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Heaton JT, Kobler JB, Otten DM, Hillman RE, Zeitels SM. Development of a Closed-Loop Stimulator for Laryngeal Reanimation: Part 2. Device Testing in the Canine Model of Laryngeal Paralysis. Ann Otol Rhinol Laryngol 2019; 128:53S-70S. [PMID: 30843434 DOI: 10.1177/0003489418820545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE: Laryngeal paralysis of central or peripheral origin can potentially be treated using functional electrical stimulation (FES) of laryngeal muscles. Experiments in canines (dogs) were performed using implant prototypes capable of closed-loop FES to refine engineering designs and specifications, test surgical approaches for implantation, and better understand the in vivo effects of laryngeal muscle stimulation on short- and long-term glottic function. STUDY DESIGN: Prospective, laboratory. METHODS: We designed and tested a series of microprocessor-based implantable devices that can stimulate glottic opening or closing based on input from physiological control signals (real-time processing of electromyographic [EMG] signals). After acute device testing experiments, 2 dogs were implanted for 8 and 24 months, with periodic testing of closed-loop laryngeal muscle stimulation triggered from EMG signals. In total, 5 dogs were tested for the effects of laryngeal muscle stimulation on vocal fold (VF) posturing in larynges with nerve supplies that were intact (7 VFs), synkinetically reinnervated (2 VFs), or chronically denervated (1 VF). In 3 cases, the stimulation was combined with airflow-driven phonation to study the consequent modulation of phonatory parameters. RESULTS: Initial device prototypes used inductive coupling for power and communication, while later iterations used battery power and infrared light communication (detailed descriptions are provided in the Part 1 companion paper). Two animals were successfully implanted with the inductively powered units, which operated until removed at 8 months in 1 animal or for more than 16 months in the second animal. Surgically, the encapsulated implants were well tolerated, and procedures for placing, attaching, and connecting the devices were developed. To simulate EMG control signals in anesthetized animals, we created 2 types of nerve/muscle signal sources. In one approach, a neck muscle had a cuff electrode placed on its motor nerve that was connected to transdermal electrical connection ports for periodic testing. In the second approach, the recurrent laryngeal nerve on one side of the larynx was stimulated to generate a VF EMG signal, which was then used to trigger FES of the paralyzed contralateral side (eg, restoring VF movement symmetry). Implant testing identified effective stimulation parameters and closed-loop stimulation artifact rejection techniques for FES of both healthy and paralyzed VFs. Stimulation levels effective for VF adduction did not cause signs of discomfort during awake testing. CONCLUSION: Our inductive and battery-powered prototypes performed effectively during in vivo testing, and the 2 units that were implanted for long-term evaluation held up well. As a proof of concept, we demonstrated that elicited neck strap muscle or laryngeal EMG potentials could be used as a control signal for closed-loop stimulation of laryngeal adduction and vocal pitch modulation, depending on electrode positioning, and that VFs were stimulable in the presence of synkinetic reinnervation or chronic denervation.
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Affiliation(s)
- James T Heaton
- 1 Department of Surgery, Harvard Medical School, Boston, MA, USA
- 2 Division of Laryngeal Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - James B Kobler
- 1 Department of Surgery, Harvard Medical School, Boston, MA, USA
- 2 Division of Laryngeal Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David M Otten
- 3 Laboratory for Electromagnetic and Electronic Systems, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Robert E Hillman
- 1 Department of Surgery, Harvard Medical School, Boston, MA, USA
- 2 Division of Laryngeal Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Steven M Zeitels
- 1 Department of Surgery, Harvard Medical School, Boston, MA, USA
- 2 Division of Laryngeal Surgery, Massachusetts General Hospital, Boston, MA, USA
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Zeng T, Zhang Z, Peng W, Zhang F, Shi BY, Chen F. Unilateral Laryngeal Pacing System and Its Functional Evaluation. Neural Plast 2017; 2017:8949165. [PMID: 28203464 PMCID: PMC5288527 DOI: 10.1155/2017/8949165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/25/2016] [Accepted: 12/27/2016] [Indexed: 11/18/2022] Open
Abstract
Goal. To establish a reliable instrumental system for synchronized reactivation of a unilaterally paralyzed vocal fold and evaluate its functional feasibility. Methods. Unilateral vocal fold paralysis model was induced by destruction of the left recurrent laryngeal nerve (RLN) in anesthetized dogs. With a micro controller-based electronic system, electromyography (EMG) signals from cricothyroid (CT) muscle on the ipsilateral side were recorded and used to trigger pacing of paralyzed vocalis muscles. The dynamic movement of vocal folds was continuously monitored using an endoscope, and the opening and closing of the glottis were quantified with customized imaging processing software. Results. The recorded video images showed that left side vocal fold was obviously paralyzed after destructing the RLN. Using the pacing system with feedback triggering EMG signals from the ipsilateral CT muscle, the paralyzed vocal fold was successfully reactivated, and its movement was shown to be synchronized with the healthy side. Significance. The developed unilateral laryngeal pacing system triggered by EMG from the ipsilateral side CT muscle could be successfully used in unilateral vocal fold paralysis with the advantage of avoiding disturbance to the healthy side muscles.
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Affiliation(s)
- Taiping Zeng
- State Key Laboratory of Robotics, Shenyang Institute of Automation, Chinese Academy of Sciences, Shenyang 110016, China
- Department of Biomedical Engineering, Southern University of Science & Technology, Shenzhen 518055, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zhiping Zhang
- The First Affiliated Hospital of the Medical College, Shihezi University, Shihezi, China
| | - Weiwei Peng
- Brain Function and Psychological Science Research Center, Shenzhen University, Shenzhen, China
| | - Fei Zhang
- Children's Hospital of Zhengzhou, Zhengzhou, China
| | - Baker Y. Shi
- Metokos LLC, P.O. Box 219244, Portland, OR 9221, USA
| | - Fangyi Chen
- Department of Biomedical Engineering, Southern University of Science & Technology, Shenzhen 518055, China
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Neurolaryngology. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2012. [DOI: 10.1016/j.otoeng.2012.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Núñez-Batalla F, Díaz-Molina JP, Costales-Marcos M, Moreno Galindo C, Suárez-Nieto C. [Neurolaryngology]. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2011; 63:132-40. [PMID: 21349470 DOI: 10.1016/j.otorri.2010.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Accepted: 12/01/2010] [Indexed: 11/18/2022]
Abstract
The neuroanatomy of voice and speech is complex. An intricate neural network is responsible for ensuring the main functions of the larynx: airway protection, cough and Valsalva production, and providing voice. Coordination of these roles is very susceptible to disruption by neurological disorders. Neurological disorders that affect laryngeal function include Parkinson's disease, stroke, amyotrophic lateral sclerosis, multiple sclerosis, dystonia and essential tremor. A thorough neurological evaluation should be routine for any patient presenting with voice complaints suggestive of neurogenic cause. Endoscopic visualisation of the larynx using a dynamic voice assessment with a flexible laryngoscope is a crucial part of the evaluation and ancillary tests are sometimes performed. Otolaryngologic evaluation is important in the diagnosis and treatment of neurological disorders that affect laryngeal function.
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DUCHARME NG, CHEETHAM J, SANDERS I, HERMANSON JW, HACKETT RP, SODERHOLM LV, MITCHELL LM. Considerations for pacing of the cricoarytenoid dorsalis muscle by neuroprosthesis in horses. Equine Vet J 2010; 42:534-40. [DOI: 10.1111/j.2042-3306.2010.00115.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rubin AD, Sataloff RT. Vocal fold paresis and paralysis: what the thyroid surgeon should know. Surg Oncol Clin N Am 2008; 17:175-96. [PMID: 18177806 DOI: 10.1016/j.soc.2007.10.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The thyroid surgeon must have a thorough understanding of laryngeal neuroanatomy and be able to recognize symptoms of vocal fold paresis and paralysis. Neuropraxia may occur even with excellent surgical technique. Patients should be counseled appropriately, particularly if they are professional voice users. Preoperative or early postoperative changes in voice, swallowing, and airway function should prompt immediate referral to an otolaryngologist. Early recognition and treatment may avoid the development of complications and improve patient quality of life.
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Affiliation(s)
- Adam D Rubin
- Lakeshore Professional Voice Center, Lakeshore Ear, Nose, and Throat Center, 21000 East 12 Mile Road, Suite 111, St. Clair Shores, MI 48081, USA.
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Abstract
Diagnosis and treatment of the immobile or hypomobile vocal fold are challenging for the otolaryngologist. True paralysis and paresis result from vocal fold denervation secondary to injury to the laryngeal or vagus nerve. Vocal fold paresis or paralysis may be unilateral or bilateral, central or peripheral, and it may involve the recurrent laryngeal nerve, superior laryngeal nerve, or both. The physician's first responsibility in any case of vocal fold paresis or paralysis is to confirm the diagnosis and be certain that the laryngeal motion impairment is not caused by arytenoid cartilage dislocation or subluxation, cricoarytenoid arthritis or ankylosis, neoplasm, or other mechanical causes. Strobovideolaryngoscopy, endoscopy, radiologic and laboratory studies, and electromyography are all useful diagnostic tools.
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Affiliation(s)
- Adam D Rubin
- Lakeshore Professional Voice Center, Lakeshore Ear Nose and Throat Center, 21000 East 12 Mile, Suite 111, St. Clair Shores, MI 48081, USA
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Katada A, Nonaka S, Adachi M, Kunibe I, Arakawa T, Imada M, Hayashi T, Zealear DL, Harabuchi Y. Functional electrical stimulation of laryngeal adductor muscle restores mobility of vocal fold and improves voice sounds in cats with unilateral laryngeal paralysis. Neurosci Res 2004; 50:153-9. [PMID: 15380322 DOI: 10.1016/j.neures.2004.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2004] [Accepted: 06/22/2004] [Indexed: 10/26/2022]
Abstract
Functional electrical stimulation (FES) has been proposed as a potential treatment for restoring motor functions of denervated motor systems. We investigated whether FES of paralyzed laryngeal adductor muscles could restore adduction to the vocal folds. In addition, we studied the effect of stimulated vocal fold adduction on the intensity and overall quality of voice production. We recorded movement of the vocal fold, electromyographic activity of muscles recruited for vocalization, and sound production in unanesthetized decerebrate cats during FES of the paralyzed thyroarytenoid (TA) muscle. FES of the paralyzed TA muscle induced adduction of the vocal fold. Appropriate stimulus parameters for induction was 1.5-3.0 mA intensity pulses delivered at a frequency of 30-50 pulses per second (pps). FES of the paralyzed TA muscle prolonged phonation time and increased intensity of voice sounds during vocalization induced by electrical stimulation (0.2 ms, 20-50 microA, 50 pps) of the periaqueductal gray (PAG). The quality of voice sounds evaluated by sound spectrography was shown to improve during vocalization with FES. We conclude that FES of the paralyzed laryngeal adductor muscle was effective in restoring adduction of the vocal fold and improving voice sounds impaired by unilateral laryngeal paralysis.
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Affiliation(s)
- Akihiro Katada
- Department of Otolaryngology-Head and Neck Surgery, Asahikawa Medical College, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan.
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Affiliation(s)
- Steven M Zeitels
- Department of Otology and Laryngology, Harvard Medical School, Boston, USA.
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Ludlow CL, Bielamowicz S, Daniels Rosenberg M, Ambalavanar R, Rossini K, Gillespie M, Hampshire V, Testerman R, Erickson D, Carraro U. Chronic intermittent stimulation of the thyroarytenoid muscle maintains dynamic control of glottal adduction. Muscle Nerve 2000; 23:44-57. [PMID: 10590405 DOI: 10.1002/(sici)1097-4598(200001)23:1<44::aid-mus6>3.0.co;2-e] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Patients with laryngeal motor control disorders need improved dynamic glottal closure for speech and swallowing. To evaluate the functional outcome of intermittent chronic thyroarytenoid muscle stimulation in an animal model, 6 canines were implanted with bilateral Medtronic Xtrel systems containing Peterson-type electrodes in the inferior and superior portions of the thyroarytenoid muscle. Stimulation was on one side only at 60 Hz, for 5 s on and 5 s off, over 8 h, 5 days per week, up to 8 months. Monthly videorecordings were done under anesthesia to measure the voltage threshold for detectable movement on each side, and vocal fold displacement and velocity during maximal stimulation of each side. Movement thresholds were lower in the inferior portion of the thyroarytenoid muscle (P </= 0.0005). Movement velocity was greater on the stimulated than on the nonstimulated side after 3 to 8 months (P = 0.039). No differences in the percentage distribution of different myosin heavy chain types were found between the stimulated and nonstimulated muscle samples. Sustained dynamic glottal adduction with no alteration in thyroarytenoid muscle function or fiber type was achieved with intermittent stimulation over 8 months. The results suggest that chronic intermittent thyroarytenoid stimulation has good potential for improving airway protection in dysphagia.
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Affiliation(s)
- C L Ludlow
- Laryngeal and Speech Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Building 10, Room 5D38, 10 Center Drive, MSC 1416, Bethesda, Maryland, 20892-1416, USA.
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Abstract
Active and passive characteristics of the canine cricothyroid muscle were investigated through a series of experiments conducted in vitro and compared with their counterparts in the thyroarytenoid muscle. Samples from separate portions of canine cricothyroid muscle, namely, the pars recta and pars obliqua, were dissected from dog larynges excised a few minutes before death and kept in Krebs-Ringer solution at a temperature of 37 degrees C +/- 1 degrees C and a pH of 7.4+/-0.05. Active tetanic stress was obtained in isometric and isotonic conditions by applying field stimulation to the muscle samples through a pair of parallel-plate platinum electrodes and using a train of square pulses of 0.1-ms duration and 85-V amplitude. Force and elongation of the samples were obtained electronically with a dual-servo system (ergometer). The results indicate that the dynamic response of the canine cricothyroid muscle is almost twice as slow as that of the thyroarytenoid muscle. The average 50% tetanic contraction times for pars recta and pars obliqua were 84 ms and 109 ms, respectively, in comparison to 50 ms for thyroarytenoid. The examination of force-velocity response of this muscle indicates a maximum shortening velocity of 2 to 3 times its length per second, which is about half of the thyroarytenoid shortening speed. The passive properties of the pars recta and pars obliqua portions are similar to those of thyroarytenoid muscle.
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Affiliation(s)
- F Alipour
- Department of Speech Pathology and Audiology, National Center for Voice and Speech, The University of Iowa, Iowa City 52242-1012, USA.
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Abstract
Experimental induced phonation in the dog has been used in short-term studies by several investigators and has proved quite useful in laryngeal research. In this study a long-term canine phonation model is described that uses permanently implanted electrodes on the superior and recurrent laryngeal nerves. A serial induced phonation model has not been previously reported and is needed for laryngeal research in which voice results are a primary end point. Inexpensive, reliable, nontoxic electrodes were designed and fabricated. The laryngeal nerves were found to be quite susceptible to injury, necessitating a series of changes in electrode design. Electrode durability and laryngeal nerve viability improved with each design modification; the final design gave a recurrent laryngeal nerve viability rate of 100% at 6 weeks, 83% at 9 weeks, and 73% at 12 weeks. Induced phonation was successfully produced on a repeated basis by stimulating the recurrent laryngeal nerves while passing air through the larynx, in 22 (95.6%) of 23 animals. Stimulation of the superior laryngeal nerves increased vocal fold length and tension but was not required for phonation. Technical aspects of chronic implantation and stimulation of the laryngeal nerves are discussed. The development and successful long-term implantation of electrodes on the laryngeal nerves and their use in repeated induced phonation have not been reported previously.
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Affiliation(s)
- R C Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Otto RA. Restoration of function in the paralyzed rabbit orbicularis oculi muscle by direct functional electrical stimulation. Laryngoscope 1997; 107:101-11. [PMID: 9001273 DOI: 10.1097/00005537-199701000-00020] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Restoration of the ability to blink and protect the eye in the patient with facial paralysis remains a challenge. Although many treatments exist, no one approach corrects all the deficits associated with the loss of orbicularis oculi function. In this study, the author investigated the feasibility of restoring function by direct electrical stimulation of the paralyzed orbicularis oculi muscle in the rabbit model. Using a pacing device developed by the author, functional restoration of a normal-appearing blink was produced throughout 30 days of continuous pacing in six rabbits with transected facial nerves. Histologic evaluations of the paced tissues demonstrated no evidence of detrimental effects attributable to the electrical stimulation. The findings of this study support the feasibility of employing direct electrical stimulation to restore the function of paralyzed orbicularis oculi muscles. Potential applications may also exist in other areas in which peripheral denervation creates functional impairment.
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Affiliation(s)
- R A Otto
- Department of Otolaryngology, University of Texas Health Science Center, San Antonio 78284-6200, USA
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Abstract
We summarize etiologies of vocal fold paralysis and current treatments. The recent literature involving electrical stimulation of the larynx is reviewed. Four canines were involved in a study to test a new laryngeal pacemaker system. This system was used to stimulate both the lateral cricoarytenoid and thyroarytenoid muscles. The data are taken from two of these canines. One of the goals was to stimulate the paralyzed side of the larynx based on the activity of the normal (nonparalyzed) side of the larynx. The best stimulation parameters for full addition of the paralyzed vocal cord were 3-7 V, pulse duration of 0.5 ms at a frequency of 84-100 Hz. Principles for electrode design and electrophysiologic parameters pertaining to laryngeal pacing are discussed. We believe that unilateral vocal fold paralysis may someday be treated by stimulating the paralyzed lateral cricoarytenoid and thyroarytenoid muscles to move in synchrony with the normal, unparalyzed, lateral cricoarytenoid and thyroarytenoid muscles.
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Affiliation(s)
- D Goldfarb
- Department of Otolaryngology-Head and Neck Surgery, Medical Center at Princeton, New Jersey 08540
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