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Walluks K, Hoffmann B, Svensson CM, Förster G, Müller AH, Jarvis J, Perkins J, Figge MT, Arnold D. Long-term stimulation by implanted pacemaker enables non-atrophic treatment of bilateral vocal fold paresis in a human-like animal model. Sci Rep 2024; 14:10440. [PMID: 38714750 PMCID: PMC11076618 DOI: 10.1038/s41598-024-60875-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/29/2024] [Indexed: 05/10/2024] Open
Abstract
A wide variety of treatments have been developed to improve respiratory function and quality of life in patients with bilateral vocal fold paresis (BVFP). One experimental method is the electrical activation of the posterior cricoarytenoid (PCA) muscle with a laryngeal pacemaker (LP) to open the vocal folds. We used an ovine (sheep) model of unilateral VFP to study the long-term effects of functional electrical stimulation on the PCA muscles. The left recurrent laryngeal nerve was cryo-damaged in all animals and an LP was implanted except for the controls. After a reinnervation phase of six months, animals were pooled into groups that received either no treatment, implantation of an LP only, or implantation of an LP and six months of stimulation with different duty cycles. Automated image analysis of fluorescently stained PCA cross-sections was performed to assess relevant muscle characteristics. We observed a fast-to-slow fibre type shift in response to nerve damage and stimulation, but no complete conversion to a slow-twitch-muscle. Fibre size, proportion of hybrid fibres, and intramuscular collagen content were not substantially altered by the stimulation. These results demonstrate that 30 Hz burst stimulation with duty cycles of 40% and 70% did not induce PCA atrophy or fibrosis. Thus, long-term stimulation with an LP is a promising approach for treating BVFP in humans without compromising muscle conditions.
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Affiliation(s)
- Kassandra Walluks
- Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany
- Faculty of Biological Sciences, Friedrich Schiller University Jena, Jena, Germany
- Institute of Zoology and Evolutionary Research, Faculty of Biological Sciences, Friedrich Schiller University Jena, Jena, Germany
| | - Bianca Hoffmann
- Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany
| | - Carl-Magnus Svensson
- Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany
| | - Gerhard Förster
- Clinic for Otorhinolaryngology/Plastic Surgery, Wald-Klinikum Gera, Gera, Germany
| | - Andreas H Müller
- Clinic for Otorhinolaryngology/Plastic Surgery, Wald-Klinikum Gera, Gera, Germany
| | - Jonathan Jarvis
- Faculty of Science, Sport and Exercise Sciences, John Moores University, Liverpool, UK
| | | | - Marc Thilo Figge
- Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany.
- Institute of Microbiology, Faculty of Biological Sciences, Friedrich Schiller University Jena, Jena, Germany.
| | - Dirk Arnold
- Clinic and Polyclinic for Otorhinolaryngology, University Hospital Jena, Jena, Germany.
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Cai J, Kim YJ, Xu X, Ma Y, Scholp A, Jiang JJ, Liu T, Zhuang P. To Explore the Changes and Differences of Microstructure of Vocal Fold in Vocal Fold Paralysis and Cricoarytenoid Joint Dislocation by Diffusion Tensor Imaging. J Voice 2023; 37:187-193. [PMID: 33388227 DOI: 10.1016/j.jvoice.2020.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The diffusion characteristics of water molecules were measured in the vocal folds of canines exhibiting unilateral vocal fold paralysis and unilateral cricoarytenoid joint dislocation. These characteristics were used in conjunction with a histological examination of the microstructural changes of vocal fold muscle fibers to explore the feasibility of diffusion tensor imaging (DTI) in distinguishing unilateral vocal fold paralysis and unilateral cricoarytenoid joint dislocation as well as evaluating microstructural changes. METHODS Ten beagles were randomly divided into three groups: four in the unilateral vocal fold paralysis group, four in the unilateral cricoarytenoid joint dislocation group, and two in the normal group. Unilateral recurrent laryngeal nerve resection was performed in the vocal fold paralysis group. Unilateral cricoarytenoid joint dislocation surgery was performed in the dislocation group. No intervention was performed in the normal group. Four months postintervention, the larynges were excised and put into a magnetic resonance imaging (MRI) system (9.4T BioSpec MRI, Bruker, German) for scanning, followed by an analysis of diffusion parameters among the different groups for statistical significance. After MRI scanning, the vocal folds were cut into sections, stained with hematoxylin and eosin, and scanned digitally. The mean cross-sectional area of muscle fibers, and the mean diameter of muscle fibers in the vocal folds were calculated by target detection and extraction technology. Mean values of each measurement were used to compare the differences among the three groups. Pearson correlation analysis was performed on the DTI parameters and the results from histological section extraction. RESULTS The paralysis group had significantly higher Fractional Anisotropy (FA) compared to the dislocation group and normal group (P = 0.004). The paralysis group also had a significantly lower Tensor Trace value compared to the dislocation group and normal group (P = 0.000). The average cross-sectional area of vocal fold muscle fibers in the paralysis group was significantly smaller than the dislocation group and normal group (P = 0.000). Pearson correlation analysis yielded values of, r = -0.785, P = 0.01 between the average cross-sectional area of vocal muscle fibers and FA, and values of r = 0.881, P = 0.00 between Tensor Trace and the average cross-sectional area of vocal muscle. CONCLUSION FA and Tensor Trace can be used as effective parameters to reflect the changes of microstructure in vocal fold paralysis and cricoarytenoid joint dislocation. DTI is an objective and quantitative method to effectively evaluate unilateral vocal fold paralysis and unilateral cricoarytenoid joint dislocation, also capable of noninvasively evaluating vocal fold muscle fiber microstructure.
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Affiliation(s)
- Jie Cai
- School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Young Jin Kim
- Department of Surgery Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Xinlin Xu
- Department of Voice, Zhongshan Hospital, Xiamen University, Xiamen, Fujian, China
| | - Yanli Ma
- Department of Voice, Zhongshan Hospital, Xiamen University, Xiamen, Fujian, China
| | - Austin Scholp
- Department of Surgery Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jack J Jiang
- Department of Surgery Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ting Liu
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen, Fujian, China.
| | - Peiyun Zhuang
- Department of Voice, Zhongshan Hospital, Xiamen University, Xiamen, Fujian, China.
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Neuromuscular Specializations of the Human Hypopharyngeal Muscles. Dysphagia 2020; 36:769-785. [PMID: 33159539 DOI: 10.1007/s00455-020-10212-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Abstract
The hypopharyngeal muscles in humans play a vital role in swallowing, speech, and respiration. Increasing evidence indicates that these muscles are specialized to perform life-sustaining upper aerodigestive functions. This review aims to provide current knowledge regarding the key structural, physiological, and biochemical features of the hypopharyngeal muscles, including innervation, contractile properties, histochemistry, biochemical properties, myosin heavy chain (MyHC) expression and regulation, and age-related alterations. These would clarify the unique neuromuscular specializations of the human hypopharyngeal muscles for a better understanding of the functions and pathological conditions of the pharynx and for the development of novel therapies to treat related upper airway disorders.
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Experience with laryngeal reinnervation using nerve-muscle pedicle in pediatric patients. Int J Pediatr Otorhinolaryngol 2020; 138:110254. [PMID: 33137867 DOI: 10.1016/j.ijporl.2020.110254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/04/2020] [Accepted: 07/05/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Vocal fold paralysis (VFP) in adducted position remains a challenge for airway surgeons. Alternatives to tracheostomies such as lateralization, cordectomy, and posterior rib grafting disrupt the laryngeal tissue or framework and carry an increased risk of aspiration. Laryngeal reinnervation using nerve-muscle pedicle (NMP), carries the distinct advantage of preserving the larynx, sparing the recurrent laryngeal nerve, and obtaining an active VF abduction. The aim of this study was to evaluate the success and complications of laryngeal reinnervation using nerve-muscle pedicle (NMP) in pediatric patients presenting with dyspnea related to VFP in adducted position. METHODS In this case series performed at a tertiary care referral center, review of medical records on all pediatric patients with VFP in adduction treated with laryngeal reinnervation using NMP between 1999 and 2017. Data were collected on the preoperative flexible laryngoscopy, suspension micro-laryngoscopy, and laryngeal electromyography as well as post-operative clinical assessment of the voice and airway. All patients underwent surgery consisting of the transfer of an innervated omohyoid muscle pedicle onto the paralyzed posterior cricoarytenoid muscle. The main outcomes measured were the clinical and fiberoptic laryngoscopic airway assessment monthly for the first 6 months, then at 12 months and annually thereafter. Clinical assessment included dyspnea evaluation based on a visual analog scale and voice assessment using the GRBAS scores. Complications from the treatment were also noted. These outcomes were determined before collection of data. RESULTS 16 cases were identified, with a mean age of 4 years. The recurrent laryngeal nerve paralysis was bilateral in 3 cases and unilateral in 13 cases. There were no peri or postoperative complications. After a mean follow-up of 7 years, vocal fold abduction was observed in 10 out of 16 cases and disappearance of paradoxical inspiratory adduction in 3 cases. Persistent dyspnea was noted in 7 cases (44%), and moderate dysphonia was present in 11 cases (69%). Finally, additional procedures were necessary in 2 patients (13%) to achieve the outcomes. CONCLUSIONS Laryngeal reinnervation using NMP may be used in pediatric patients. This procedure, is safe and allows us to spare the recurrent laryngeal nerve while obtaining an active VF abduction in the majority of cases, and an improvement in breathing in most cases. QUALITY OF EVIDENCE 4.
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Xie Y, Schneider KJ, Ali SA, Hogikyan ND, Feldman EL, Brenner MJ. Current landscape in motoneuron regeneration and reconstruction for motor cranial nerve injuries. Neural Regen Res 2020; 15:1639-1649. [PMID: 32209763 PMCID: PMC7437597 DOI: 10.4103/1673-5374.276325] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 10/31/2019] [Accepted: 12/23/2019] [Indexed: 12/16/2022] Open
Abstract
The intricate anatomy and physiology of cranial nerves have inspired clinicians and scientists to study their roles in the nervous system. Damage to motor cranial nerves may result from a variety of organic or iatrogenic insults and causes devastating functional impairment and disfigurement. Surgical innovations directed towards restoring function to injured motor cranial nerves and their associated organs have evolved to include nerve repair, grafting, substitution, and muscle transposition. In parallel with this progress, research on tissue-engineered constructs, development of bioelectrical interfaces, and modulation of the regenerative milieu through cellular, immunomodulatory, or neurotrophic mechanisms has proliferated to enhance the available repertoire of clinically applicable reconstructive options. Despite these advances, patients continue to suffer from functional limitations relating to inadequate cranial nerve regeneration, aberrant reinnervation, or incomplete recovery of neuromuscular function. These shortfalls have profound quality of life ramifications and provide an impetus to further elucidate mechanisms underlying cranial nerve denervation and to improve repair. In this review, we summarize the literature on reconstruction and regeneration of motor cranial nerves following various injury patterns. We focus on seven cranial nerves with predominantly efferent functions and highlight shared patterns of injuries and clinical manifestations. We also present an overview of the existing reconstructive approaches, from facial reanimation, laryngeal reinnervation, to variations of interposition nerve grafts for reconstruction. We discuss ongoing endeavors to promote nerve regeneration and to suppress aberrant reinnervation and the development of synkinesis. Insights from these studies will shed light on recent progress and new horizons in understanding the biomechanics of peripheral nerve neurobiology, with emphasis on promising strategies for optimizing neural regeneration and identifying future directions in the field of motor cranial neuron research.
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Affiliation(s)
- Yanjun Xie
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kevin J. Schneider
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Syed A. Ali
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Norman D. Hogikyan
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Eva L. Feldman
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael J. Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
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Hamdan AL, Khalifee E, Al Arab N, Asmar K, Hourani R. Volumetric measures of the paralyzed vocal fold using computerized tomography; its clinical implication. LOGOP PHONIATR VOCO 2020; 46:42-46. [PMID: 32319340 DOI: 10.1080/14015439.2020.1753809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To report the volumetric measures of the paralyzed vocal fold in patients undergoing injection laryngoplasty. MATERIAL AND METHOD All the medical records of patients with unilateral vocal fold paralysis who had high resolution computerized tomography scan of the neck and chest prior to injection laryngoplasty between October 2015 and May 2018 were included. Volumetric evaluation of the vocal folds was performed by measuring the vocal fold height using coronal images and the vocal fold length and width using axial images. RESULTS A total of 21 patients divided into 13 males and 8 females were identified. The mean age was 56.66 ± 20.94 years. The mean volume of the paralyzed vocal fold was significantly smaller than that of the non-paralyzed vocal fold (p < .05). Similarly, the mean length and height of the paralyzed vocal folds were smaller than those of the non-paralyzed vocal folds (p < .05). CONCLUSION Volumetric measurements of the paralyzed vocal fold in comparison to the normal vocal fold in a group of 21 patients with unilateral vocal fold paralysis shows the presence of significant difference between the normal and affected site, and the presence of large inter-subject variation. Information on the volume difference between the two vocal folds may be used to better estimate the amount that needs to be injected in medialization procedures.
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Affiliation(s)
| | - Elie Khalifee
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Natally Al Arab
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Karl Asmar
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Roula Hourani
- American University of Beirut Medical Center, Beirut, Lebanon
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Cai J, Klein L, Wu P, Wilson A, Xu X, Scholp A, Bao H, Wang X, Jiang JJ, Liu T, Zhuang P. Evaluation of Diffusional Characteristics and Microstructure in Unilateral Vocal Fold Paralysis Using Diffusion Tensor Imaging. EAR, NOSE & THROAT JOURNAL 2019; 100:NP177-NP184. [PMID: 31550925 DOI: 10.1177/0145561319874721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the value of diffusion tensor imaging (DTI) in the evaluation of vocal fold tissue microstructure after recurrent laryngeal nerve (RLN) injury. METHODS Six canines were divided into 2 groups: a unilateral vocal fold paralysis group (n = 4) and a control group (n = 2). The RLN was cut in the unilateral vocal fold paralysis group, and no intervention was applied in the control group. After 4 months, the canines' larynges were removed and placed in a small animal magnetic resonance imaging (MRI) system (9.4T BioSpec MRI; Bruker, Germany). After scanning, the vocal folds were isolated, sectioned, and stained. The slides were then analyzed for the cross-sectional area and muscle fiber density through feature extraction technology. Pearson correlation analysis was performed on the DTI scan and histological section extraction results. RESULTS In the vocal fold muscle layer, the fractional anisotropy (FA) of the unilateral RLN injury group was higher than that of the control group, and the Tensor Trace was lower than that of the control group. This difference was statistically significant, P < .05. In the lamina propria, the FA of the unilateral RLN injury group was lower than that of the control group, P > .05, and the Tensor Trace was lower than that of the control group, P < .05. The muscle fiber cross-sectional area of the RLN injury group was significantly smaller than the control group with statistical significance, P < .05, and the density of muscle fibers was lower, P < .05. The correlation coefficient between FA and the cross-sectional area was -0.838, P = .002, and .726; P = .017 between Tensor Trace and the cross-sectional area. CONCLUSION Diffusion tensor imaging is an effective method to assess the changes in the microstructure of atrophic vocal fold muscle tissue after RLN injury.
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Affiliation(s)
- Jie Cai
- School of Medicine, 12466Xiamen University, Xiamen, China
| | - Logan Klein
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, 5232School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Pinhong Wu
- 5919Barnard College of Columbia University, Manhattan, NY, USA
| | - Azure Wilson
- Department of Communication Science and Disorders, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Xinlin Xu
- Department of ENT, Zhongshan Hospital, 12466Xiamen University, Xiamen, China
| | - Austin Scholp
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, 5232School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Huijing Bao
- School of Medicine, 12466Xiamen University, Xiamen, China
| | - Xi Wang
- School of Medicine, 12466Xiamen University, Xiamen, China
| | - Jack J Jiang
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, 5232School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Ting Liu
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen, China
| | - Peiyun Zhuang
- Department of ENT, Zhongshan Hospital, 12466Xiamen University, Xiamen, China
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Cercone M, Jarvis JC, Ducharme NG, Perkins J, Piercy RJ, Willand MP, Mitchell LM, Sledziona M, Soderholm L, Cheetham J. Functional electrical stimulation following nerve injury in a large animal model. Muscle Nerve 2019; 59:717-725. [PMID: 30815883 DOI: 10.1002/mus.26460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 02/12/2019] [Accepted: 02/25/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Controversy exists over the effects of functional electrical stimulation (FES) on reinnervation. We hypothesized that intramuscular FES would not delay reinnervation after recurrent laryngeal nerve (RLn) axonotmesis. METHODS RLn cryo-injury and electrode implantation in ipsilateral posterior cricoarytenoid muscle (PCA) were performed in horses. PCA was stimulated for 20 weeks in eight animals; seven served as controls. Reinnervation was monitored through muscle response to hypercapnia, electrical stimulation and exercise. Ultimately, muscle fiber type proportions and minimum fiber diameters, and RLn axon number and degree of myelination were determined. RESULTS Laryngeal function returned to normal in both groups within 22 weeks. FES improved muscle strength and geometry, and induced increased type I:II fiber proportion (p = 0.038) in the stimulated PCA. FES showed no deleterious effects on reinnervation. DISCUSSION Intramuscular electrical stimulation did not delay PCA reinnervation after axonotmesis. FES can represent a supportive treatment to promote laryngeal functional recovery after RLn injury. Muscle Nerve 59:717-725, 2019.
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Affiliation(s)
- Marta Cercone
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | | | - Norm G Ducharme
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Justin Perkins
- Comparative Neuromuscular Diseases Laboratory, Department of Clinical Sciences and Services, Royal Veterinary College, London, UK
| | - Richard J Piercy
- Comparative Neuromuscular Diseases Laboratory, Department of Clinical Sciences and Services, Royal Veterinary College, London, UK
| | | | - Lisa M Mitchell
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Michael Sledziona
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Leo Soderholm
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Jonathan Cheetham
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
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Bach Á, Sztanó B, Matievics V, Bere Z, Volk F, Müller A, Förster G, Castellanos PF, Rovó L. Isolated Recovery of Adductor Muscle Function Following Bilateral Recurrent Laryngeal Nerve Injuries. Laryngoscope 2018; 129:2334-2340. [PMID: 30548882 DOI: 10.1002/lary.27718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/23/2018] [Accepted: 11/05/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS The aim of this study was to analyze the phoniatric and respiratory outcomes of a subset of bilateral vocal cord paralysis (BVCP) patients who were all treated with unilateral endoscopic arytenoid abduction lateropexy (EAAL). EAAL is a nondestructive, minimally invasive glottis widening operation, which does not damage either the surgically treated or the contralateral vocal cord. Therefore, it does not impair the regeneration potential of the recurrent laryngeal nerve. STUDY DESIGN Case series. METHODS Ten out of 21 BVCP patients who were treated with EAAL showed signs of isolated adduction recovery at 1 year and were chosen for this study. Functional results (objective and subjective voice analysis, spirometric measurement) and vocal cord movements were assessed preoperatively, 1 week and 1 year after EAAL. Laryngeal electromyography was performed on the 12th postoperative month. RESULTS The volitional adductor movement seen on laryngoscopy was corroborated by laryngeal electromyography evaluation. Peak inspiratory flow increased significantly after EAAL. Quality-of-life scores also showed high patient satisfaction. Shimmer showed consistent improvement along with harmonic-to-noise ratio and average maximal phonation time in parallel with the improving vocal cord movement. Complex voice analysis and subjective self-evaluation tests also demonstrated significant improvement. CONCLUSIONS EAAL, as a minimally invasive, nondestructive airway widening technique, does not interfere with the potential regeneration process that can still occur after BVCP, allowing for laryngeal functional recovery. It is a safe and effective treatment for BVCP that allows a simple solution with good phonatory, swallowing, and respiratory benefits by unilateral passive and reversible vocal cord lateralization. LEVEL OF EVIDENCE 4 Laryngoscope, 129:2334-2340, 2019.
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Affiliation(s)
- Ádám Bach
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Szeged, Szeged, Hungary
| | - Balázs Sztanó
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Szeged, Szeged, Hungary
| | - Vera Matievics
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Szeged, Szeged, Hungary
| | - Zsófia Bere
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Szeged, Szeged, Hungary
| | - Fabian Volk
- Department of Otorhinolaryngology, Jena University Hospital, Jena, Germany
| | - Andreas Müller
- Department of Otorhinolaryngology, SHR Wald-Klinikum Gera, Gera, Germany
| | - Gerhard Förster
- Department of Otorhinolaryngology, SHR Wald-Klinikum Gera, Gera, Germany
| | | | - László Rovó
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Szeged, Szeged, Hungary
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Pardal-Refoyo JL, Parente-Arias P, Arroyo-Domingo MM, Maza-Solano JM, Granell-Navarro J, Martínez-Salazar JM, Moreno-Luna R, Vargas-Yglesias E. Recomendaciones sobre el uso de la neuromonitorización en cirugía de tiroides y paratiroides. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2018; 69:231-242. [DOI: 10.1016/j.otorri.2017.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 06/15/2017] [Indexed: 11/27/2022]
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11
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Recommendations on the Use of Neuromonitoring in Thyroid and Parathyroid Surgery. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2018. [DOI: 10.1016/j.otoeng.2017.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Haidar YM, Sahyouni R, Moshtaghi O, Wang BY, Djalilian HR, Middlebrooks JC, Verma SP, Lin HW. Selective recurrent laryngeal nerve stimulation using a penetrating electrode array in the feline model. Laryngoscope 2017; 128:1606-1614. [PMID: 29086427 DOI: 10.1002/lary.26969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 08/21/2017] [Accepted: 09/21/2017] [Indexed: 01/13/2023]
Abstract
OBJECTIVES/HYPOTHESIS Laryngeal muscles (LMs) are controlled by the recurrent laryngeal nerve (RLN), injury of which can result in vocal fold (VF) paralysis (VFP). We aimed to introduce a bioelectric approach to selective stimulation of LMs and graded muscle contraction responses. STUDY DESIGN Acute experiments in cats. METHODS The study included six anesthetized cats. In four cats, a multichannel penetrating microelectrode array (MEA) was placed into an uninjured RLN. For RLN injury experiments, one cat received a standardized hemostat-crush injury, and one cat received a transection-reapproximation injury 4 months prior to testing. In each experiment, three LMs (thyroarytenoid, posterior cricoarytenoid, and cricothyroid muscles) were monitored with an electromyographic (EMG) nerve integrity monitoring system. Electrical current pulses were delivered to each stimulating channel individually. Elicited EMG voltage outputs were recorded for each muscle. Direct videolaryngoscopy was performed for visualization of VF movement. RESULTS Stimulation through individual channels led to selective activation of restricted nerve populations, resulting in selective contraction of individual LMs. Increasing current levels resulted in rising EMG voltage responses. Typically, activation of individual muscles was successfully achieved via single placement of the MEA by selection of appropriate stimulation channels. VF abduction was predominantly observed on videolaryngoscopy. Nerve histology confirmed injury in cases of RLN crush and transection experiments. CONCLUSIONS We demonstrated the ability of a penetrating MEA to selectively stimulate restricted fiber populations within the feline RLN and selectively elicit contractions of discrete LMs in both acute and injury-model experiments, suggesting a potential role for intraneural MEA implantation in VFP management. LEVEL OF EVIDENCE NA. Laryngoscope, 128:1606-1614, 2018.
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Affiliation(s)
- Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
| | - Ronald Sahyouni
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
| | - Omid Moshtaghi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
| | - Beverly Y Wang
- Department of Pathology, University of California, Irvine, Irvine, California
| | - Hamid R Djalilian
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
| | - John C Middlebrooks
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
| | - Sunil P Verma
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A.,University Voice and Swallowing Center, University of California Irvine School of Medicine, Irvine, California, U.S.A
| | - Harrison W Lin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
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Mau T, Pan HM, Childs LF. The natural history of recoverable vocal fold paralysis: Implications for kinetics of reinnervation. Laryngoscope 2017; 127:2585-2590. [PMID: 28608475 DOI: 10.1002/lary.26734] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/05/2017] [Accepted: 05/15/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Patients with unilateral vocal fold paralysis (UVFP) are commonly told to wait 12 months for spontaneous recovery. This study aims to 1) determine the time to vocal recovery in UVFP, 2) use that data to develop a neurophysiologically plausible model for recovery, and 3) use the model to generate meaningful predictions for patient counseling. STUDY DESIGN Case series with de novo mathematical modeling. METHODS Patients with UVFP who could pinpoint a discrete onset of vocal improvement were identified. The time-to-recovery data were modeled by assuming an "early" recovery group with neuropraxia and a "late" recovery group with more severe nerve injury. For the late group, a two-stage model was developed to explain the time to recovery: regenerating axons must cross the site of injury in stage 1 (probabilistic), followed by unimpeded regrowth to the larynx in stage 2 (deterministic). RESULTS Of 727 cases of UVFP over a 7-year period, 44 reported spontaneous recovery with a discrete onset of vocal improvement. A hybrid distribution incorporating the two stages (exponentially modified Gaussian) accurately modeled the time-to-recovery data (R2 = 0.918). The model predicts 86% of patients with recoverable UVFP will recover within 6 months, with 96% recovering within 9 months. Earlier vocal recovery is associated with recovery of vocal fold motion and younger age. CONCLUSIONS Waiting 12 months for spontaneous recovery is probably too conservative. Repair across the site of injury, and not regrowth to larynx, is likely the rate-determining step in reinnervation, consistent with other works on peripheral nerve regeneration. LEVEL OF EVIDENCE 4. Laryngoscope, 127:2585-2590, 2017.
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Affiliation(s)
- Ted Mau
- Clinical Center for Voice Care, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Hao-Min Pan
- Clinical Center for Voice Care, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Lesley F Childs
- Clinical Center for Voice Care, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
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Busto-Crespo O, Uzcanga-Lacabe M, Abad-Marco A, Berasategui I, García L, Maraví E, Aguilera-Albesa S, Fernández-Montero A, Fernández-González S. Longitudinal Voice Outcomes After Voice Therapy in Unilateral Vocal Fold Paralysis. J Voice 2016; 30:767.e9-767.e15. [DOI: 10.1016/j.jvoice.2015.10.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
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15
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Oldenburg MS, Janus J, Voss S, San Marina S, Chen T, Garcia J, Ekbom D. Histologic Evaluation of Micronized
A
llo
D
erm After Injection Laryngoplasty in a Rabbit Model. Laryngoscope 2016; 127:E166-E169. [DOI: 10.1002/lary.26262] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/27/2016] [Accepted: 07/29/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Michael S. Oldenburg
- Department of Otolaryngology–Head and Neck SurgeryMayo Clinic School of MedicineRochester Minnesota U.S.A
| | - Jeff Janus
- Department of Otolaryngology–Head and Neck SurgeryMayo Clinic School of MedicineRochester Minnesota U.S.A
| | - Steve Voss
- Department of Otolaryngology–Head and Neck SurgeryMayo Clinic School of MedicineRochester Minnesota U.S.A
| | - Serban San Marina
- Department of Otolaryngology–Head and Neck SurgeryMayo Clinic School of MedicineRochester Minnesota U.S.A
| | - Tiffany Chen
- Department of Anatomic PathologyMayo Clinic School of MedicineRochester Minnesota U.S.A
| | - Joaquin Garcia
- Department of Anatomic PathologyMayo Clinic School of MedicineRochester Minnesota U.S.A
| | - Dale Ekbom
- Department of Otolaryngology–Head and Neck SurgeryMayo Clinic School of MedicineRochester Minnesota U.S.A
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Hydman J, Remahl S, Björck G, Svensson M, Mattsson P. Nimodipine Improves Reinnervation and Neuromuscular Function after Injury to the Recurrent Laryngeal Nerve in the Rat. Ann Otol Rhinol Laryngol 2016; 116:623-30. [PMID: 17847731 DOI: 10.1177/000348940711600811] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Injury of the recurrent laryngeal nerve (RLN) is associated with a high degree of neuronal survival, but leads to various levels of vocal fold motion impairment or laryngeal synkinesis, which has been attributed to misdirected reinnervation of the target muscles in the larynx or aberrant, competing reinnervation from adjacent nerve fibers. The aim of the present study was to evaluate the impact of the regeneration-promoting agent nimodipine on reinnervation and neuromuscular function following RLN crush injury. Methods: Sixty adult rats were randomized into nimodipine-treated or untreated groups and then underwent RLN crush injury. Reinnervation of the posterior cricoarytenoid muscle (PCA) was assessed by electrophysiological examination, retrograde tracing of lower motor neurons before and after injury, and quantification of neuromuscular junctions in the PCA muscle. Results: At 6 weeks after injury, the nimodipine-treated animals showed significantly enhanced neuromuscular function and also demonstrated a higher number of motor neurons in the brain stem that had reinnervated the PCA, compared to the untreated animals. The somatotopic organization of ambiguus motor neurons innervating the larynx was similar before injury and after reinnervation. Conclusions: Nimodipine improves regeneration and neuromuscular function following RLN injury in the adult rat, and could be of use in future strategies following RLN injury.
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Affiliation(s)
- Jonas Hydman
- Department of Clinical Neuroscience, Section of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Woodson GE. Spontaneous Laryngeal Reinnervation after Recurrent Laryngeal or Vagus Nerve Injury. Ann Otol Rhinol Laryngol 2016; 116:57-65. [PMID: 17305279 DOI: 10.1177/000348940711600110] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: The status of innervation in patients with laryngeal paralysis is somewhat controversial. Electromyographic activity has been frequently documented in the laryngeal muscles of patients with laryngeal paralysis, and animal experiments report a strong propensity for reinnervation after laryngeal nerve injury. However, a study of intraoperative electromyography performed in patients during reinnervation surgery failed to document activity with stimulation of the recurrent laryngeal nerve (RLN). Noting the long-observed differences in the symptoms of patients with vagus nerve injury and those with RLN injury, I hypothesized that reinnervation is influenced by the site of nerve injury. Methods: Cats were sacrificed at various intervals after resection of 1 cm of either the RLN or the vagus nerve, without any attempt to repair the nerve. Results: Four months after RLN resection, distal nerve biopsy revealed unmyelinated axons scattered through fibrous tissue. By 6 months, myelinated axons were organized, and electromyographic and histologic examination showed preferential reinnervation of the thyroarytenoid muscle. After vagotomy, the RLN was fibrotic and no axons were present. Both the thyroarytenoid and posterior cricoarytenoid muscles were fibrotic and had no electromyographic activity. Conclusions: The results confirm the strong propensity for laryngeal reinnervation after RLN injury, but not after vagus nerve injury. Preferential reinnervation of adductor muscles may account for a medial position of the paralyzed vocal fold.
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Affiliation(s)
- Gayle E Woodson
- Division of Otolaryngology, Southern Illinois University, Springfield, Illinois, USA
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Wang B, Yuan J, Xu J, Xie J, Wang G, Dong P. Neurotrophin expression and laryngeal muscle pathophysiology following recurrent laryngeal nerve transection. Mol Med Rep 2015; 13:1234-42. [PMID: 26677138 PMCID: PMC4732864 DOI: 10.3892/mmr.2015.4684] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 11/19/2015] [Indexed: 11/05/2022] Open
Abstract
Laryngeal palsy often occurs as a result of recurrent laryngeal or vagal nerve injury during oncological surgery of the head and neck, affecting quality of life and increasing economic burden. Reinnervation following recurrent laryngeal nerve (RLN) injury is difficult despite development of techniques, such as neural anastomosis, nerve grafting and creation of a laryngeal muscle pedicle. In the present study, due to the limited availability of human nerve tissue for research, a rat model was used to investigate neurotrophin expression and laryngeal muscle pathophysiology in RLN injury. Twenty-five male Sprague-Dawley rats underwent right RLN transection with the excision of a 5-mm segment. Vocal fold movements, vocalization, histology and immunostaining were evaluated at different time-points (3, 6, 10 and 16 weeks). Although vocalization was restored, movement of the vocal fold failed to return to normal levels following RLN injury. The expression of brain‑derived neurotrophic factor and glial cell line-derived neurotrophic factor differed in the thyroarytenoid (TA) and posterior cricoarytenoid muscles. The number of axons did not increase to baseline levels over time. Furthermore, normal muscle function was unlikely with spontaneous reinnervation. During regeneration following RLN injury, differences in the expression levels of neurotrophic factors may have resulted in preferential reinnervation of the TA muscles. Data from the present study indicated that neurotrophic factors may be applied for restoring the function of the laryngeal nerve following recurrent injury.
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Affiliation(s)
- Baoxin Wang
- Department of Otolaryngology, Head and Neck Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, P.R. China
| | - Junjie Yuan
- Department of Orthopedics, Shanghai Fengxian District Central Hospital, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai 200011, P.R. China
| | - Jiafeng Xu
- School of Economics and Finance, Shanghai International Studies University, Shanghai 200083, P.R. China
| | - Jin Xie
- Department of Otolaryngology, Head and Neck Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, P.R. China
| | - Guoliang Wang
- Department of Otolaryngology, Head and Neck Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, P.R. China
| | - Pin Dong
- Department of Otolaryngology, Head and Neck Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, P.R. China
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Cheetham J, Perkins JD, Jarvis JC, Cercone M, Maw M, Hermanson JW, Mitchell LM, Piercy RJ, Ducharme NG. Effects of Functional Electrical Stimulation on Denervated Laryngeal Muscle in a Large Animal Model. Artif Organs 2015; 39:876-85. [DOI: 10.1111/aor.12624] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jon Cheetham
- Department of Clinical Sciences; College of Veterinary Medicine; Cornell University; Ithaca NY USA
| | - Justin D. Perkins
- Comparative Neuromuscular Disease Laboratory; Royal Veterinary College; London
| | | | - Marta Cercone
- Department of Clinical Sciences; College of Veterinary Medicine; Cornell University; Ithaca NY USA
| | | | - John W. Hermanson
- Department of Biomedical Sciences; College of Veterinary Medicine; Cornell University; Ithaca NY USA
| | - Lisa M. Mitchell
- Department of Clinical Sciences; College of Veterinary Medicine; Cornell University; Ithaca NY USA
| | - Richard J. Piercy
- Comparative Neuromuscular Disease Laboratory; Royal Veterinary College; London
| | - Norm G. Ducharme
- Department of Clinical Sciences; College of Veterinary Medicine; Cornell University; Ithaca NY USA
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Spataro EA, Grindler DJ, Paniello RC. Etiology and Time to Presentation of Unilateral Vocal Fold Paralysis. Otolaryngol Head Neck Surg 2014; 151:286-93. [PMID: 24796331 DOI: 10.1177/0194599814531733] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 03/25/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the etiology, laterality, and time to presentation of unilateral vocal fold paralysis (UVFP) at a tertiary care institution over 10 years. STUDY DESIGN Case series with chart review. SETTING Academic medical center. SUBJECTS AND METHODS All patients seen between 2002 and 2012 by the Department of Otolaryngology at the Washington University School of Medicine (WUSM), with a diagnosis of unilateral vocal fold paralysis, were included. Medical records were reviewed for symptom onset date, presentation date(s), and etiology of UVFP. RESULTS Of the patients, 938 met inclusion criteria and were included. In total, 522 patients (55.6%) had UVFP due to surgery; 158 (16.8%) were associated with thyroid/parathyroid surgery, while 364 (38.8%) were due to nonthyroid surgery. Of the patients, 416 (44.4%) had nonsurgical etiologies, 124 (13.2%) had idiopathic UVFP, and 621 (66.2%) had left-sided UVFP. The diagnosis was more common on the left side in cases of intrathoracic surgeries and malignancies, as expected, but also in idiopathic, carotid endarterectomy, intubation, and skull base tumors. In total, 9.8% of patients presented first to an outside otolaryngologist at a median time of 2.1 months after onset, but these patients presented to WUSM at a median time of 9.5 months. Overall, 70.6% of patients presented to a WUSM otolaryngologist within 3 months of onset. CONCLUSION Iatrogenic injury remains the most common cause of UVFP. Thyroidectomy remains the leading cause of surgery-related UVFP. Patients are typically seen within 3-4 months of onset; however, a significant delay exists for those referred to WUSM.
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Affiliation(s)
- Emily A Spataro
- Department of Otolaryngology-Head and Neck Surgery, Washington, University School of Medicine, St Louis, Missouri, USA
| | - David J Grindler
- Department of Otolaryngology-Head and Neck Surgery, Washington, University School of Medicine, St Louis, Missouri, USA
| | - Randal C Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington, University School of Medicine, St Louis, Missouri, USA
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Kupfer RA, Old MO, Oh SS, Feldman EL, Hogikyan ND. Spontaneous laryngeal reinnervation following chronic recurrent laryngeal nerve injury. Laryngoscope 2013; 123:2216-27. [PMID: 23817931 DOI: 10.1002/lary.24049] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/21/2012] [Accepted: 01/17/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS To enhance understanding of spontaneous laryngeal muscle reinnervation following severe recurrent laryngeal nerve injury by testing the hypotheses that 1) nerve fibers responsible for thyroarytenoid muscle reinnervation can originate from multiple sources and 2) superior laryngeal nerve is a source of reinnervation. STUDY DESIGN Prospective, controlled, animal model. METHODS A combination of retrograde neuronal labeling techniques, immunohistochemistry, electromyography, and sequential observations of vocal fold mobility were employed in rat model of chronic recurrent laryngeal nerve injury. The current study details an initial set of experiments in sham surgical and denervated group animals and a subsequent set of experiments in a denervated group. RESULTS At 3 months after recurrent laryngeal nerve resection, retrograde brainstem neuronal labeling identified cells in the characteristic superior laryngeal nerve cell body location as well as cells in a novel caudal location. Regrowth of neuron fibers across the site of previous recurrent laryngeal nerve resection was seen in 87% of examined animals in the denervated group. Electromyographic data support innervation by both the superior and recurrent laryngeal nerves following chronic recurrent laryngeal nerve injury. CONCLUSIONS Following chronic recurrent laryngeal nerve injury in the rat, laryngeal innervation is demonstrated through the superior laryngeal nerve from cells both within and outside of the normal cluster of cells that supply the superior laryngeal nerve. The recurrent laryngeal nerve regenerates across a surgically created gap, but functional significance of regenerated nerve fibers is unclear.
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Affiliation(s)
- Robbi A Kupfer
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
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Kumai Y, Aoyama T, Nishimoto K, Sanuki T, Minoda R, Yumoto E. Recurrent Laryngeal Nerve Regeneration through a Silicone Tube Produces Reinnervation without Vocal Fold Mobility in Rats. Ann Otol Rhinol Laryngol 2013; 122:49-53. [DOI: 10.1177/000348941312200109] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: We established an animal model of recurrent laryngeal nerve reinnervation with persistent vocal fold immobility following recurrent laryngeal nerve injury. Methods: In 36 rats, the left recurrent laryngeal nerve was transected and the stumps were abutted in a silicone tube with a 1-mm interspace, facilitating regeneration. The mobility of the vocal folds was examined endoscopically 5, 10, and 15 weeks later. Electromyography of the thyroarytenoid muscle was performed. Reinnervation was assessed by means of a quantitative immunohistologic evaluation with anti-neurofilament antibody in the nerve both proximal and distal to the silicone tube. The atrophy of the thyroarytenoid muscle was assessed histologically. Results: We observed that all animals had a fixed left vocal fold throughout the study. The average neurofilament expression in the nerve both distal and proximal to the silicone tube, the muscle area, and the amplitude of the compound muscle action potential recorded from the thyroarytenoid muscle on the treated side increased significantly (p < 0.05) over time, demonstrating regeneration through the silicone tube. Conclusions: Recurrent laryngeal nerve regeneration through a silicone tube produced reinnervation without vocal fold mobility in rats. The efficacy of new laryngeal reinnervation treatments can be assessed with this model.
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Short-term laryngeal electromyography and histopathological findings after primary reconstruction of the inferior laryngeal nerve in rabbits: prospective study. The Journal of Laryngology & Otology 2012; 127:48-53. [PMID: 23164098 DOI: 10.1017/s0022215112002381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The recurrent laryngeal nerve can be injured during surgery. This study investigated recurrent laryngeal nerve reinnervation. OBJECTIVE To study the short-term effects of primary anastomosis of the recurrent laryngeal nerve, by laryngeal electromyography and histopathological analysis, in a rabbit model. METHOD Twenty Zealand rabbits underwent either right recurrent laryngeal nerve (1) transection with excision of 1 cm or (2) transection and end-to-end primary anastomosis. Vocal fold movements, laryngeal electromyography results and histological changes were recorded. RESULTS Vocal fold analysis showed a paramedian vocal fold in both groups, with perceptible vibratory movements in group two. Electromyography revealed total denervation potentials in group one, but denervation and regeneration signs in group two. Histopathologically, hyperkeratosis and parakeratosis of the vocal fold mucosa were seen in group one, and signs of parakeratosis and hyperplasia in group two. CONCLUSION Even under ideal conditions for primary recurrent laryngeal nerve anastomosis, a return to normal muscle function is unlikely. However, such anastomosis prevents muscle atrophy, and should be performed as soon as possible. The degree of nerve recovery is associated with the number, amplitude and myelination level of fibrils returning to the original motor end-plaque.
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Abstract
PURPOSE OF REVIEW The pathophysiology of bilateral vocal fold immobility includes two broad categories: mechanical fixation and neurogenic paralysis. A mobile arytenoid can be surgically abducted, and this procedure has been reported as a treatment for patients with bilateral neurogenic laryngeal paralysis. This article reviews the theoretical basis and clinical outcomes of this procedure. RECENT FINDINGS Two concepts form the theoretical basis for arytenoid abduction. First, in most cases of neurogenic paralysis, laryngeal muscles are not denervated; there is considerable residual or regenerated function of adductor muscles. The vocal fold lies near the midline, because there is inadequate force to abduct the vocal fold. Second, the cricoarytenoid joint is multiaxial. The posterior cricoarytenoid (PCA) muscle rotates the arytenoid about an oblique axis to pull the vocal process laterally and superiorly, while the axis of adduction is nearly vertical. Thus, surgical abduction of the arytenoid, by simulating contraction of the PCA muscle, should not preclude active adduction during phonation or swallow. Surgical arytenoid abduction has been reported to improve the airway in many patients with bilateral laryngeal paralysis, with little or no impairment of vocal function. It is less successful in patients with inspiratory adductor muscle activity, long-term immobility, or previous procedures to statically enlarge the glottis. SUMMARY Arytenoid abduction is a promising treatment for selected patients with bilateral neurogenic laryngeal paralysis.
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Old MO, Oh SS, Feldman E, Hogikyan ND. Novel Model to Assess Laryngeal Function, Innervation, and Reinnervation. Ann Otol Rhinol Laryngol 2011; 120:331-8. [DOI: 10.1177/000348941112000509] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Wang W, Chen S, Chen D, Xia S, Qiu X, Liu Y, Zheng H. Contralateral ansa cervicalis-to-recurrent laryngeal nerve anastomosis for unilateral vocal fold paralysis: A long-term outcome analysis of 56 cases. Laryngoscope 2011; 121:1027-34. [DOI: 10.1002/lary.21725] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Vega-Cordova X, Cosenza NM, Helfert RH, Woodson GE. Neurotrophin expression of laryngeal muscles in response to recurrent laryngeal nerve transection. Laryngoscope 2010; 120:1591-6. [PMID: 20641073 DOI: 10.1002/lary.21026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE/HYPOTHESIS The recurrent laryngeal nerve (RLN) commonly regenerates after injury; however, functional motion is rarely recovered. Animal experiments have documented aberrant reinnervation after nerve transection, with motor axons reaching inappropriate muscles. More recently, experimental results suggest that lack of vocal fold motion after RLN injury is due to preferential reinnervation of adductor muscles, with inadequate reinnervation of the posterior cricoarytenoid muscle (PCA), the only abductor muscle of the larynx. Information on factors that could influence the receptiveness of these muscles to reinnervation could be useful in developing new therapeutic strategies. It is hypothesized that the thyroarytenoid muscle (TA) and the PCA differ in expression of neurotrophins in response to denervation. STUDY DESIGN Laboratory experiment. METHODS Rats were sacrificed at 3 days, 6 weeks, or 4 months after unilateral RLN injury measure expression of brain-derived nerve growth factor (BDNF), nerve growth factor (NGF), and neurotrophin 4 (NT-4) in the TA and PCA muscles, using immunohistochemistry. We also assessed nerve regeneration. RESULTS NGF was significantly diminished in the denervated TA muscle at 3 days after injury and increased at 6 weeks. BDNF expression was unchanged in the TA, but was diminished in both PCA muscles at 3 days and 6 weeks, returning to near-normal levels at 4 months after injury. Robust nerve regeneration of distal RLN was present at 4 months. CONCLUSIONS Results suggest that the TA and PCA muscles respond differently to denervation.
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Affiliation(s)
- Xavier Vega-Cordova
- Division of Otolaryngology, Southern Illinois University, School of Medicine, Springfield, Illinois, USA
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Stager SV, Bielamowicz SA. Using laryngeal electromyography to differentiate presbylarynges from paresis. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2010; 53:100-113. [PMID: 19948754 DOI: 10.1044/1092-4388(2009/08-0244)] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
PURPOSE Differential diagnosis of patients over 64 years of age reporting hoarseness is challenging. Laryngeal electromyography (LEMG) was used to determine the status of the recurrent and superior laryngeal nerves. The authors hypothesized that individuals with hoarseness but normal LEMG would have measures similar to those of patients from previous studies with presbylarynges and significantly different from those of patients with abnormal LEMG. METHOD A retrospective chart review of acoustic, aerodynamic, endoscopic, and self-rating measures was completed for 52 individuals over 64 years of age reporting moderate to severe hoarseness. RESULTS Individuals with normal LEMG had measures similar to those of patients from previous studies diagnosed with presbylarynges. The group with LEMG abnormalities was subcategorized by specific nerve(s) affected. Significant differences were found for measures between presbylarynges and unilateral but not bilateral paresis groups. Several endoscopic findings were observed more often than expected in the presbylarynges group. Using electromyography as a gold standard, the presence of any impairment in arytenoid movement had the most sensitivity (77%) in making the diagnosis of paresis, and the absence of any impairment had the most specificity (67%) in making the diagnosis of presbylarynges. CONCLUSION LEMG may be useful in differentially diagnosing hoarseness in older patients, especially to distinguish between bilateral paresis and presbylarynges.
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Affiliation(s)
- Sheila V Stager
- The George Washington University Medical Center, Washington, DC 20037, USA.
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Donghui C, Shicai C, Wei W, Fei L, Jianjun J, Gang C, Hongliang Z. Functional modulation of satellite cells in long-term denervated human laryngeal muscle. Laryngoscope 2009; 120:353-8. [DOI: 10.1002/lary.20796] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Quantitative Assessment of Laryngeal Muscle Morphology After Recurrent Laryngeal Nerve Injury: Right vs. Left Differences. Laryngoscope 2008; 118:1768-70. [DOI: 10.1097/mlg.0b013e31817f1940] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVES/HYPOTHESIS To determine the effects of long-term denervation on the rat thyroarytenoid (TA) muscle and neuromuscular junctions. STUDY DESIGN A quantitative histologic assessment of the TA muscle after long-term denervation. METHODS Thirty Wistar rats were euthanized 10, 18, 26, 42, and 58 weeks after left recurrent laryngeal nerve resection. The areas of the entire muscle and individual muscle fibers were evaluated using hematoxylin-eosin staining, and neuromuscular junctions were detected by immunohistochemistry. Changes after denervation were evaluated by comparing the treated (T) and untreated (U) sides (T/U ratio). The ratio of the number of nerve terminals (NTs) to that of acetylcholine receptors (AChRs) (NT/AChR ratio) was also assessed. RESULTS The average T/U ratio for the entire muscle area of the denervation groups ranged between 61.1% and 72.5% and did not differ significantly. Similarly, the T/U ratios for the individual muscle fiber area ranged between 45.0% and 51.9%, and the differences were not significant. The T/U ratio of AChRs at 58 weeks (35.3 +/- 20.2%) was significantly lower than that at 10 weeks (76.3 +/- 9.0%; P < .01). The NT/AChR ratios ranged between 30.3% and 35.6% and did not differ significantly among the denervation groups. CONCLUSIONS The entire TA muscle area, individual muscle fiber area, and NT/AChR ratio did not decrease with long-term denervation. Thus, the TA muscle may retain an ability to receive regenerating nerve axons. However, the ability of the TA muscle to receive nerve axons may deteriorate after an excessively long denervation period because the T/U ratio of AChRs decreased with long-term denervation.
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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
Numerous neurologic diseases affect voice production either through direct effects on the larynx or by affecting muscles involved with support or resonation of the voice. Voice changes can be the initial presenting symptoms of neurodegenerative disorders, especially in patients who have increased awareness of their vocal quality. Some patients present to the otolaryngologist before the neurologist. The otolaryngologist must have an understanding and familiarity with laryngeal manifestations of neurodegenerative diseases to make the appropriate diagnosis in a timely fashion. Moreover, the otolaryngologist can play a significant role in the care of patients who have neurodegenerative disease. Video procedures for neurolaryngologic evaluation accompany this content online.
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Affiliation(s)
- Adam D Rubin
- Lakeshore Professional Voice Center, Lakeshore Ear, Nose and Throat Center, 21000 E. Twelve Mile Road, Suite 111, Saint 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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Arch-Tirado E, Verduzco-Mendoza A, Taboada-Picazo V, Mota-Rojas D, Alonso-Spilsbury MDL, Alfaro-Rodríguez A. Analysis of normal and denerved laryngeal vocalization in guinea pigs (Cavia porcellus). J Voice 2007; 23:34-9. [PMID: 18023326 DOI: 10.1016/j.jvoice.2007.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2006] [Accepted: 03/07/2007] [Indexed: 11/26/2022]
Abstract
Paralysis of the left vocal chord is frequent in human clinical practice; because of its anatomic similarity with human, the guinea pig might be a suitable biological model to analyze the phoniatric behavior in denerved animals. Forty newborn guinea pigs were used (20 control and 20 experimental); an incision was made in the ventricular region with the animals under general anesthesia over the middle line of the neck, until the lower left laryngeal nerve was found, the same was secured with alligator clips so that afterward a two-part dissection could be performed and the middle section could be removed (1cm) from the nerve endings (distal and proximal) before they were separated from the laryngeal structure. After recovery from surgery, vocal emissions were recorded in solitary for 6 minutes. The animals that had nerves removed showed an increase in fundamental vocalization frequency compared with the controls. F test was carried out (P=0.05) and no significant difference was found. When analyzing functional recovery, we found that the guinea pigs compensated vocal emissions at 20 days. With regard to the unilateral paralysis, the motility was frequently compensated by the healthy vocal chord, improving voice emission, and loss of air inhalation.
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Affiliation(s)
- Emilio Arch-Tirado
- Instituto Nacional de Rehabilitación, Secretaría de Salud., Laboratorio de Bioacústica, México, Mexico
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Abstract
AbstractAccepted concepts of the pathophysiology and treatment of laryngeal paralysis have changed over the years. It has long been observed that symptoms of laryngeal paralysis vary greatly, both between patients and over time. There have been various theories to explain these differences. This article reviews how these ideas have changed over time as research has produced new information. Currently, the most popular view is that the laryngeal nerve regenerates after injury, albeit incompletely and inconsistently, and that variations in symptoms and laryngeal posture can be accounted for by muscle activity.
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Affiliation(s)
- G Woodson
- Division of Otolaryngology, Southern Illinois University, Springfield, Illinois 62794-9662, USA.
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Heavner SB, Rubin AD, Fung K, Old M, Hogikyan ND, Feldman EL. Dysfunction of the recurrent laryngeal nerve and the potential of gene therapy. Ann Otol Rhinol Laryngol 2007; 116:441-8. [PMID: 17672247 DOI: 10.1177/000348940711600609] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Injury to the recurrent laryngeal nerve causes vocal fold paresis or paralysis resulting in poor voice quality, and possibly swallowing dysfunction and/or airway compromise. Injury can occur as part of a neurodegenerative disease process or can be due to direct nerve trauma or tumor invasion. Management depends upon symptoms, the cause and severity of injury, and the prognosis for recovery of nerve function. Surgical treatment techniques can improve symptoms, but do not restore physiologic motion. Gene therapy may be a useful adjunct to enhance nerve regeneration in the setting of neurodegenerative disease or trauma. Remote injection of viral vectors into the recurrent laryngeal nerve is the least invasive way to deliver neurotrophic factors to the nerve's cell bodies within the nucleus ambiguus, and in turn to promote nerve regeneration and enhance both nuclear and nerve survival. The purpose of this review is to discuss the potential role for gene therapy in treatment of the unsolved problem of vocal fold paralysis.
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Affiliation(s)
- S Brett Heavner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor 48109-2200, USA
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Nagai H, Ota F, Connor NP. Effect of deficits in laryngeal sensation on laryngeal muscle biochemistry. Ann Otol Rhinol Laryngol 2005; 114:352-60. [PMID: 15966521 DOI: 10.1177/000348940511400504] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Swallowing deficits in elderly people are significant clinical problems and may be associated with impaired pharyngolaryngeal sensation. However, the extent to which sensory innervation affects the motor system is unclear. Our purpose was to examine differences in biochemical properties of laryngeal muscles following sensory nerve ablation. We used sodium dodecyl sulfate-polyacrylamide gel electrophoresis to evaluate laryngeal muscles of young and old Fischer 344/Brown Norway rats, and rats that underwent sensory ablation via bilateral section of the superior laryngeal nerve, internal branch (SLNi), or mixed sensory-motor nerve ablation via left-sided recurrent laryngeal nerve (RLN) section. In lateral thyroarytenoid muscle, a reduction was found in the proportion of the most rapidly contracting myosin heavy chain isoform (type 2B) with SLNi section, RLN section, and aging. Section of the SLNi did not alter the proportion of any myosin heavy chain isoform within the lateral cricoarytenoid or posterior cricoarytenoid muscles, but RLN section resulted in a reduction in the proportion of type 2B. Accordingly, alteration in biochemical properties of the lateral thyroarytenoid muscle alone was demonstrated following sensory ablation. We conclude that sensory changes may affect properties of laryngeal muscles, and may thus have an impact on motor control during critical functions, such as airway protection during swallowing.
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Affiliation(s)
- Hiromi Nagai
- Department of Otololaryngology--Head and Neck Surgery, Kitasato University School of Medicine, Kanagawa, Japan
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Tóth A, Szucs A, Harasztosi C, Matesz K, Pucsok K, Mikó I, Sziklai I. Intrinsic laryngeal muscle reinnervation with nerve-muscle pedicle. Otolaryngol Head Neck Surg 2005; 132:701-6. [PMID: 15886621 DOI: 10.1016/j.otohns.2005.01.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To test the application of the nerve-muscle pedicle (NMP) technique for selective reinnervation of previously denervated posterior cricoarytenoid (PCA) muscle. METHODS The left recurrent laryngeal nerve (RLN) was severed in 5 mongrel dogs, and an ansa cervicalis-sternohyoid muscle pedicle was sutured to the left PCA muscle. Three dogs underwent a sham operation. Videolaryngoscopy was performed, and electromyographic data were collected after 1 year on average. Finally, histologic analysis of the NMP was performed. RESULTS The video records showed the return of mobility of the PCA muscle reinnervated by the NMP. EMG data as to show evoked polyphasic potentials showed also evidence of reinnervation of the PCA muscle. With immunohistochemical reaction (antineurofilament antibody+biotin) we could show neurofilaments and motor endplates in both sides in all 5 animals. CONCLUSIONS The NMP technique could eliminate the need for arytenoidectomy and laterofixation in patients with unilateral or bilateral vocal fold paralysis. The quality of life and voice may be improved.
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Affiliation(s)
- Andrea Tóth
- Department of Otolaryngology-Head and Neck Surgery, Medical and Health Science Centre, University of Debrecen, 4012 Debrecen, Nagyerdei krt. 98, Hungary.
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Yeon SC, Lee HC, Chang HH, Lee HJ. Sound signature for identification of tracheal collapse and laryngeal paralysis in dogs. J Vet Med Sci 2005; 67:91-5. [PMID: 15699602 DOI: 10.1292/jvms.67.91] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The aims of this study were to investigate whether upper airway sounds of dogs with laryngeal paralysis and tracheal collapse have distinct sound characteristics, compared with unaffected dogs. The sounds of 5 dogs with laryngeal paralysis and 5 dogs with tracheal collapse were recorded. Honking sound appeared as predominant clinical signs in dogs with tracheal collapse. Laryngeal stridors appeared as predominant clinical signs in dogs with experimentally produced laryngeal paralysis by resection of laryngeal nerve, in which two types of stridor, I and II, were recorded. All these sounds were analyzed using sound spectrogam analysis. There were significant differences in duration (sec), intensity (dB), pitch (Hz), first formant (Hz), second formant (Hz), third formant (Hz), fourth formant (Hz) of sounds between the normal bark and two types of stridor or honking sound, indicating that the sound analysis might be a useful diagnostic modality for dogs with tracheal collapse and laryngeal paralysis.
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Affiliation(s)
- Seong-Chan Yeon
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, Republic of Korea
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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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Abstract
Laryngeal EMG has become a useful tool for the otolaryngologist in the four decades since the pioneering work of Faaborg-Anderson and Buchtal. It is able to distinguish between mechanical limitation and denervation in an immobile vocal fold. In the paralyzed vocal fold, it can guide workup by pointing to the site of the lesion. In the hands of a circumspect clinician, it can provide clinically valuable information regarding prognosis. Useful application of laryngeal EMG must rest on the basic fact that it isa qualitative test. Because of factors like sampling error, interfering signal from neighboring muscles, difficulties in needle placement, and our in-complete understanding of reinnervation physiology, the boundary between sophisticated, subtle interpretation and overreading is particularly difficult to distinguish. EMG diagnosis is based on patterns of abnormalities over time and, like other tests, requires interpretation in a clinical context. As in any such undertaking, there is no substitute for good judgment and experience. The most important benefit of clinical use of laryngeal EMG may be that it has catalyzed and broadened interest in laryngeal neurophysiology in the same way that stroboscopy has focused attention on the structure and function of the vocal fold lamina propria. The continuing refinement of electrodiagnostic approaches to the larynx that has resulted, including quantitative, single-fiber. and vector laryngeal EMG, and evolving methods of nerve conduction testing will continue to yield important insights into mechanisms of neural control that are likely to drive developments in the treatment of vocal fold paralysis in the future.
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Affiliation(s)
- Lucian Sulica
- Center for the Voice, New York Eye and Ear Infirmary and Beth Israel Medical Center, New York, NY 10003, USA.
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43
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Abstract
Felix Semon's 'laws' of vocal cord paralysis were conceived over a century ago, based on the simple concept that abductor function of the recurrent laryngeal nerve was more vulnerable than adductor function. It is now clear that the neuromuscular pathology of laryngeal innervation is much more complex. Whether the nerve has been cut, crushed, stretched, cauterized or otherwise injured, it is seldom completely transected. There might be no detectable vocal cord movement at laryngoscopy, yet, electromyography usually shows at least some activity because of incomplete denervation and/or developing synkinesis. Electrical silence hardly ever persists forever. Disordered vocal fold movement following nerve injury appears to depend on laryngeal synkinesis with disorganized neuromuscular function caused by misdirected regeneration and aberrant reinnervation, sometimes by adjacent nerves. The severity of the injury, abnormal random reinnervation, scar tissue formation and nerve growth-stimulating and inhibiting factors influence the final position of the vocal fold. For a better understanding of neurolaryngological disorders it is no longer sufficient to think merely in terms of 'vocal cord paralysis'.
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Affiliation(s)
- Bruce Benjamin
- Departments of Otolaryngology and Head and Neck Surgery, Sydney UniversitySydney, Australia
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Glatz FR, Kalkanis J, Neumeister M, Suchy H, Lyons S, Mowlavi A, Mowlawi A. Volume analysis of preadipocyte injection for vocal cord medialization. Laryngoscope 2003; 113:1113-7. [PMID: 12838006 DOI: 10.1097/00005537-200307000-00003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the volume retention of injected preadipocytes with that of standard fat injection in a paralyzed rabbit true vocal cord. STUDY DESIGN Prospective analysis with blinded data collection. METHODS Thirteen New Zealand white rabbits were divided into two groups. Group 1 consisted of seven animals undergoing left-side vocal cord paralysis by resection of a 1-cm segment of the left-side recurrent laryngeal nerve and abdominal fat harvest for isolation of preadipocytes. Preadipocytes were cultured under sterile conditions in cell culture media. Animals in group 2 also underwent left-side vocal cord paralysis without fat harvest. After 10 to 14 days, in a second procedure, group 1 underwent injection of 0.1 mL cultured autologous preadipocytes, and group 2 underwent routine injection of 0.1 mL abdominal fat harvested during the same procedure. At 6 and 12 months, volumetric analysis was performed. RESULTS Volume analysis at 6 months showed a mean volume of 0.029 mL retained fat in group 2 representing a retention of approximately 29% (SD = 0.023) of the original injected volume. Retention in group 1 animals approximated 0.002 mL (SD = 0.0024) or 2% of the injected volume. Analysis at 12 months showed a mean volume of 0.008 mL (SD = 0.0078) in group 2 and of 0.002 mL (SD = 0.0015) in group 1. Group 2 showed significantly higher volumes of the injected fat at 6 and 12 months (P <.033). CONCLUSION Volumes obtained with standard fat injection were superior to those obtained with preadipocyte injection at both 6 and 12 months.
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Affiliation(s)
- Frank R Glatz
- Department of Otolaryngology-Head & Neck Surgery, Southern Illinois University School of Medicine, 301 North 8th Street, Springfield, IL, USA.
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Johns MM, Urbanchek M, Chepeha DB, Kuzon WM, Hogikyan ND. Thyroarytenoid muscle maintains normal contractile force in chronic vocal fold immobility. Laryngoscope 2001; 111:2152-6. [PMID: 11802015 DOI: 10.1097/00005537-200112000-00014] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Denervation of skeletal muscle typically results in irreversible denervation atrophy over time. This finding has generated controversy as to the efficacy of reinnervation procedures for chronic vocal fold immobility related to recurrent laryngeal nerve injury. OBJECTIVE To test the hypothesis that chronic vocal fold immobility after recurrent laryngeal nerve injury does not result in diminished maximal isometric force generation in the thyroarytenoid muscle. STUDY DESIGN Adult random-bred cats underwent either unilateral laryngeal denervation (n = 6) or sham surgery (n = 6). After 6 months, videolaryngoscopy was performed followed by in vitro measurement of maximal isometric tetanic force produced by the thyroarytenoid muscle. RESULTS All animals in the denervation group showed right vocal fold paralysis after the initial denervation operation; none of these animals had return of appropriately phased movement with respiration. Four had intermittent disorganized twitching movements. One had these movements plus an occasional weak adduction, and one had no movement. Normal vocal fold mobility was observed in 6 of 6 animals undergoing sham surgery. The maximal isometric tetanic force measured from the thyroarytenoid muscle in the sham group was 438 mN (+/-92 mN standard deviation [SD]). The maximal isometric tetanic force measured from the thyroarytenoid muscle in the chronically immobile group was 405 mN (+/-107 mN SD). Differences were not statistically significant. CONCLUSION Maximal isometric force in the thyroarytenoid muscle is not diminished in chronic vocal fold immobility after recurrent laryngeal nerve injury. We conclude that the possibility for restoration of contractile force to the chronically immobile thyroarytenoid muscle exists. This finding supports the pursuit of reinnervation procedures in the treatment of chronic vocal fold immobility.
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Affiliation(s)
- M M Johns
- Department of Otolaryngology--Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan 48109-0312, USA
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Paniello RC, West SE, Lee P. Laryngeal reinnervation with the hypoglossal nerve. I. Physiology, histochemistry, electromyography, and retrograde labeling in a canine model. Ann Otol Rhinol Laryngol 2001; 110:532-42. [PMID: 11407844 DOI: 10.1177/000348940111000607] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study was performed to determine whether the hypoglossal nerve (cranial nerve XI [XII]) would serve as a useful donor for laryngeal reinnervation by anastomosis to the recurrent laryngeal nerve (RLN). Twenty hemilarynges in 10 dogs were studied prospectively after XII-RLN anastomosis (group A; n = 5), split XII-RLN anastomosis (group B; n = 3), XII-RLN anastomosis with a 2-cm interposition graft (group C; n = 2), no treatment (group D; n = 5), RLN section (group E; n = 2), or ansa cervicalis-RLN anastomosis (group F; n = 3). Spontaneous activity was observed monthly by infraglottic examination through permanent tracheostomies and was recorded by electromyography. Laryngeal adductory pressure and induced phonation were obtained by stimulating the RLN while passing a pressure transducer balloon or humidified air through the glottis. At sacrifice, the laryngeal muscles were stained for adenosine triphosphatase to determine the ratio of type I to type II fibers. Retrograde labeling of the brain stem was performed with horseradish peroxidase. Infraglottic examination at 6 months showed a full range of adductory motion in groups A and B during the swallow reflex, comparable with that in group D. Groups C and F showed good bulk and tone, but little spontaneous motion. Group E remained paralyzed. Stimulation of the transferred nerves caused more activity in groups A and B than in the other groups; groups C and F partially adducted at high levels. The laryngeal adductory pressure responses of groups A and B were similar to those of group D. The XII-reinnervated larynges were capable of producing normal induced phonation. Retrograde labeling of the RLN showed that the reinnervating axons originated only in the hypoglossal nucleus. Electromyography of the reinnervated adductor muscles confirmed spontaneous activity in the dogs (awake). Histochemical analysis confirmed slow-to-fast transformation of both the posterior and lateral cricoarytenoid muscles, indicating that significant reinnervation occurred. We conclude that the hypoglossal nerve functions well as a donor for adductory reinnervation of the larynx.
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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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Heaton JT, Kobler JB, Goldstein EA, McMahon TA, Barry DT, Hillman RE. Recurrent laryngeal nerve transposition in guinea pigs. Ann Otol Rhinol Laryngol 2000; 109:972-80. [PMID: 11051439 DOI: 10.1177/000348940010901012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Improved control of prosthetic voice aids for laryngectomees might be possible to obtain with residual laryngeal motor nerve signals. We were able to recover motor signals from the recurrent laryngeal nerve (RLN) by transposing it into the ipsilateral denervated sternohyoid muscle (SH) in 8 guinea pigs. Reinnervation was monitored by electromyographic recordings from surface and intramuscular needle electrodes in awake animals. Within 4 to 14 weeks after surgery, all animals demonstrated laryngeal-like motor activity in the reinnervated SH, including activity during respiration, sniffing, swallowing, and/or vocalizing. After 3 to 6 months, the animals were reanesthetized, and nerve stimulation and section experiments confirmed the RLN as the source of reinnervation in all cases. In several animals, activity of the RLN-innervated SH was demonstrated to be correlated with that of contralateral laryngeal muscles. Histochemical analysis of the SH indicated a unilateral transformation from mostly fatigable to mostly fatigue-resistant fiber types ipsilateral to the RLN transposition, a phenotype more typical of laryngeal muscles. Thus, RLN transposition at the time of laryngectomy may be a method for salvaging laryngeal control signals that could be used to control prosthetic voice devices.
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Affiliation(s)
- J T Heaton
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
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48
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Abstract
First described in 1982, laryngeal synkinesis continues to play an important diagnostic and therapeutic role following recurrent laryngeal nerve (RLN) injury. Vocal fold motion impairment (formerly called "vocal cord paralysis"), hyperadducted and hyperabducted vocal folds, and certain laryngeal spasmodic and tremor disorders are often best explained by synkinesis. A closer look at these mechanisms confirms that following RLN injury, immobile vocal folds may be nearly normally functional (favorable), or spastic, hyperadducted, or hyperabducted (unfavorable). This has resulted in a functional classification of laryngeal synkinesis as follows: type I laryngeal synkinesis, with satisfactory voice and airway (vocal fold poorly mobile, or immobile); type II synkinesis, with spasmodic vocal folds and an unsatisfactory voice and/or airway; type III synkinesis, with hyperadducted vocal folds and airway compromise; and type IV synkinesis, with hyperabducted vocal folds, poor voice, and possible aspiration. This classification facilitates the understanding of laryngeal pathophysiology following RLN injuries and promotes a more scientific basis for management.
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Affiliation(s)
- R L Crumley
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, USA
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Kobayashi J, Yumoto E, Hyodo M, Gyo K. Two-dimensional analysis of vocal fold vibration in unilaterally atrophied larynges. Laryngoscope 2000; 110:440-6. [PMID: 10718435 DOI: 10.1097/00005537-200003000-00022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Considerable inconsistencies regarding the vibratory pattern of the vocal fold among patients with unilateral vocal fold paralysis (UVFP) have been reported. These differences are derived from differences in the position, stiffness, and atrophy of the paralyzed vocal fold and other factors among patients. The purpose of this study was to assess the effects of unilateral atrophy of the vocal fold on vocal fold vibration. METHODS Seven excised canine larynges were studied. The unilateral recurrent laryngeal nerve was severed to cause vocal fold atrophy in four of the seven. The lateral and vertical displacements were monitored simultaneously with photoglottography and a laser Doppler vibrometer, respectively. Videostroboscopy of each larynx was also performed before and after the experiment to translate photoglottographic output into absolute lengths. Atrophy of the unilateral vocal fold was confirmed histologically. RESULTS The lateral amplitude was significantly greater than the vertical amplitude in all larynges. The Lissajous trajectories in the normal larynges were shaped like a reverse crescent. Vibration in the unilaterally atrophied larynges was periodical and symmetrical in phase when the thyroid ala on the atrophied side was pressed medially. The lateral and vertical amplitudes on the atrophied side were significantly greater than those on the normal side. The Lissajous trajectories differed from those of the normal larynges. CONCLUSIONS In the absence of a prephonatory glottal gap, periodical vibration occurs in unilaterally atrophied larynges and the amplitude of vibrations of the atrophied vocal fold is greater in the lateral and vertical directions than that of the normal fold. This implies that phonosurgical procedures aiming at closure of the prephonatory glottal gap may have a beneficial effect on hoarseness in UVFP patients, although displacements of the vocal folds during vibration are not symmetrical.
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Affiliation(s)
- J Kobayashi
- Department of Otolaryngology, School of Medicine, Ehime University, Onsen-gun, Japan
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Abstract
OBJECTIVES The effects of denervation on myosin heavy chain (MHC) expression in specific laryngeal muscles are characterized using gel electrophoresis. Observed temporal changes in MHC composition will then be used as a biologic marker in studies designed to develop strategies for laryngeal reinnervation and gene therapy. STUDY DESIGN Animal study using an adult rat model for laryngeal paralysis. METHODS In anesthetized rats the left recurrent and superior laryngeal nerve were divided. Animals were survived for 7, 14, 28, 90, and 180 days. Animals were euthanized and the thyroarytenoid (TA), vocalis (VOC), posterior cricoarytenoid (PCA), lateral cricoarytenoid (LCA), and cricothyroid (CT) muscle excised. Each muscle was processed for sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and densitometric measurements were obtained to determine composition of MHC fiber types. RESULTS The changes in relative MHC composition are described for each specific laryngeal muscle. In general, a decrease in type IIB and an increase in IIA and IIX are seen after denervation. Expression of IIL in the denervated condition is variable and the relative change in type I is minimal. CONCLUSION This study supports previous work using rat soleus muscle in which IIA/IIX expression is favored in conditions with decreased neuromuscular activity, and conversely, IIB expression is activity dependent. Expression of type I appears to be independent of neural activity. Further study will be undertaken to quantify expression of MHC components and to study factors modulating expression.
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Affiliation(s)
- A Shiotani
- Department of Otolaryngology and Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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