The Comparison of Thyroarytenoid Muscle Myectomy and Type II Thyroplasty for Spasmodic Dysphonia.

OBJECTIVE: Surgical treatments for adductor spasmodic dysphonia include bilateral thyroarytenoid muscle myectomy (TAM) and type II thyroplasty (TPII), both of which are commonly performed. The present study aimed to compare the effects of TAM and TPII. STUDY DESIGN: Retrospective study. METHODS: Subjects were 30 and 35 patients who underwent TAM and TPII, between March 2008 and November 2012. Voice quality was evaluated based on "voice handicap index 10 (VHI10)" and auditory impressions before and 6 months after surgery using five parameters: "strangulation," "interruption," "tremor," "grade," and "breathiness." RESULTS: Comparison of the two procedures revealed significant improvements in VHI10, strangulation, interruption, and tremor, and a significant decline in breathiness after surgery. In particular, VHI10 was improved by more than six points in 90% of patients with TAM, and 96% with TPII. No significant difference was observed between the severities of two procedures preoperatively. Comparison of each postoperative score between the two procedures revealed that TAM significantly improved strangulation, interruption, and tremor, and significantly worsened breathiness, with no significant difference in VHI10. Scatter plots (x: preoperative scores; y: postoperative scores) and regression lines of evaluation items demonstrated that TAM is more effective than TPII in severe cases. CONCLUSIONS: Compared with TPII, TAM tends to improve strangulation, interruption, and tremor; however, it tends to worsen breathiness postoperatively. Postoperative VHI10 scores did not differ significantly between the two procedures. Given favorable improvement rates, both surgical procedures were considered effective.

New approach to diagnose arytenoid dislocation and subluxation using three-dimensional computed tomography.

Understanding the complex three-dimensional (3D) arrangement of the arytenoid cartilage is necessary for diagnosing arytenoid dislocation (AD) and arytenoid subluxation (AS). We examined the 3D arrangements of AD and AS (AD/AS) cases by region and considered their new diagnoses. This retrospective study included 2 patients with AD, 10 with AS, and 23 with unilateral vocal fold paralysis (UVFP) for comparison. The etiologies were intubation-induced and idiopathic. We classified the AD/AS position into four joint regions: mediocaudal, laterocaudal, mediocranial, and laterocranial. We generated 3D computed tomography (3DCT) images during rest and phonation to analyze functional movements. We attempted to compare the endoscopic findings and 3DCT images of patients with UVFP and AD/AS. To examine the joint status, we especially focused on the position and movements of the muscular process (MP) on the joint because the arytenoid facet is mainly located on the back of the MP. We were able to obtain endoscopic and 3DCT findings characteristic of each AD/AS region. The dislocated MPs were localized to the mediocaudal, mediocranial, and laterocranial regions. Two AD cases were diagnosed due to complete separation of the joint surfaces during rest and phonation. The finding of MPs displacing partially outside the cricoid facet is common to both severe UVFP and AS. The most important differentiation point was that the MP in UVFP cases was located on both the medial and lateral side regions of the joint, but that of AS was on one side region only. Furthermore, no cases of passive gliding movements characteristic of UVFP that have been described previously by us were observed in AD/AS cases. AD can be diagnosed by findings of complete joint separation. AS can be diagnosed based on positions and movements distinct from those of UVFP.

Morphological change of the cupula due to an ototoxic agent: a comparison with semicircular canal pathology.

CONCLUSION: The cupula shows various degrees of changes after gentamicin (GM) injection into the inner ear, with or without damage of the sensory cells. This cupula change may be a part of the etiology of peripheral vertigo, and is also potentially one of the mechanisms of reduced caloric response. OBJECTIVES: To observe the morphological changes of the cupula after injecting GM in the frog inner ear and to compare the changes of the cupula with those of the ampullary sensory cells. METHODS: We injected 300 microg (7.5 microl) of GM into the inner ear of 30 bullfrogs (Rana catesbeiana) using a microsyringe under ether anesthesia. The same amount of saline was injected into the other ear as control. The cupulae were observed at 3, 7, and 14 days after GM injection by stereoscopic microscope. The ampullae were fixed, and the sensory cells were assessed using a scanning electron microscope (SEM). The correlation between the changes in the cupula and sensory cells was evaluated using our own scale. RESULTS: In over half of the cupulae in the 7- and 14-day groups, cupula changes such as shrinkage were observed. In about 50% of the total cases, the degree of cupula and sensory cell change correlated in the two groups. In the 14-day group, these changes were more marked. However, there were cases in which the changes of the cupula and sensory cells did not correlate, indicating that the cupula alone can sustain changes without sensory cell damage.

Characterization of arytenoid vertical displacement in unilateral vocal fold paralysis by three-dimensional computed tomography.

The paralyzed arytenoid is not immobile and is subjected to passive movement during phonation. If anatomical changes during inspiration and phonation are compared by three-dimensional computed tomography (3D CT), it is possible to observe vertical movement of the paralyzed arytenoid. Our aim was to use 3D CT to examine the characteristics of 3D arytenoid movement in unilateral vocal fold paralysis (UVFP). This is a prospective study. A total of 61 patients (18 females and 43 males) with UVFP who had undergone 3D CT imaging between April 2005 and January 2007 were included. Cricoid and arytenoid cartilage was imaged by 3D CT. We detected the movements of the paralyzed side when comparing inspiration and phonation. The degree of cranial displacement of the paralyzed arytenoids was classified into three grades (I for mild to III for severe). The mean flow rate (MFR) was calculated for each grade. By comparing the MFR of each grade with the normal control group, we determined whether cases would worsen according to grade. Passive gliding movement of the paralyzed arytenoids was found in 90.7% of cases. In all cases, the paralyzed arytenoids were displaced cranially compared to the unaffected side. MFR worsened significantly as the grade became more severe. We believe that the passive gliding movements observed when comparing inspiration and phonation are characteristic of paralysis. Even in mild cases, the paralyzed arytenoids are passively displaced cranially during phonation, and the degree of this displacement is one indicator that can be used to evaluate the severity of UVFP.

A "fenestration approach" for arytenoid adduction through the thyroid ala combined with type I thyroplasty.

OBJECTIVE: To develop and evaluate the voice outcomes of an approach of arytenoid adduction (AA) through a fenestration of the thyroid ala for unilateral vocal cord paralysis. STUDY DESIGN: Twelve consecutive patients with severe unilateral vocal cord paralysis, whose maximum phonation times (MPTs) were less than or equal to 5 seconds, underwent laryngoplasty using an approach of AA performed through a fenestration of the thyroid ala combined with type I thyroplasty. METHOD: Two surgical windows were made in the lower part of the thyroid ala. The anterior window was for typical type I thyroplasty, and the posterior window was for AA. AA was performed by pulling the lateral cricoarytenoid muscle (LCA) (5 patients) or muscular process (7 patients) through the posterior fenestration in the contractile direction of the LCA without releasing the cricoarytenoid joint. The operation was performed under local anesthesia with sedation except in two patients who underwent general anesthesia using a laryngeal mask. The vocal cord medialization was confirmed endoscopically during the operation. For all patients, the MPT and mean airflow rate (MFR) were measured before and after the operation. The postoperative voices were analyzed using shimmer and jitter. RESULT: All patients achieved a MPT of over 12 seconds. The MFR, which ranged from 340 to 1902 mL/second before the operation, improved to less than 200 mL/second, except in one patient whose MFR was 210 mL/second. Shimmer and jitter improved significantly after the operation. Perceptual evaluation using the GRBAS (grade, roughness, breathiness, aesthenia, strain) scale also improved significantly. CONCLUSION: A fenestration-based approach simplified the combination of AA and type I thyroplasty because the two treatments could be performed in the same operating field and provided good voice improvement. Pulling the AA braid in the contractile direction of the LCA and endoscopic vocal cord observation during surgery may have contributed to the positive results.

A new procedure of arytenoid adduction combined with type I thyroplasty under general anesthesia using a laryngeal mask.

Laryngeal framework surgery is usually performed under local anesthesia. However, some patients are unable to tolerate extended surgery. A case of an 82-year-old woman who underwent medialization thyroplasty and arytenoid adduction of direct lateral cricoarytenoid (LCA) muscle pulling at the same time under general anesthesia using a laryngeal mask is reported. Endoscopic observation through the laryngeal mask allows direct visual control of the vocal cord. The LCA pulling method does not touch the posterior border of the thyroid cartilage so that the laryngeal mask does not disturb the arytenoid adducts.

[Two cases of laryngoplasty performed under a general anesthesia applied using a laryngeal mask for the treatment of unilateral vocal cord paralysis].

In general, laryngoplasty for unilateral vocal cord paralysis is performed under local anesthesia because the patient's voice must be heard and the movement of the vocal cords visualized during the endoscopic procedure to ensure good results. We encountered two cases who could not endure a long operation under local anesthesia and the insertion of an endoscope because of their age and gag reflex. We thus performed a combined lateral cricoarytenoid muscle pull (LCA-pull) and a type I thyroplasty under general anesthesia applied using a laryngeal mask. Although the patients could not phonate during the operation, the laryngeal mask allowed the vocal cords to be observed. Both patients achieved in maximal phonation time over 13 seconds, and the postoperative mean flow rates improved to under 110 mL/s. The postoperative period perturbation quotient and amplitude perturbation quotient also improved to within the normal limits.

Pleomorphic adenoma of the external auditory canal complicated by hearing loss secondary to chronic otitis media.

Pleomorphic adenoma (PA) rarely occurs in the external auditory canal (EAC). A case of PA complicated with chronic otitis media is reported. The patient was a 36-year-old male who began to experience a hearing loss in the left ear in 1996. He sought medical attention only after ear pain developed in April 2003. At the initial examination, a tumor covered by smooth skin was seen filling the left EAC. Pure-tone audiometry showed residual hearing at low frequencies and scale-out across middle to high frequency range. The CT and MRI findings led to a diagnosis of a tumor of the left EAC complicated with an inflammatory middle-ear lesion. The tumor was excised en bloc with the overlying skin, and tympanoplasty was performed. The pathological diagnosis was PA of the left EAC and inflammatory granuloma of the middle ear.

Direct pull of lateral cricoarytenoid muscle for unilateral vocal cord paralysis.

CONCLUSION: Lateral cricoarytenoid muscle-pull surgery (LCA pull) is a safe and effective method for the treatment of unilateral vocal cord paralysis. OBJECTIVE: To evaluate the results of an improved method of LCA pull for unilateral vocal cord paralysis. MATERIAL AND METHODS: Thirteen patients with unilateral vocal cord paralysis underwent LCA pull between April 2003 and January 2004. A small window was made in the posterior lower part of the thyroid cartilage and 2-3 mm in a cranial direction to the lower edge of the thyroid cartilage. The inner perichondrium was carefully removed to expose the LCA muscle. A 4-0 nylon suture placed through the LCA muscle was pulled to adduct the arytenoid and was tied to the anterior lower part of the thyroid cartilage. All cases were treated by LCA pull alone. In all cases, the maximum phonation time was measured and an auditory evaluation was performed using the grade, roughness, breathiness, asthenia and strain scale. The airflow rate was measured in five cases. RESULTS: Vocal improvement was obtained in 11/13 cases (85%). One of the unimproved cases had cricoarytenoid joint ankylosis. No complications were observed.