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Kumai Y, Kodama N, Murakami D, Yumoto E. Comparison of vocal outcome following two different procedures for immediate RLN reconstruction. Eur Arch Otorhinolaryngol 2015; 273:967-72. [PMID: 26667805 DOI: 10.1007/s00405-015-3852-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
Abstract
The objective of this study was to compare time-dependent improvements in phonatory function and stroboscopic findings following two different procedures for immediate reconstruction of the recurrent laryngeal nerve (RLN) during neck tumor extirpation. Seventeen patients with neck tumors, consisting of advanced thyroid cancer (n = 15), metastatic neck lymph nodes from other malignant lesions (n = 2), underwent resection of the primary lesion and involved RLN. Immediate RLN reconstruction by either: (1) ansa cervicalis nerve (ACN) to RLN anastomosis (n = 8); or (2) placement of the great auricular nerve (GAN) between the cut ends of the RLN (n = 9) was performed from 2000 to 2011. Phonatory function [maximum phonation time, mean airflow rate (MFR), jitter, and shimmer) and stroboscopic findings (regularity, amplitude, and glottal gap) were examined at 1, 6, and 12 months postoperatively. Stroboscopic findings were assessed by two otolaryngologists and one speech pathologist. There were no significant differences in any parameter for either phonatory function or stroboscopic findings between ACN and GAN with the exception of jitter and shimmer, in which ACN was superior to GAN at 1 month postoperatively. All parameters improved significantly between 1 and 12 months postoperatively for both phonatory function and stroboscopic findings (P < 0.05). Either method of immediate RLN reconstruction at the time of neck tumor extirpation (i.e., ACN or GAN) provided both excellent long-term postoperative phonatory function and stroboscopic findings, and there was little difference in vocal outcome between the two procedures.
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Affiliation(s)
- Yoshihiko Kumai
- Department of Otolaryngology Head and Neck Surgery, Kumamoto University School of Medicine, 1-1-1 Honjo, Kumamoto City, Kumamoto, Japan.
| | - Narihiro Kodama
- Department of Otolaryngology Head and Neck Surgery, Kumamoto University School of Medicine, 1-1-1 Honjo, Kumamoto City, Kumamoto, Japan
| | - Daizo Murakami
- Department of Otolaryngology Head and Neck Surgery, Kumamoto University School of Medicine, 1-1-1 Honjo, Kumamoto City, Kumamoto, Japan
| | - Eiji Yumoto
- Department of Otolaryngology Head and Neck Surgery, Kumamoto University School of Medicine, 1-1-1 Honjo, Kumamoto City, Kumamoto, Japan
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Li M, Chen S, Wang W, Chen D, Zhu M, Liu F, Zhang C, Li Y, Zheng H. Effect of duration of denervation on outcomes of ansa-recurrent laryngeal nerve reinnervation. Laryngoscope 2014; 124:1900-5. [PMID: 24473920 DOI: 10.1002/lary.24623] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/03/2014] [Accepted: 01/27/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Meng Li
- Department of Otolaryngology-Head and Neck Surgery; Changhai Hospital, Second Military Medical University; Shanghai 200433 People's Republic of China
| | - Shicai Chen
- Department of Otolaryngology-Head and Neck Surgery; Changhai Hospital, Second Military Medical University; Shanghai 200433 People's Republic of China
| | - Wei Wang
- Department of Otolaryngology-Head and Neck Surgery; Changhai Hospital, Second Military Medical University; Shanghai 200433 People's Republic of China
| | - Donghui Chen
- Department of Otolaryngology-Head and Neck Surgery; Changhai Hospital, Second Military Medical University; Shanghai 200433 People's Republic of China
| | - Minhui Zhu
- Department of Otolaryngology-Head and Neck Surgery; Changhai Hospital, Second Military Medical University; Shanghai 200433 People's Republic of China
| | - Fei Liu
- Department of Otolaryngology-Head and Neck Surgery; Changhai Hospital, Second Military Medical University; Shanghai 200433 People's Republic of China
| | - Caiyun Zhang
- Department of Otolaryngology-Head and Neck Surgery; Changhai Hospital, Second Military Medical University; Shanghai 200433 People's Republic of China
| | - Yan Li
- Department of Otolaryngology-Head and Neck Surgery; Changhai Hospital, Second Military Medical University; Shanghai 200433 People's Republic of China
| | - Hongliang Zheng
- Department of Otolaryngology-Head and Neck Surgery; Changhai Hospital, Second Military Medical University; Shanghai 200433 People's Republic of China
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Li J, Liu S, Cheng Q, Nie M, Zhang S, Sheng X, Chen S, Ge P. Changes in electrical response function and myosin heavy chain isoforms following denervation and reinnervation of bilateral posterior cricoarytenoid muscles in dogs. Acta Otolaryngol 2014; 134:318-25. [PMID: 24460155 DOI: 10.3109/00016489.2013.860657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSIONS Both electrical response function and mRNA expression of myosin heavy chain (MyHC) types 2X, 1, and Neonatal of bilateral posterior cricoarytenoid (PCA) muscle changed after denervation or reinnervation in canines. OBJECTIVES There is a need to investigate the electrical response function MyHC alteration of denervation or reinnervation in the bilateral PCA muscle of large animals. METHODS MyHC isoforms expression profile and PCA muscle function outcome were detected by real-time reverse transcribed-polymerase chain reaction and muscle response to functional electrical stimulation, 9 weeks after denervation and reinnervation with ansa-recurrent laryngeal nerve anastomosis in dogs. RESULTS Denervation produced up-regulation of MyHC-1 and MyHC-Neonatal messenger ribonucleic acid (mRNA) expression. Reinnervation caused a decrease of MyHC-2X mRNA expression. The electrical voltage threshold of vocal fold movement and maximum abduction of denervation were greater than that of the reinnervated or control group. The denervated vocal abduction maximum of response to electrical stimulation was less than that in reinnervation or control groups.
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Affiliation(s)
- Jingyuan Li
- Department of Otolaryngology, Guangdong General Hospital & Guangdong Academy of Medical Sciences , Guangzhou city and
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Wang W, Chen D, Chen S, Li D, Li M, Xia S, Zheng H. Laryngeal reinnervation using ansa cervicalis for thyroid surgery-related unilateral vocal fold paralysis: a long-term outcome analysis of 237 cases. PLoS One 2011; 6:e19128. [PMID: 21559458 PMCID: PMC3084757 DOI: 10.1371/journal.pone.0019128] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 03/16/2011] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate the long-term efficacy of delayed laryngeal reinnervation using the main branch of the ansa cervicalis in treatment of unilateral vocal fold paralysis (UVFP) caused by thyroid surgery. Summary of Background Data UVFP remains a serious complication of thyroid surgery. Up to now, a completely satisfactory surgical treatment of UVFP has been elusive. Methods From Jan. 1996 to Jan. 2008, a total of 237 UVFP patients who underwent ansa cervicalis main branch-to-recurrent laryngeal nerve (RLN) anastomosis were enrolled as UVFP group; another 237 age- and gender-matched normal subjects served as control group. Videostroboscopy, vocal function assessment (acoustic analysis, perceptual evaluation and maximum phonation time), and electromyography were performed preoperatively and postoperatively. The mean follow-up period was 5.2±2.7 years, ranging from 2 to 12 years. Results Analysis of videostroboscopic findings indicated that the glottic closure, vocal fold edge, vocal fold position, phase symmetry and regularity were significantly improved in the UVFP group (P<0.001, postoperative vs. preoperative). The postoperative parameters of vocal function were also significantly improved in the UVFP group (P<0.001) and showed no statistical differences compared to the control group (P>0.05, respectively). Postoperative laryngeal electromyography confirmed successful reinnervation of laryngeal muscle. Conclusions Delayed laryngeal reinnervation with the main branch of ansa cervicalis is a feasible and effective approach for treatment of thyroid surgery-related UVFP; it can restore the physiological laryngeal phonatory function to the normal or a nearly normal voice quality.
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Affiliation(s)
- Wei Wang
- Department of Otorhinolaryngology-Head and Neck Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Donghui Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Shicai Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ding Li
- Department of Otorhinolaryngology-Head and Neck Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Meng Li
- Department of Otorhinolaryngology-Head and Neck Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Siwen Xia
- Department of Otorhinolaryngology-Head and Neck Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Hongliang Zheng
- Department of Otorhinolaryngology-Head and Neck Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- * E-mail:
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Modified arytenoid adduction for cancer-related unilateral vocal fold paralysis. The Journal of Laryngology & Otology 2010; 125:173-80. [PMID: 21106137 DOI: 10.1017/s0022215110002434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES (1) To evaluate the efficacy of modified arytenoid adduction in the management of patients with symptomatic cancer-related unilateral vocal fold paralysis, and (2) to assess the impact of this treatment on patients' quality of life. METHODS Forty-two patients with cancer-related unilateral vocal fold paralysis underwent modified arytenoid adduction between February 2001 and December 2008. Of these, 37 patients were enrolled in this retrospective study (one patient died of primary disease and four were lost to follow up). Laryngostroboscopy was performed to evaluate vocal fold orientation and mobility. Pre- and post-operative assessment of subjective and objective voice, aerodynamic parameters, and quality of life were also undertaken, and aspiration was subjectively rated. RESULTS Laryngostroboscopic findings indicated a significant post-operative improvement in vocal fold posterior glottal closure and vertical gap. Significant improvements in voice quality, aerodynamic parameters and quality of life were noted three months post-operatively in all patients (p < 0.01). The overall success rate for swallowing rehabilitation was 94.6 per cent (35/37). Subjective aspiration ratings decreased significantly post-operatively, compared with pre-operative values (p < 0.01). No major complication occurred in any patient, except for dyspnoea in one patient. CONCLUSION Modified arytenoid adduction is an effective and reliable medialisation technique which can restore satisfactory voice quality, prevent aspiration and lead to a better quality of life for patients with cancer-related unilateral vocal fold paralysis.
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Intrinsic Laryngeal Muscle Reinnervation Using the Muscle-Nerve-Muscle Technique. Ann Otol Rhinol Laryngol 2008; 117:382-8. [DOI: 10.1177/000348940811700509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: This study was performed to investigate the muscle-nerve-muscle reinnervation technique in the larynx, in which a nerve conduit implanted into an innervated muscle conducts axonal sprouting into a denervated muscle while maintaining function of the donor muscle. Methods: In this study, the muscle-nerve-muscle technique was used to direct superior laryngeal nerve axons to reinnervate intrinsic laryngeal muscles by implanting the recurrent laryngeal nerve stump into the cricothyroid muscle in 8 dogs. In 4 of the dogs, the recurrent laryngeal nerve trunk to the adductor muscles was divided so that all axonal sprouting was directed to the posterior cricoarytenoid muscle. Six-month electromyography data were obtained from 6 of the 8 dogs. Results: All 6 dogs showed evidence of successful reinnervation of the thyroarytenoid or posterior cricoarytenoid muscles with action potentials that corresponded to spontaneous respiratory efforts, while the donor cricothyroid muscles retained their phasic contraction. These responses were obliterated when the recurrent laryngeal nerve conduit was divided. Histologic examination of the intrinsic laryngeal muscles demonstrated successful reinnervation. Conclusions: The results confirm that intrinsic laryngeal muscles may be successfully reinnervated by the superior laryngeal nerve with the muscle-nerve-muscle technique, without sacrifice of function of the cricothyroid muscle. This method offers an alternative source of appropriately firing axons for laryngeal reinnervation procedures.
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Abstract
OBJECTIVE The objective of this prospective study was to assess the long-term effects of immediate reconstruction of the recurrent laryngeal nerve (RLN) during thyroid cancer extirpation on postoperative phonatory function. SUBJECTS AND METHODS The subjects were 22 patients with advanced thyroid cancer who underwent resection of the primary lesion and involved RLN. RLN paralysis was seen in 12 patients preoperatively and involvement of the RLN was noted intraoperatively in 10. Immediate reconstruction of the RLN was performed on eight patients using the great auricular nerve and one underwent direct anastomosis of the RLN stumps (group I). Nine patients opted not to have phonosurgical procedures (group II). The remaining four had arytenoid adduction immediately after cancer extirpation (group III). Phonatory function (stroboscopy, maximum phonation time [MPT], mean airflow rate [MFR], harmonics-to-noise ratio [HNR], jitter, and shimmer) was followed for at least 9 months. RESULTS Minimal or no glottal gap during phonation was observed in six patients in group I, whereas the patients in group II had a large gap along the entire fold. HNR, MPT, and MFR were significantly better in group I (17.7 +/- 3.6 dB, 15.1 +/- 6.3 s, and 100 +/- 32 mL/s, respectively) than in group II (12.1 +/- 2.9 dB, 5.4 +/- 3.1 s, and 430 +/- 207 mL/s, respectively). Patients in group III had a gap of varying degrees along the membranous fold. Although HNR, shimmer, and MPT in group III were comparable to group I, the other parameters were less favorable than in group I. CONCLUSION Immediate RLN reconstruction at the time of thyroid cancer extirpation can provide excellent postoperative phonatory function.
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Affiliation(s)
- Eiji Yumoto
- Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kumamoto University, Kumamoto, Japan
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Abstract
Laryngeal reinnervation refers to any of a number of surgical procedures intended to restore neural connections to the larynx, which have usually been lost from some type of trauma (eg, surgical). The nerve function(s) to be restored may be those of the recurrent laryngeal nerve or its subdivisions, those of the superior laryngeal nerve, or both, and they may be motor or sensory. Several different donor nerves are available and have been described. The technique used may be direct end-to-end anastomosis (neurorrhaphy), direct implantation of a nerve ending into a muscle, the nerve-muscle pedicle technique, or muscle-nerve-muscle methods. These nerves and techniques may be combined in many ways. A number of new techniques have been reported in animal studies; however, the animal studies do not always predict the results of analogous surgeries in human patients. The historical and current perspectives on these techniques are discussed in this article.
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Affiliation(s)
- Randal C Paniello
- Department of Otolaryngology, Washington University School of Medicine, 660 South Euclid, Campus Box 8115, St. Louis, MO 63110, USA.
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Abstract
Although a tremendous volume of energy and literature has been devoted to laryngeal paralysis in the past decade, there are still substantial gaps in our understanding of fundamental issues. Oddly enough, controversy remains regarding the actual innervation pathways of the larynx and whether the paralyzed larynx is truly denervated or dysfunctionally reinnervated. An appreciation of these basic issues is prerequisite to making prudent decisions regarding the most appropriate type of intervention. The purpose of this article is to provide a brief overview of basic laryngeal anatomy and neurophysiology to prepare the reader for a subsequent discussion of futuristic research for treatment of laryngeal paralysis.A novel approach is described, which can induce selective reinnervation of individual laryngeal muscles by their original motor fibers within the recurrent laryngeal nerve.
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Affiliation(s)
- David L Zealear
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University School of Medicine, S2100 Medical Center North, Nashville, TN 37232, USA.
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Maronian N, Waugh P, Robinson L, Hillel A. Electromyographic findings in recurrent laryngeal nerve reinnervation. Ann Otol Rhinol Laryngol 2003; 112:314-23. [PMID: 12731626 DOI: 10.1177/000348940311200405] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abductor, adductor, and combined reinnervation procedures have been explored with variable success rates. We describe the experience of a tertiary care center with adductor reinnervation procedures, including preoperative and postoperative videostroboscopy and electromyography (EMG) findings. A retrospective chart review was performed from 1997 to 2001 that included 9 patients. Preoperative and postoperative voice comparison was performed by 3 blinded speech pathologists. Clinical comparisons of videostroboscopy findings for vocal fold bulk, tone, position, presence of gap, and movement are elucidated. The preoperative and postoperative EMG findings are described. In all patients, preoperative EMG revealed a dense, complete denervation of the affected recurrent laryngeal nerve. No movement was noted on videostroboscopy with persistent glottic gap. Reinnervation involved a nerve-muscle pedicle or a direct neurorrhaphy of the ansa cervicalis to the recurrent laryngeal nerve. Voice improvement was noted between 60 days and 3 months after reinnervation. Four postoperative EMG studies were performed. An early postoperative EMG study at 5 months revealed activation of the lateral cricoarytenoid muscle and thyroarytenoid muscle with head-lift. Videostroboscopy showed excellent near-midline static positioning of the vocal fold. Late EMG studies, performed 12 to 16 months after reinnervation, revealed "learning" of these muscles, with new activation on "eee" phonation. We conclude that recurrent laryngeal nerve reinnervation procedures belong in the armamentarium of the laryngologist for the treatment of vocal fold paralysis. The EMG findings reported in this study suggest that ongoing reinnervation allows for activation with phonation in matured neuronal anastomoses. Overall, this procedure results in excellent patient acceptance and near-normal vocal quality.
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Affiliation(s)
- Nicole Maronian
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
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Paniello RC. Laryngeal reinnervation with the hypoglossal nerve: II. Clinical evaluation and early patient experience. Laryngoscope 2000; 110:739-48. [PMID: 10807353 DOI: 10.1097/00005537-200005000-00004] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine whether the hypoglossal nerve (XII) can serve as a suitable donor for human laryngeal reinnervation. STUDY DESIGN Prospective, nonrandomized. METHODS Measurements were made on patients undergoing open neck procedures to determine the length of XII available and that required to perform XII-recurrent laryngeal nerve (RLN) anastomosis. The morbidity of combined XII and RLN injuries was studied using temporary lidocaine block of the ipsilateral XII in patients with unilateral vocal fold paralysis (UVFP). A pilot series of patients with UVFP who underwent XII-RLN reinnervation was evaluated for morbidity of the procedure, and for improvement in voice and swallowing. RESULTS In 89 necks the average available length of XII was 2 cm less than that needed to reach the larynx, indicating the RLN stump must be at least 3 cm to allow tension-free anastomosis. Twenty-five patients with untreated UVFP underwent temporary lidocaine block of XII; 8 had slight changes in their speech, none had increased aspiration. Nine patients underwent XII-RLN reinnervation. Postoperative speech analysis correlated well with the findings of the temporary lidocaine block of XII. One-year follow-up of five patients showed excellent voice quality, resolution of any preoperative aspiration, and minimal morbidity. Slight adductory movement of the reinnervated vocal fold was seen during tongue thrust. Electromyography confirmed substantial polyphasic action potentials in the thyroarytenoid muscle. CONCLUSIONS The hypoglossal nerve is a very suitable donor for reinnervation of patients with UVFP. There should be enough length for primary XII-RLN anastomosis in most patients. Donor site morbidity is acceptable. Preoperative lidocaine block of XII is a good predictor of actual donor site morbidity and could be used to assess patients undergoing facial-hypoglossal anastomosis as well.
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Affiliation(s)
- R C Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine and the John Cochran Veterans Affairs Medical Center, St. Louis, Missouri 63110-1007, USA
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Zheng H, Zhou S, Chen S, Li Z, Cuan Y. An experimental comparison of different kinds of laryngeal muscle reinnervation. Otolaryngol Head Neck Surg 1998; 119:540-7. [PMID: 9807090 DOI: 10.1016/s0194-5998(98)70122-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In this study, we attempted to determine which method was the best for reinnervating the laryngeal adductor muscles by comparing nerve suture, nerve implantation, and nerve-muscular pedicle (NMP) transfer, as well as the length of time that could elapse after denervation and still allow for successful reinnervation with the ansa cervicalis. Reinnervation was performed in 36 dogs, at 6-, 8-, 10-, 12- and 18-month intervals after denervation via the three methods of muscle reinnervation described above. We noted some return of adduction in the cases using nerve suture before a 10-month interval after denervation, and with nerve implantation and NMP transfer before the 8-month intervals. The variable adduction was caused by reinnervation of the adductor muscles from the ansa cervicalis, as demonstrated by laryngeal spontaneous and evoked electromyography, the strength of muscle contraction, and histologic findings. Adduction was not observed in the cases after the above-mentioned intervals but partial improvement of the bulk and strength of the reinnervated vocal cord was still achieved. An analysis of the experimental results showed that nerve suture was superior to nerve implantation and the NMP technique. Little difference was noted between nerve implantation and the NMP technique.
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Affiliation(s)
- H Zheng
- Department of Otolaryngology, Changhai Hospital, Second Military Medical University, Shanghai, PR China
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Zheng H, Li Z, Zhou S, Cuan Y, Wen W. Update: laryngeal reinnervation for unilateral vocal cord paralysis with the ansa cervicalis. Laryngoscope 1996; 106:1522-7. [PMID: 8948615 DOI: 10.1097/00005537-199612000-00015] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Eight patients underwent ansa cervicalis anastomosis to the adductor branch of the recurrent laryngeal nerve for unilateral vocal cord paralysis. They were followed long enough (at least 1 year) to determine if the procedure was successful. All cases have been subjected to preoperative and postoperative voice recording, acoustic analysis, and videolaryngoscopy. Some of them have been subjected to stroboscopy and electromyography (EMG). Data from these cases indicate that satisfactory phonatory quality may be achieved after the procedure. The reinnervated vocal cord neither abducted nor adducted, but it presented itself in midline for precise apposition with the normal cord. Synchronous mucosal waves in both vocal cords could be observed. EMG showed that the procedure produced satisfactory reinnervation of the adductory muscles. Therefore, the authors believe that the procedure could be proposed as an alternative to Teflon injection or thyroplasty in selected cases.
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Affiliation(s)
- H Zheng
- Department of Otolaryngology, Changhai Hospital, Shanghai, China
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