reanastomosis and one for anastomosis to a vein for drainage, seems to be of critical importance for the success of this tissue transfer.