Assessment and validation of glottic motion using cone-beam CT and real-time cine MRI

PURPOSE

This study aimed to assess the margin for the planning target volume (PTV) using the Van Herk formula. We then validated the proposed margin by real-time magnetic resonance imaging (MRI).

METHODS

An analysis of cone-beam computed tomography (CBCT) data from early glottic cancer patients was performed to evaluate organ motion. Deformed clinical target volumes (CTV) after rigid registration were acquired using the Velocity program (Varian Medical Systems, Palo Alto, CA, USA). Systematic (Σ) and random errors (σ) were evaluated. The margin for the PTV was defined as 2.5 Σ + 0.7 σ according to the Van Herk formula. To validate this margin, we accrued healthy volunteers. Sagittal real-time cine MRI was conducted using the ViewRay system (ViewRay Inc., Oakwood Village, OH, USA). Within the obtained sagittal images, the vocal cord was delineated. The movement of the vocal cord was summed up and considered as the internal target volume (ITV). We then assessed the degree of overlap between the ITV and the PTV (vocal cord plus margins) by calculating the volume overlap ratio, represented as (ITV∩PTV)/ITV.

RESULTS

CBCTs of 17 early glottic patients were analyzed. Σ and σ were 0.55 and 0.57 for left-right (LR), 0.70 and 0.60 for anterior-posterior (AP), and 1.84 and 1.04 for superior-inferior (SI), respectively. The calculated margin was 1.8 mm (LR), 2.2 mm (AP), and 5.3 mm (SI). Four healthy volunteers participated for validation. A margin of 3 mm (AP) and 5 mm (SI) was applied to the vocal cord as the PTV. The average volume overlap ratio between ITV and PTV was 0.92 (range 0.85-0.99) without swallowing and 0.77 (range 0.70-0.88) with swallowing.

CONCLUSION

By evaluating organ motion by using CBCT, the margin was 1.8 (LR), 2.2 (AP), and 5.3 mm (SI). The margin acquired using CBCT fitted well in real-time cine MRI. Given that swallowing during radiotherapy can result in a substantial displacement, it is crucial to consider strategies aimed at minimizing swallowing and related motion.

How reliable is assessment of true vocal cord-arytenoid unit mobility in patients affected by laryngeal cancer? a multi-institutional study on 366 patients from the ARYFIX collaborative group

PURPOSE

In clinical practice the assessment of the "vocal cord-arytenoid unit" (VCAU) mobility is crucial in the staging, prognosis, and choice of treatment of laryngeal squamous cell carcinoma (LSCC). The aim of the present study was to measure repeatability and reliability of clinical assessment of VCAU mobility and radiologic analysis of posterior laryngeal extension.

METHODS

In this multi-institutional retrospective study, patients with LSCC-induced impairment of VCAU mobility who received curative treatment were included; pre-treatment endoscopy and contrast-enhanced imaging were collected and evaluated by raters. According to their evaluations, concordance, number of assigned categories, and inter- and intra-rater agreement were calculated.

RESULTS

Twenty-two otorhinolaryngologists evaluated 366 videolaryngoscopies (total evaluations: 2170) and 6 radiologists evaluated 237 imaging studies (total evaluations: 477). The concordance of clinical rating was excellent in only 22.7% of cases. Overall, inter- and intra-rater agreement was weak. Supraglottic cancers and transoral endoscopy were associated with the lowest inter-observer reliability values. Radiologic inter-rater agreement was low and did not vary with imaging technique. Intra-rater reliability of radiologic evaluation was optimal.

CONCLUSIONS

The current methods to assess VCAU mobility and posterior extension of LSCC are flawed by weak inter-observer agreement and reliability. Radiologic evaluation was characterized by very high intra-rater agreement, but weak inter-observer reliability. The relevance of VCAU mobility assessment in laryngeal oncology should be re-weighted. Patients affected by LSCC requiring imaging should be referred to dedicated radiologists with experience in head and neck oncology.

Use of the Disposcope endoscope for awake orotracheal intubation in an elderly patient with a large vocal cord polyp: a case report

Background

Vocal cord polyps are commonly encountered in the otorhinolaryngology department. The risk of anesthesia is high in patients with large vocal cord polyps. Awake intubation with appropriate airway tools provides a favorable safety profile.

Case

We present the case of a 60-year-old male patient who had been suffering from a large vocal cord polyp for 16 years. Electronic laryngoscopy revealed that the vocal cord polyp was approximately 1.5 cm in diameter. The polyp had a pedicle and demonstrated synchronous motion with respiratory excursion. It covered almost the entire glottic area during inspiration and moved away from the glottis during expiration. A Disposcope endoscope was used for awake tracheal intubation, and the surgery was completed successfully.

Conclusion

The Disposcope endoscope can be a useful option for awake orotracheal intubation in cases of anticipated difficult intubation and difficult facemask ventilation.

A Rare Case of Intravascular Papillary Endothelial Hyperplasia (Masson's Tumor) of Vocal Cord

BACKGROUND

Intravascular papillary endothelial hyperplasia (IPEH) also known as Masson's tumour named after Pierre Masson is a benign lesion of vascular origin which is characterized by reactive proliferation of endothelial cells with papillary formation. It is an extremely rare entity which can present anywhere in the body but is particularly found in the extremities and head and neck regions most commonly the lips, oral mucosa, tongue, gingiva, or buccal mucosa and due to its close resemblance to Angiosarcoma, it becomes important to distinguish between these two entities to avoid unnecessary aggressive treatment.

CASE REPORT

Here, we describe a case of 23-year-old male who presented with change in voice since 8 months. Preoperatively, laryngoscopic examination showed right vocal cord polyp in the anterior one-third of the cord with hemorrhagic changes. He underwent micro-laryngeal surgery using suspension laryngoscope and the lesion was excised completely. Histopathological report was consistent with IPEH.

CONCLUSION

Herein, we describe a rare benign case of IPEH arising from the vocal cord and we provide a brief review of relevant literature and a detailed report of this rare entity.

Vocal Cord Nodule with Stromal Atypia: Case Report and Review of Literature

Vocal cord nodule is a common reactive transformation of the laryngeal mucosa encountered routinely. Although benign, rare instances of stromal atypia have been demonstrated, which can often be confused with other spindle cell lesions. There is a dearth of literature explaining this peculiar transformation. Hence, the diagnosis of these lesions can be put-forth only after histopathological evaluation and appropriate immunohistochemical analysis. Herein, we report a case of a 55-year-old male who presented with vocal cord nodule with stromal atypia.

Successful emergency Lichtenberger lateralisation for immediate bilateral laryngeal immobility after total thyroidectomy: a CARE case report

OBJECTIVE

This case report discusses a successful emergency Lichtenberger lateralisation procedure after immediate bilateral laryngeal immobility, occurring after total thyroidectomy.

METHODS

A 63-year-old female with right-sided vocal fold paralysis due to compression by a multinodular thyroid goitre underwent total thyroidectomy, which resulted in immediate post-operative bilateral vocal fold immobility. The patient had acute-onset post-operative dyspnoea, was promptly re-intubated, and an emergency lateralisation Lichtenberger suture was placed over the right vocal fold and fixated on the outer surface of the neck.

RESULTS

After two weeks, her right vocal fold recovered first, with the suture still in place. At four weeks, both vocal folds regained function and the suture was extracted.

CONCLUSION

The take-away message is that an emergency lateralisation suture may be a viable option in maintaining airway patency, while allowing for normal deglutition, in patients who would otherwise be candidates for prolonged intubation, posterior cordotomy, medial arytenoidectomy or tracheostomy.

Dynamic vocal cord behavior and stridor during emergence from general anesthesia in small children with supraglottic airway

PURPOSE

Stridor during emergence from anesthesia is not rare in children managed with supraglottic airway (SGA). However, we know little about the mechanisms of stridor and behavior of the vocal cords (VC). This study aimed to clarify patterns of VC movement and laryngeal airway maintenance function during recovery from anesthesia in children with SGA.

METHODS

This is a secondary analysis of data collected from an observational study involving 27 anesthetized children. Using a multi-panel recording system, endoscopic VC image, vital sign monitor, multi-channel tracings of respiratory variables and respiratory sound and patient's view were simultaneously captured in one monitor. Inspiratory and expiratory VC angles formed by lines connecting anterior and posterior commissures were measured at the first spontaneous breath and the breath one minute after the first breath. VC narrowing and dilation were assessed by differences of VC angles.

RESULTS

Inspiratory VC narrowing (median (IQR): 5.3 (2.7, 9.1) degree at the first breath) and dilation (- 2.7 (- 3.8, - 1.7) degree at the first breath) were observed in 15 and 12 out of 27 children, respectively. The former group achieved greater tidal volume compared to the latter in one minute. Five children (19%) temporarily developed stridor-like sound from outside with inspiratory VC narrowing. The stridor-like sound was captured by microphones attached to the neck and anesthesia circuit, but was not evident from the chest.

CONCLUSION

Laryngeal narrowing occurs in half of the children with SGA during emergence from anesthesia, and temporal stridor-like sound is relatively common.

CLINICAL TRIAL REGISTRATION

UMIN (University Hospital Information Network) Clinical Registry: UMIN000025058 ( https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000028697 ).

Primary Laryngeal Aspergillosis - Case Series, Reported in a Tertiary Care Hospital, Bhubaneswar, Odisha, India

We report 2 vocal fold aspergillosis cases from Otolaryngology department of a tertiary hospital, Bhubaneswar. A 26 years old female visited the OPD with chief complaint of progressive hoarseness and pain while talking since 6 months. While another 29 years old female complained of having progressive hoarseness since 4 months preceded by an episode of sore throat. Both cases had microlaryngeal surgery/ endo laryngeal surgery followed by excisional biopsy.

Pathologically Negative Excision for Biopsy-Proven Early Glottic Carcinoma

In certain instances, patients who underwent endoscopic laser excision (ELE) for biopsy-proven early glottic carcinoma do not show any evidence of carcinomatous cells on histopathologic analysis. Our study aims to determine the incidence of this phenomenon. A retrospective analysis of patients with biopsy-proven early glottic squamous cell carcinoma who underwent ELE was conducted. 121 patients with a mean age of 68.2 ± 10.7 were included in this study. Initial biopsy showed carcinoma in situ in 38 patients, (31.4%), T1a in 41 patients (33.9%), and T1b in 42 patients (34.7%). Following ELE, a pathologically negative excision was seen in 26 patients (21.5%). Disease recurrence occurred in 3 patients who had a pathologically negative excision (11.5%). Following repeat ELE, all patients remained disease free. A significant number of early glottic carcinoma present with small volume disease which may be eradicated with diagnostic biopsy alone.

Hypertrophic olivary degeneration associated with bilateral vocal cord adductor dystonia

BACKGROUND

Hypertrophic olivary degeneration (HOD) is a rare condition caused by lesions within the dentato-rubro-olivary pathway, resulting in ocular nystagmus and palatal myoclonus (oculopalatal tremor) but not usually dystonia. Dystonia is an uncommon association, and we present the first reported association of hypertrophic olivary degeneration with bilateral vocal cord dystonia.

CASE PRESENTATION

A 33 year old male presented initially with acute hydrocephalus on the background of previous ventriculoperitoneal (VP) shunting for previously treated medulloblastoma. After revision of the VP shunt, the patient developed progressive hiccups and stridor leading to respiratory failure requiring intubation. Ocular pendular nystagmus and palatal myoclonus at 3 Hz was observed. Flexible nasendoscopy (FNE) demonstrated bilateral tonic adduction of the vocal folds with 3 Hz coarse supraglottic, pharyngeal and palatal rhythmic myoclonus. MRI imaging demonstrated T2 hyperintensity within the bilateral inferior olivary nuclei consistent with stage 3 radiological HOD.

CONCLUSIONS

Dystonia is a rarely reported phenomenon in HOD but is not unexpected with the inferior olivary nucleus implicated in dystonic disorders. We report the association of HOD with bilateral vocal cord adductor dystonia, a potentially life threatening condition.

Oncological outcome of vocal cord-only radiotherapy for cT1-T2 glottic laryngeal squamous cell carcinoma

PURPOSE

Early-stage glottic cancer can be treated with radiotherapy only. Modern radiotherapy solutions allow for individualized dose distributions, hypofractionation and sparing of organs at risk. The target volume used to be the entire voice box. This series describe the oncological outcome and toxicity of individualized vocal cord-only hypofractionated radiotherapy for early stage (cT1a-T2 N0).

METHODS

Retrospective cohort study with patients treated in a single center between 2014 and 2020.

RESULTS

A total of 93 patients were included. Local control rate was 100% for cT1a, 97% for cT1b and 77% for cT2. Risk factor for local recurrence was smoking during radiotherapy. Laryngectomy-free survival was 90% at 5 years. Grade III or higher late toxicity was 3.7%.

CONCLUSION

Vocal cord-only hypofractionated radiotherapy appears to be oncologically safe in early-stage glottic cancer. Modern, image-guided radiotherapy led to comparable results as historical series with very limited late toxicity.

3D VOSNet: Segmentation of endoscopic images of the larynx with subsequent generation of indicators

Video laryngoscope is available for visualizing the motion of vocal cords and aid in the assessment of analyzing the larynx-related lesion preliminarily. Laryngeal Electromyography (EMG) needs to be performed to diagnose the factors of vocal cord paralysis, which may cause patient feeling unwell. Thus, the problem is the lack of credible larynx indicators to evaluate larynx-related diseases in the department of otolaryngology. Therefore, this paper aims to propose a 3D VOSNet model, which has the characteristics of sequence segmentation to extract the time-series features in the video laryngoscope. The 3D VOSNet model can keep the time-series features of three images before and after of the specific image to achieve translation and occlusion invariance, which explicitly signifies that our model can segment and classify each item in the video of laryngoscopy not affected by extrinsic causes such as shaking or occlusion during laryngoscope. Numerical results revealed that the testing accuracy rates of the glottal, right vocal cord, and the left vocal cord are 89.91%, 94.63%, and 93.48%, respectively. Our proposed model can segment glottal and vocal cords from the sequence of laryngoscopy. Finally, using the proposed algorithm computes six larynx indicators, which are the area of the glottal, area of vocal cords, length of vocal cords, deviation of length of vocal cords, and symmetry of the vocal cords. In order to assist otolaryngologists in staying credible and objective when making decisions without any doubt during diagnosis and also explaining the clinical symptoms of the larynx such as vocal cord paralysis to patients after diagnosis, our proposed algorithm provides otolaryngologists with explainable indicators (X-indicators).

A Case Report with Short Review of Literature

Laryngeal adult-type hemangiomas are very rare lesions, more frequent in men, whose optimal treatment consists of microlaryngoscopical excision. We herein report a case of larynx cavernous hemangioma in a 64-year-old woman with hoarseness for about six months. Histologically, the tumor was composed of multiple vessels embedded in an edematous stroma.

Cervical ultrasound for the evaluation of the vocal cords: A pilot study in an endocrine surgery unit

INTRODUCTION

Cervical ultrasound (CE) has emerged as a promising tool in recent years for vocal cord (VC) assessment in patients undergoing thyroid surgery. Our aim is to assess the reliability of CE once implemented in an endocrine surgery unit and performed by the surgeons themselves.

MATERIAL AND METHOD

86 participants with no history of laryngeal pathology or cervical surgery underwent CE by three independent endocrine surgeons. Laryngeal structures and specifically the VCs were analysed. To consider the examination as diagnostic, the VCs had to be visualised statically and during phonation. The time taken to perform the technique and the interobserver variability were also analysed.

RESULTS

Of the 86 participants, 51.2% were male with a mean age of 43 years. The range of diagnostic examinations between surgeons was 60-68%, with substantial agreement between the 3 explorers (Fleiss's K-value = .714). Male sex and advanced age were factors associated with non-assessability of the technique. The mean procedure time was 72 s.

CONCLUSIONS

CE is a fast, non-invasive, feasible bedside tool useful for the assessment of VCs prior to thyroid surgery, mainly in young women.

Changing Trend in the Etiological Spectrum of Hoarseness of Voice in Rural India: A Prospective Hospital-Based Study

Hoarseness of voice is one of the common symptoms with which patient presents to an otorhinolaryngologist. Hoarseness is a symptom of diverse etiology. The aim of the study was to study the problem of hoarseness relating to its incidence and to identify the common etiologies and predisposing factors leading to hoarseness of voice. This study comprises of 70 cases of hoarseness presenting to Department of Otorhinolaryngology, VIMS, Ballari, Karnataka from October 2015 to March 2017. After taking a thorough history, a complete otolaryngological examination was carried out and supported by relevant investigations, diagnosis was reached. The incidence of hoarseness of voice was noted to be 0.21% in our study. The majority of patients were in 31-40 years and 51-60 years of age group, and male to female ratio was 3.7:1, farmers constituted single largest group (34.3%), and most of the patients were from the rural area (82.9%). Smoking was the commonest habit (54.29%) predisposing to hoarseness of voice. Maximum patients presented with hoarseness of duration of 1-3 months. Laryngeal malignancy was the commonest aetiology noted in our study (38.6%). A complaint of hoarseness may represent a serious disease and, therefore, should not be ignored, especially if present for more than 2 weeks. It needs a complete evaluation to rule out malignancy as a cause.

Ultrasound of the vocal cords in infants

Vocal cord paralysis is a common cause of respiratory and feeding problems in the pediatric population. While the causes of vocal cord paralysis are multiple, iatrogenic injury of the recurrent laryngeal nerve after cardiovascular surgery is the most frequent cause. Vocal cord paralysis increases the risk of swallowing dysfunction, tracheal aspiration and pneumonia. It also increases the need for nasoenteric feeds and gastrostomy tube placement. Flexible nasopharyngolaryngoscopy is considered the gold standard for diagnosing vocal cord paralysis, but it has significant drawbacks: it is uncomfortable, it can trigger a cardiovascular event in children with unstable cardiovascular status, it can be challenging to perform, and it can be difficult to interpret. Laryngeal US has become a popular imaging modality to evaluate the function of the vocal cords. Laryngeal US is well-tolerated, easy to perform, simple to interpret and has a lower physiological impact compared to flexible nasopharyngolaryngoscopy. Laryngeal US is an accurate and low-cost diagnostic test for vocal cord paralysis. In this review, we describe the anatomy of the larynx and recurrent laryngeal nerve; the causes, symptoms and pathophysiology of vocal cord paralysis; laryngeal US technique; diagnostic criteria for vocal cord paralysis; and a reporting system.

ROLE OF ULTRASONOGRAPHY IN UPPER AIRWAY ASSESSMENT FOR DECANNULATING TRACHEOSTOMY IN ACQUIRED BRAIN INJURY - A PILOT STUDY

OBJECTIVE

To compare the findings of ultrasonography of the upper airway with flexible fiberoptic laryngoscopy and determine the efficacy of transcutaneous laryngeal ultrasonography for decannulation.

DESIGN

Prospective cross sectional study SETTING: Tertiary care referral centre in South India PARTICIPANTS: Twenty- four patients with acquired brain injury MAIN OUTCOME MEASURES: Participants underwent an airway assessment by ultrasonography followed by assessment of airway by flexible laryngoscopy done within the next 72 hours.

RESULTS

Vocal cord assessment by ultrasonography revealed a sensitivity of 81.2% and specificity of 87.5%. A statistically significant association between vocal cord mobility as assessed by ultrasonography and decannulation was observed (sensitivity of 81.25%, specificity of 87.5%, p= 0.002). Although aspiration was not assessed by ultrasonography, a statistically significant association was observed between vocal cord mobility on ultrasonography and aspiration as assessed by laryngoscopy (sensitivity of 81.25%, specificity of 87.5%, p= 0.011).

CONCLUSION

Laryngeal ultrasonography is an emerging diagnostic modality with a potential role for assessing vocal cord mobility and airway prior to decannulation in centres which lack the expertise and the infrastructure to perform a flexible laryngoscopy.

Laryngeal Myxoma: A rare localization

INTRODUCTION

Myxomas are benign mesenchymal neoplasms which arise mainly in the heart. The laryngeal localization is very rare. We aim to describe the clinical, histological and therapeutic features of this condition.

CASE REPORT

We report two cases of laryngeal myxomas occurred in male and female patients, presenting with a history of prolonged hoarseness. Laryngoscopy revealed a polypoid mass on the true vocal folds. The lesions were excised with cold instruments. One patient presented a recurrence 4 years after the first surgery.

CONCLUSIONS

Laryngeal myxoma should be considered in case of a benign looking vocal fold lesion, especially a vocal cord polyp. Histologic exam is the only tool to confirm the diagnosis. It is treated by surgical resection. In the literature, recurrence is rare in laryngeal site, but patients need to be kept on close follow-up.

A case report and revision of the literature]

Inflammatory myofibroblastic tumour (IMT) is a rare entity that can occur in practically any location. Although it has an increased incidence in infancy and adolescence, cases of IMT in the head and neck are more frequent in adults. We report the case of a 74-year-old male who presented with a two month history of dysphonia. Laryngoscopy and cervical TAC revealed a nodular lesion affecting the anterior half of the left vocal cord. He underwent endoscopic laser cordectomy. Histopathology concluded that the lesion was an IMT. Cases of IMT in the head and neck are infrequent and in the vocal cord extremely rare, with only a few previously reported cases.

Vocal-cord Only vs. Complete Laryngeal radiation (VOCAL): a randomized multicentric Bayesian phase II trial

BACKGROUND

Radiotherapy, along with laser surgery, is considered a standard treatment option for patients with early glottic squamous cell cancer (SCC). Historically, patients have received complete larynx radiotherapy (CL-RT) due to fear of swallowing and respiratory laryngeal motion and this remains the standard approach in many academic institutions. Local control (LC) rates with CL-RT have been excellent, however this treatment can carry significant toxicities include adverse voice and swallowing outcomes, along with increased long-term risk of cerebrovascular morbidity. A recent retrospective study reported improved voice quality and similar local control outcomes with focused vocal cord radiotherapy (VC-RT) compared to CL-RT. There is currently no prospective evidence on the safety of VC-RT. The primary objective of this Bayesian Phase II trial is to compare the LC of VC-RT to that of CL-RT in patients with T1N0 glottic SCC.

METHODS

One hundred and fifty-five patients with T1a-b N0 SCC of the true vocal cords that are n ot candidate or declined laser surgery, will be randomized in a 1:3 ratio the control arm (CL-RT) and the experimental arm (VC-RT). Randomisation will be stratified by tumor stage (T1a/T1b) and by site (each site will be allowed to select one preferred radiation dose regimen, to be used in both arms). CL-RT volumes will correspond to the conventional RT volumes, with the planning target volume extending from the top of thyroid cartilage lamina superiorly to the bottom of the cricoid inferiorly. VC-RT volumes will include the involved vocal cord(s) and a margin accounting for respiration and set-up uncertainty. The primary endpoint will be LC at 2-years, while secondary endpoints will include patient-reported outcomes (voice impairment, dysphagia and symptom burden), acute and late toxicity radiation-induced toxicity, overall survival, progression free survival, as well as an optional component of acoustic and objective measures of voice analysis using the Consensus Auditory-Perceptual Evaluation of Voice.

DISCUSSION

This study would constitute the first prospective evidence on the efficacy and safety of VC-RT in early glottic cancer. If positive, this study would result in the adoption of VC-RT as standard approach in early glottic cancer.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03759431 Registration date: November 30, 2018.

Prognostic Significance of Vocal Cord Mobility after Laryngeal Preservation Protocols in Locally Advanced Laryngopharyngeal Cancers: A Retrospective Analysis

In the present study, we look at the prognostic implications of the recovery of vocal cord mobility after treatment in T3 laryngeal and hypopharyngeal cancers with fixed vocal cords. Patients with T3 laryngeal and hypopharyngeal carcinoma were considered for the study. All patients were treated with standard laryngeal preservation protocols as per treatment guidelines. Recovery of vocal cord functions was assessed with serial flexible laryngoscopic evaluation. Recovery of vocal cord mobility was compared with oncological outcomes. Twenty seven patients were available for final analysis. Cases, where vocal cords remained fixed or continued to have restricted mobility on follow up, were categorised as "unfavourable" and those with complete recovery of function as compared to pre treatment FOL as "Favourable". Thirteen (48%) patients did not regain complete mobility of vocal cords. Six patients from the 'unfavourable' group (46%) developed recurrence, whereas only one patient from the 'favourable' group (7%) had a recurrence (p = 0.03). The findings of the present study suggest that failure to regain complete vocal cord mobility after CTRT is a poor prognostic factor in T3 laryngeal and hypopharyngeal cancers.

Evaluation of one-year incidence of vocal dysfunction and associated demographic factors in thyroidectomy patients: A descriptive analytical study

Background

Voice changes are common complaint following thyroidectomy that might or might not be associated with laryngeal nerve damage. Objective: The aim of this study is to evaluate the effect thyroidectomy on voice alteration and its association with gender and age.

Methods

In this descriptive analytical study, patients who underwent thyroidectomy at (XXX) without laryngeal nerve damage were included. These patients were evaluated based on subjective (self-reported) and objective (videostroboscopy) voice assessment. The data was collected immediately after the surgery and 6 months after the surgery during the follow-up.

Results

Of 76 patients included, the mean age of patients was 46.3 year. 25 (43.4%) were males and 51 (56.6%) were female. 28.9% patients were presented with apparent damage to the vocal cords, of which 8 (10.5) had voice changes. There was no statistically significant difference between sex and postoperative vocal cord dysfunction (P = 0.592). However, in male gender, late postoperative voice changes were significantly more, p = 0.013. The age was also not associated with immediate or late postoperative changes and damage to vocal cords, p > 0.05.

Conclusion

Our study reported that male gender can be an important factor in deterring voice changes after thyroidectomy nonetheless, it can not predict the risk of vocal cord damage. Furthermore, age might not a risk factor either. Studies with greater sample size are required to confirm these findings.

•

Voice changes are common complaint following thyroidectomy.

•

That might or might not be associated with laryngeal nerve damage.

•

Male gender can be an important factor in deterring voice changes after thyroidectomy.

•

Studies with greater sample size are required to confirm these findings.

Laryngeal granular cell tumors in children: A literature review

OBJECTIVE

Granular cell tumors of the larynx are exceedingly rare in the pediatric population. The purpose of this review is to further characterize features of these tumors and trends in their management.

METHODS

A search of the PubMed, Ovid Medline and Cochrane Collaboration databases was undertaken using the terms: pediatric, child, laryngeal, larynx, granular cell tumor, granular cell myoblastoma, benign mass.

RESULTS

A total of 38 children with laryngeal granular cell tumor were identified. Their ages ranged from 4 to 16 years. The most common presenting symptom was dysphonia. Five patients were previously treated for asthma. Within the laryngeal subsites, 49% presented with subglottic tumors, while 43% were found at the level of the glottis. Subglottic tumors were found anteriorly 42% of the time and posteriorly 53% of the time. Multifocal disease was present in four patients. Around half of patients were treated by cold steel excision and/or CO₂ laser, 31% through laryngofissure, and two required laryngectomy. There were four documented cases of recurrence ranging from 4 months to 3 years after treatment.

CONCLUSIONS

Laryngeal granular cell tumor during childhood occurs most commonly in the subglottis. Posterior laryngeal tumors were more frequent than anterior tumors. Patients should be carefully evaluated for multifocal disease. Long-term surveillance for recurrence is recommended.

The Role of TREK-1 and AQP5 in Gonadocorticoid-Related Voice Disorders

OBJECTIVES

TWIK-related potassium channel-1 (TREK-1) and Aquaporin 5 (AQP5) are involved in epithelial integrity and fluid transport, respectively. In this study, we aimed to compare physiological and gestational patterns of TREK-1 and AQP5 location and expression in rat larynx. Our secondary objective was to reveal the effect of estradiol (E2) and progesterone (PG) on these two biomolecules.

METHODS

This study was conducted on 20 Wister albino female rats which were assigned as control (group A) and pregnant group (group B). The rats were sacrificed at 20th day of pregnancy. Blood was obtained directly from the ventricle for detection of serum E2 and PG levels. Larynx was resected for immunohistochemical analyses and real-time polymerase chain reaction testing for detection of TREK-1 and AQP5 staining and expression, respectively.

RESULTS

Relative TREK-1 (P = 0.035) and AQP5 (P = 0.019) expression was found to be significantly high in group B when compared with group A. We found positive correlation between serum E2 levels and both biomolecules (TREK-1; P = 0.018, AQP5; P = 0.016). We also found positive correlation between serum PG levels and both biomolecules (TREK-1; P = 0.001, AQP5; P = 0.019). TREK-1 immunostaining was found to be higher in surface epithelium and lamina propria of vocal cord mucosa. AQP5 was particularly found to be located in basement membrane and adjacent superficial lamina propria. We revealed the physiological and gestational pattern of laryngeal TREK-1 and AQP5 expression for the first time. Gestational expression of both TREK-1 and AQP5 was found to be increased. Stimulatory effect of E2 and PG on laryngeal TREK-1 and AQP5 expression was also revealed.

CONCLUSIONS

We revealed upregulatory effect of E2 and PG on laryngeal TREK-1 and AQP5 expression. Based on this finding, it can be suggested that TREK-1 and AQP5 play role in biomolecular processes leading gonadocorticoid-related voice changes.

The diagnostic value of perpendicular vascular patterns of vocal cords defined by narrow-band imaging

PURPOSE

According to the classification of glottic lesions by narrow-band imaging (NBI) proposed by the European Laryngological Society (ELS), lesions without perpendicular patterns are benign, while wide- and narrow-angled perpendicular lesions include both papilloma and carcinoma/high-grade lesions, respectively. The purpose of the study was to investigate the effectiveness of the ELS classification.

METHODS

One hundred and forty four patients with glottic lesions underwent microlaryngoscopy with NBI. The affected vocal cords (arm A) were histologically analysed. The unaffected vocal cords (arm B) were not histologically analysed and were considered to be true negatives if no suspicious changes appeared during the follow-up. The vocal cords from arm A were categorised into three groups-those with a benign disease (papilloma excluded), those with a carcinoma/high-grade lesion and those with papilloma. The ratio of vascular patterns was determined and the groups were statistically compared using the Chi-square test.

RESULTS

Perpendicular patterns were identified only in 9.3% (9/97) of those in the benign group (without papilloma). Wide-angled patterns were mainly identified in cases of papilloma (80%, 12/15), while the narrow-angled ones were mostly identified in cases of carcinoma and high-grade lesions (96.2%, 76/79) (P < 0.001). The sensitivity, specificity, positive and negative predictive values and accuracy were 98%, 95%, 88%, 99% and 95%, respectively.

CONCLUSION

The ELS classification of vocal cord lesions by NBI is effective in differentiating between carcinoma/high-grade lesions and papilloma and the remaining benign lesions of the vocal cords.

Comparison of arytenoid vertical height discrepancy in normal versus patients with vocal cord palsy

OBJECTIVE

Cadaveric experiments and more recently clinical data have demonstrated that patients with vertical height discrepancy between their arytenoids experience poorer voice outcomes in patients with unilateral vocal cord palsy (UVP) after medialisation laryngoplasty. However, the presence or severity of height discrepancy in normal patients without UVP has not yet been clearly defined.

STUDY DESIGN

Case-control study.

SETTING

Tertiary Australian hospitals.

SUBJECTS AND METHODS

A retrospective review was performed on patients who underwent high computed tomography imaging of the neck. Scans were assessed for discrepancy in arytenoid vertical height discrepancy and compared to a cohort with known UVP.

RESULTS

44 normal patients (50% female, mean age 57.6 ± 14.8 years) were compared to 23 patients with UVP (43.4% female, mean age 52.3 ± 14.9 years.) Normal patients were found to have a smaller height discrepancy compared to UVP patients (student's t-test,2.00 mm ± 0.00 vs 2.39 mm ± 0.72, p < .001.) CONCLUSION: This study suggests that discrepancy is pathologic, and it is plausible that this results in acoustic consequences.

Acute tissue damage induced by monopolar microelectrodes and radiofrequency in vocal cords after transoral cordectomy

INTRODUCTION

In 2006 and 2009, we reported the levels of acute and chronic tissue damage after cordectomy associated with use of the microlectrodes using high frequency energy. In 2010, we shifted to radiofrequency rather than high frequency electrogenerators.

OBJECTIVE

The aim of this study is to evaluate acute tissue damage in the larynx after cordectomy using microelectrodes coupled to a radiofrequencygenerator.

METHODS

We studied 22 patients with a stage T1 glottic squamous cell carcinoma. The patients were randomly assigned to the two operating mode: cutting or coagulation (11 patients each mode). The strength of the study is that there are no previous studies on the effect of radiofrequency in human vocal cord.

RESULTS

Tissue damage was milder when microelectrodes were coupled to a 4 MHz generator operating in the cutting mode. Thus, when using microelectrodes and radiofrequency, we recommend that the cutting mode be used for epithelial incision and the coagulation mode to treat the stroma and muscle and for final hemostasis.

CONCLUSION

Microelectrodes and radiofrequency in transoral laryngeal surgery produced mild tissue damage and offer an excellent alternative to the use of high frequency energy.

Vocal cord dysfunction following esophageal atresia and tracheoesophageal fistula (EA/TEF) repair

BACKGROUND

The purpose of this study was to determine risk factors and long-term outcomes in patients with esophageal atresia +/-tracheoesophageal fistula (EA/TEF) with vocal cord dysfunction (VCD) owing to recurrent laryngeal nerve (RLN) injury.

METHOD

A retrospective chart review was performed for EA/TEF patients repaired at our institution from 1999 to 2014 (REB #1000032265).

RESULTS

Of 197 patients, 22 (11.2%) were diagnosed with VCD by indirect laryngoscopy following EA/TEF repair. Aspiration was documented on video swallow study for 21 patients, and as a result, 13 required thickened feeds and 8 required gastrostomy tube feeds. Of the 16 H-type TEF patients, 8 (50%) had VCD. Following discharge, 20 (90.9%) patients with VCD eventually tolerated full feeds orally without aspiration but only 8 (36.4%) had documented recovery of vocal cord movement at long-term follow up (mean 452 days). Overall, patients with VCD were more likely to have feeding modifications, increased exposure to radiological studies, and increased frequency of Otolaryngology follow-up compared to EA/TEF patients without VCD.

CONCLUSION

EA/TEF patients are at risk for VCD. Clinical improvement did not always correlate with recovery of VC motion. Strategies to minimize RLN damage will improve outcomes and quality of life for EA/TEF patients.

LEVEL OF EVIDENCE

Level III.

Arytenoid vertical height discrepancy in predicting outcomes after unilateral vocal cord medialization

OBJECTIVES/HYPOTHESIS

Unilateral vocal fold paralysis is a structural abnormality that often occurs secondary to dysfunction of the recurrent laryngeal nerve and typically presents as a breathy voice. Medialization laryngoplasty is a constellation of procedures that improves apposition of the vocal cords. Many patients, however, fail to experience sufficient improvement in vocal quality postoperatively despite apparent glottic closure on stroboscopy. This suggests that asymmetry in other cord characteristics may also have acoustic consequences. Our hypothesis is that arytenoid height symmetry may play a significant role in vocal quality. To our knowledge there are no human observational studies examining this topic. We therefore aimed to correlate asymmetry in arytenoid height and patient-reported satisfaction in voice quality after thyroplasty.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

A retrospective review of prospectively collected data on consecutive patients who underwent medialization thyroplasty at a tertiary Sydney, Australia hospital was performed. Data collected included age, sex, onset of symptoms, as well as well as preoperative and 3-month postoperative maximum phonation time and Voice Handicap Index (VHI). Preoperative computed tomography scans were assessed for discrepancy of arytenoid vertical height discrepancy.

RESULTS

Twenty-three patients (56.5% female) with mean age of 52.4 ± 14.9 years were included. Most patients underwent injection thyroplasty (78.3%, n = 5), whereas the remaining underwent an open approach. A statistically significant inverse correlation was found between increasing height discrepancy and VHI improvement (r = -0.6, P = .003.) Revision surgery was associated with increased height discrepancy.

CONCLUSIONS

Findings of this study may affect future recommendations to address height discrepancy in surgery to treat unilateral vocal cord paralysis.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:418-422, 2020.

[Trans-vocal cord prostheses - preliminary experience treating benign laryngotracheal stenosis in adults]

INTRODUCTION

Benign laryngotracheal stenosis is a rare pathology with multiple etiologies, the management of which is complex. This is because of the configuration and proximity of the larynx and the difficulty with surgical approaches, which are potentially mutilating, especially for the management of a benign disease. When surgery is challenging, iterative dilatations of the stricture or the fashioning of a definitive tracheotomy are therapeutic alternatives. Advances in rigid bronchoscopy and the evolution of prosthetic silicone material allow a new approach in the management of benign laryngotracheal stenosis, by placing flexible silicone prostheses which cover all the stenosis from the arytenoids to the trachea. This preliminary work aims to evaluate the feasibility, effectiveness, tolerance and complications of the implementation of this type of prosthesis.

PATIENTS AND METHODS

This is a retrospective single-centre study which analyzed the records of patients with symptomatic benign laryngotracheal stenosis who underwent placement of a transcordial prosthesis over a period of three years. The prosthesis used, inserted under general anesthesia during a rigid tube interventional bronchoscopy, was either a straight silicone prosthesis or a Montgomery T-tube for those with a pre-existing tracheotomy.

RESULTS

Six patients were included. Five are still alive, one patient died from a cause unrelated to the placement of the prosthesis. Four have no tracheostomy and two now have no transcordal prosthesis. The data collected on tolerance found, for three patients, two cases of minor aspiration and one case of transient cough. All patients had whispered voice dysphonia. We did not observe prosthesis migration or obstruction.

CONCLUSION

These preliminary results are encouraging. Transcordal prostheses in benign laryngotracheal stenosis have a complementary or alternative role compared to surgery with a palliative or even curative objective.

Histopathologic Evaluation of Hyaluronic Acid and Plasma-Rich Platelet Injection into Rabbit Vocal Cords: An Experimental Study

Objective

Various materials are used by otolaryngologists for vocal cord injections in the management of vocal cord paralysis. An ideal injection material should be long-term effective, readily available, cheap, easy to prepare, have no donor morbidity, easy to use, biocompatible, resistant to resorption or migration, and easy to extract during revision. In this study, we aimed to see the histopathological effects of hyaluronic acid (HYA) and platelet-rich plasma (PRP) injections into the vocal cords of New Zealand rabbits.

Methods

PRP was injected into the right vocal cords of twelve rabbits, which was prepared from their serum (PRP group). HYA was injected into the left vocal cords of first six rabbits (numbered 1-6) (HYA group), and the left vocal cords of the other six rabbits (numbered 7-12) were followed with no intervention (control group). Two months later, histomorphological findings in the vocal cords were assessed by two experienced pathologists in seven parameters: chronic inflammation, mucosal atrophy, necrosis, neovascularization, fibrosis, foreign body reaction, and muscular atrophy. They were scored double-blinded as negative (0), mild (+1), moderate (+2), and severe (+3). Fisher's chi-square test was used to evaluate any statistical significance among the three groups.

Results

Chronic inflammation, mucosal atrophy, necrosis, foreign body reaction, and muscular atrophy parameters were scored as "0" for each preparate by both pathologists. For neovascularization and fibrosis, a stasistically significant difference was seen among the three groups (p<0.05). Neovascularization was increased in the PRP and HYA groups compared with the control group. No significant difference was observed in fibrosis when the groups were compared separately. After two months, two of the six vocal cords injected with HYA revealed HYA; however, none of the PRP-injected vocal cords showed PRP.

Conclusion

HYA and PRP can be safely injected into vocal cords. Our findings show that HYA is a biocompatible and safe injection material for clinical use. Only two of the six vocal cords showed HYA at the end of two months, suggesting that HYA is a short-term effective material. Similarly, PRP was also shown to be a short-term effective material and can be used in patients for testing purpose before using a long-term effective material. The advantages of PRP are that it is inexpensive, readily available, and completely inert as it is prepared from the subject itself.

Histopathological Analysis of the Effects of Corticosteroids on Vocal Cords: Experimental Study

Local treatment with corticosteroids results in side effects involving the upper respiratory tract including candidiasis, sore throat, and dysphonia. Although these effects are well known, they have not been evaluated using a histopathological approach. This study investigated the histopathological aspects of steroid-induced dysphonia. A total of 16 female Wistar albino rats were divided into two groups. The eight rats in the experimental group were given an inhaled dose of mometasone furoate daily for 4 weeks. The control group was kept at room temperature for 4 weeks. The vocal cords were evaluated histopathologically using hematoxylin and eosin staining. Both groups had typical epithelial lining and basal membranes. Inflammation differed between the two groups (P = 0.024). There were no differences in squamous metaplasia and hyperplasia (P = 0.302 and 0.302, respectively). This study revealed that inhaled corticosteroids inhibit mucosal immunity, and may result in reversible mucosal changes.

Efficacy of Two-dimensional Scanning Digital Kymography in Evaluation of Atrophic Vocal Folds

OBJECTIVE

The purpose of this study was to evaluate the clinical feasibility and diagnostic accuracy of two-dimensional scanning digital kymography (2D DKG) in patients with vocal cord atrophy before and after treatment.

MATERIALS AND METHODS

We analyzed the characteristics of vocal fold vibration in five patients with unilateral vocal fold paralysis and five patients with presbyphonia. In patients with vocal cord paralysis, the status before and after intracordal injection was compared. Furthermore, in patients with presbyphonia, we compared the status before and after voice therapy (Seong-Tae Kim's laryngeal calibration technique). Quantitative parameters such as amplitude and phase symmetry indices, jitter, shimmer, noise-to-harmonic ratio, and maximum phonation time and qualitative parameters such as Voice Handicap Index, glottal gap, amplitude, and phase difference were used to evaluate the pre- and post-treatment status.

RESULTS

In cases of vocal cord paralysis, vibratory changes of the vocal folds before and after intracordal injection could be identified immediately using 2D DKG. In overcorrection cases, all of the measured parameters were poor except for improvement of the glottal gap. In addition, 2D DKG showed appropriately the changes in vocal cord vibration before and after voice therapy in patients with presbyphonia.

CONCLUSION

Two-dimensional DKG may be a useful diagnostic tool in evaluation of the vibratory characteristics of entire vocal cords. In addition, it may also play a role in providing a decision for treatment modalities.

Relationship between laryngoscopic and pathological characteristics of vocal cords leukoplakia

BACKGROUND

To explore the relationship between the morphological characteristics and pathological diagnosis of vocal cords leukoplakia.

METHODS

A total of 1635 vocal cords were collected. The morphology were classified into three types (Type I, II, III): flat and smooth; bulge and smooth; bulge and rough. The pathological reports were classified into five groups: no dysplasia, mild dysplasia, moderate dysplasia, severe dysplasia and cancerization. The number of the patients or vocal cords in each type and group was counted and their ratio was compared.

RESULTS

In Type I, the number of vocal cord in Group A group was 2.2 and 2.6 times of the one in Type II and Type III respectively. In Type II, the mild, moderate dysplasia ratio was higher than those in Type I. In Type III group the ratio of severe dysplasia was 2.6 and 5.5 times of the one in Type II and Type I respectively. The ratio of Group E in Type III was 2.7 and 7.9 times of the one of Type II and Type I. The result was significant (pearson Chi-square value was 517.6, p = .00).

CONCLUSIONS

The pathological results of vocal cord leukoplakia can be evaluated by morphology in most cases.

Xanthoma Disseminatum Presenting with Hoarseness

INTRODUCTION

Xanthoma disseminatum (XD) is a rare, benign, non-Langerhans cell histiocytic disorder with unknown etio-pathology. It manifests with multiple, grouped, red-brown to yellow papules and nodules involving the skin, mucous membranes, and internal organs with a predilection for flexures and the face.

CASE REPORT

We report a patient who presented with disseminated xanthomatous papules and nodules involving the face, neck, trunk, axilla, groin, and oral cavity, along with hoarseness of voice. Video laryngoscopy revealed multiple yellowish nodules over the base of the tongue, vallecula, laryngeal surface of the epiglottis, ary-epiglottic folds, interarytenoid region, and subglottic region. Histopathology was suggestive of xanthoma disseminatum and the patient was treated with tablet acitretin 25mg daily for three months without any response. Following this, the patient was prescribed tablet thalidomide 100 mg daily without any significant improvement at the end of two months.

CONCLUSION

Xanthoma disseminatum is a very rare form of non-Langerhans cell histiocytosis that classically presents with cutaneous xanthomas, mucosal xanthomas, and diabetes insipidus. Hoarseness of voice due to lesions involving the larynx is a rare symptom. Because the disease has punctated, numerous relapses and causes morbidity to the patient, its multisystem manifestations have to be known. Therefore, xanthoma disseminatum has to be kept in mind as a differential diagnosis for hoarseness of voice.

Evaluation of Vocal Cord Function Before Thyroidectomy: Experience from a Developing Country

Vocal cord palsy (VCP) is a major complication of thyroidectomy. Some patients have preexisting VCP prompting the need for routine or selective preoperative evaluation of the vocal cords. The study aims at ascertaining the prevalence of preoperative VCP and making appropriate recommendations. This is a retrospective study of all adult patients who had thyroidectomy at the University of Nigeria Teaching Hospital. Case notes of patients who had thyroidectomy at the hospital from July 2010 to June 2015 were retrieved. Variables studied included biodata, duration of goiter, preoperative hoarseness, outcome of indirect laryngoscopy (IDL), histology of specimen, duration of follow-up, and incidence of postoperative hoarseness. Descriptive statistical analysis was done using SPSS version 20. Of the 91 patients aged 21-70 years (mean 42.08 years, SD 15.40), females outnumbered males with a M:F ratio of 1:10.4. Five patients had preoperative hoarseness, but only three had VCP. IDL was done for 25 (27.4%) patients out of which 22 (88.0%) had normal studies while the remaining three (all from the five with hoarseness) had VCP. Histology of the specimens showed malignancy in 10 (11%), benign in 55 (60.4%), and no report in 26 (28.6%). Five of the malignant histology patients showed normal findings on IDL, three had VCP and two had no preoperative IDL. There was no case of asymptomatic VCP. Vocal cord evaluation is recommended for patients with voice symptoms and those with malignant goiter.

Non-functioning parathyroid adenoma: a rare differential diagnosis for vocal-cord paralysis

Introduction Adenomas of the parathyroid gland typically present with symptoms of hyperparathyroidism, manifested by fatigue, bone pain, abdominal pain, weakness, dyspepsia, nephrolithiasis and skeletal bone disease. Here, we describe, for the first time, a case of a non-functioning benign tumour of the parathyroid gland presenting as vocal-cord paralysis. Case History A 49-year-old male presented with a 10-week history of dysphonia and the feeling of having 'something stuck in my throat'. History-taking elicited no other associated symptoms. Flexible nasal endoscopy demonstrated paralysis of the left vocal cord. Computed tomography of the neck revealed a cystic lesion, 18mm in diameter adjacent to the oesophagus. After more rigorous tests, a neck exploration, left hemithyroidectomy, excision of the left paratracheal mass and level-VI neck dissection was undertaken, without incident to the patient or surgical team. Histology was consistent with a parathyroid adenoma. Conclusions This case emphasises the importance of including adenomatous disease of the parathyroid gland in the differential diagnosis despite normal parathyroid status as a cause of vocal cord palsy.

Primary aspergillosis of vocal cord: Long-term inhalational steroid use can be the miscreant

Primary laryngeal aspergillosis is extremely rare, especially in an immunocompetent host. It is commonly found as a part of systemic infection in immunocompromised patients. A case of vocal cord aspergillosis with no systemic extension in an immunocompetent patient on long-term steroid metered dose inhaler (MDI) is presented here, because of its rarity. The present case is a 28-year-old asthmatic female who was on inhalational steroid for 8 years, presented with sudden onset of severe dysphonia for 5 days. Fiberoptic laryngoscopy demonstrated whitish plaque involving right vocal cord, clinically suggestive of fungal laryngitis. Microlaryngeal laser surgery was performed with stripping of the plaque. Histopathology demonstrated ulcerated hyperplastic squamous epithelium with masses of fungal hyphae, which was confirmed to be Aspergillus species on fungal culture. This rare but serious adverse effect of long-term steroid MDI use must be kept in mind while treating an asthmatic patient. We also present a brief review of literature of laryngeal aspergillosis.

Paradoxical vocal cord movement during sleep - A unique case with review of literature

Paradoxical vocal cord movement (PVCM) refers to paradoxical adduction of the true vocal cords during inspiration resulting in variable upper airway obstruction. The condition often presents with shortness of breath, wheeze or stridor, mimicking bronchial asthma. Both organic and non-organic causes have been described. PVCM occurring only during sleep has rarely been reported in patients with CNS disease. We present a case of PVCM occurring only during sleep in a 14-year-old boy without any CNS disease, who was initially misdiagnosed as bronchial asthma.

Vocal cord dysfunction: a review

Vocal cord dysfunction (VCD) is a term that refers to inappropriate adduction of the vocal cords during inhalation and sometimes exhalation. It is a functional disorder that serves as an important mimicker of asthma. Vocal cord dysfunction can be difficult to treat as the condition is often underappreciated and misdiagnosed in clinical practice. Recognition of vocal cord dysfunction in patients with asthma-type symptoms is essential since missing this diagnosis can be a barrier to adequately treating patients with uncontrolled respiratory symptoms. Although symptoms often mimic asthma, the two conditions have certain distinct clinical features and demonstrate specific findings on diagnostic studies, which can serve to differentiate the two conditions. Moreover, management of vocal cord dysfunction should be directed at minimizing known triggers and initiating speech therapy, thereby minimizing use of unnecessary asthma medications. This review article describes key clinical features, important physical exam findings and commonly reported triggers in patients with vocal cord dysfunction. Additionally, this article discusses useful diagnostic studies to identify patients with vocal cord dysfunction and current management options for such patients.

Chemo-port insertion: A cause of vocal cord palsy

We describe extremely rare cases of vocal cord palsy following surgical insertion of a chemo port. Our cohort consisted of patients with cancer who developed hoarseness immediately after central venous line placement for the administration of chemotherapy, with vocal cord palsy confirmed with flexible laryngoscopy. Given the timing, central venous line placement appears to be the most likely cause.

Distance between Anterior Commissure and the First Tracheal Ring: An Important New Clinical Laryngotracheal Measurement

INTRODUCTION

The distance between the anterior commissure of the larynx and the first tracheal ring (AC.T. distance) is of great importance in laryngotracheal surgeries. The amount of narrowing of the subglottic airway is used as a quantitative mean to determine whether the lesion is subglottic or has extended to the trachea and therefore helps in the prediction of the final prognosis.

MATERIALS AND METHODS

In this study, the larynx was exposed by direct laryngoscopy under general anesthesia. The case was considered to be difficult because the exposure did not optimally reveal the anterior commissure, therefore a cricoid tape or anterior commissure laryngoscope was used. A zero degree Hopkins lens was used to view the anterior commissure and the first tracheal ring. Special markers were used to mark the two points with the distance between those being considered as the AC.T. distance. The relationship between AC.T. distance and the patient's age, sex, BMI, and laryngeal exposure condition during laryngoscopy was also studied.

RESULTS

Eighty-two patients participated in this study. The mean AC.T. distance was measured and was found to be 32.67±3.34 mm in males and 29.80± 3.00 mm in females. This difference was statistically significant between the two groups (P<0.05). There was no statistically significant relationship between BMI, age, laryngeal exposure condition, and the AC.T. distance.

CONCLUSION

The AC.T. distance was measured to be around 3 cm; with males measuring greater than females. However, future studies may lead to a more accurate practical scale for laryngotracheal surgeries due to possible technical or human errors, in addition to racial differences.

Laryngeal adductor function in experimental models of recurrent laryngeal nerve injury

OBJECTIVES/HYPOTHESIS

Most patients with unilateral vocal fold paralysis experience some degree of spontaneous reinnervation, which depends upon the type and severity of recurrent laryngeal nerve (RLN) injury. After partial recovery, the paretic vocal fold may or may not adduct adequately to allow glottic closure, which in turn affects phonatory and swallowing outcomes. This process was studied in a series of canine laryngeal nerve injury models.

STUDY DESIGN

Animal (canine) experiments.

METHODS

Maximum stimulable laryngeal adductor pressure (LAP) was measured pretreatment (baseline) and at 6 months following experimental RLN injuries (total n = 59). The nine study groups were designed to simulate a range of severities of RLN injury.

RESULTS

The greatest LAP recovery, at 108% of original baseline, was seen in a 50% transection model; the least recovery was seen when the RLN underwent complete transection with repair, at 56% with precise alignment and 50% with alignment reversed. Intermediate models (partial RLN injuries) gave intermediate results. Crush models recovered 105% of LAP, whereas a half-transection, half-crush injury recovered 72%, and cautery injuries recovered 61%. Controls (complete transection without repair) had no measurable recovery.

CONCLUSIONS

The injured RLN has a strong tendency to recover. Restoration of adductor strength, as determined by the LAP, was predictably related to the severity of RLN injury. The model RLN injuries studied provide a range of expected outcomes that can be used for future experiments exploring interventions that may improve postinjury adductor function.

LEVEL OF EVIDENCE

NA.

Nasolaryngoscopy

Nasolaryngoscopy is a low-risk, quick means of making a specific diagnosis for voice complaints; it should be performed before empiric treatment based on history and general examination alone. The most common indications for nasolaryngoscopy are hoarseness, globus sensation, and chronic cough. The most common findings in a primary care setting include laryngopharyngeal reflux (43%), chronic rhinitis (32%), and vocal cord lesions (13%).

Laryngeal problems

Laryngeal complaints are common reasons for patients to seek care. There is considerable overlap between patient symptoms and final diagnosis. This article begins with a general approach to laryngeal symptoms followed by individual consideration of both the common and serious conditions of the larynx. Early diagnosis and treatment are important for improving outcomes in patients with laryngeal complaints.

Delayed Unilateral Soft Palate Palsy without Vocal Cord Involvement after Microvascular Decompression for Hemifacial Spasm

Microvascular decompression is a very effective and relatively safe surgical modality in the treatment of hemifacial spasm. But rare debilitating complications have been reported such as cranial nerve dysfunctions. We have experienced a very rare case of unilateral soft palate palsy without the involvement of vocal cord following microvascular decompression. A 33-year-old female presented to our out-patient clinic with a history of left hemifacial spasm for 5 years. On postoperative 5th day, patient started to exhibit hoarsness with swallowing difficulty. Symptoms persisted despite rehabilitation. Various laboratory work up with magnetic resonance image showed no abnormal lesions. Two years after surgery patient showed complete recovery of unitaleral soft palate palsy. Various etiologies of unilateral soft palate palsy are reviewed as the treatment and prognosis differs greatly on the cause. Although rare, it is important to keep in mind that such complication could occur after microvascular decompression.

Ultrasonography assessment of vocal cords mobility in children after cardiac surgery

OBJECTIVES

Upper airway obstruction after pediatric cardiac surgery is not uncommon. In the cardiac surgical population, an important etiology is vocal cord paresis or paralysis following extubation. In this study, we aimed to evaluate the feasibility and accuracy of ultrasonography (US) assessment of the vocal cords mobility and compare it to fiber-optic laryngoscope (FL).

MATERIAL AND METHODS

A prospective pilot study has been conducted in Pediatric Cardiac ICU (PCICU) at King Abdulaziz Cardiac Center (KACC) from the 1st of June 2009 till the end of July 2010. Patients who had cardiac surgery manifested with significant signs of upper airway obstruction were included. Each procedure was performed by different operators who were blinded to each other report. Results of invasive (FL) and non-invasive ultrasonography (US) investigations were compared.

RESULTS

Ten patients developed persistent significant upper airway obstruction after cardiac surgery were included in the study. Their mean ± SEM of weight and age were 4.6 ± 0.4 kg and 126.4 ± 51.4 days, respectively. All patients were referred to bedside US screening for vocal cord mobility. The results of US were compared subsequently with FL findings. Results were identical in nine (90%) patients and partially different in one (10%). Six patients showed abnormal glottal movement while the other four patients demonstrated normal vocal cords mobility by FL. Sensitivity of US was 100% and specificity of 80%.

CONCLUSION

US assessment of vocal cord is simple, non-invasive and reliable tool to assess vocal cords mobility in the critical care settings. This screening tool requires skills that can be easily obtained.

Laryngeal tuberculosis without pulmonary involvement

BACKGROUND

Tuberculosis of the larynx is a rare form of tuberculosis. Patients usually present with hoarseness or dysphagia and other nonspecific constitutional symptoms like fever or localized pain. In this study, we present a case of primary vocal cord lesion with tuberculosis.

CASE PRESENTATION

A 72 year old man presented with hoarseness of voice, low grade fever, and night sweating with in three month duration. Laryncoscopic study showed unilateral thickening of vocal cord and biopsy of the lesion showed granuloma with caseous necrosis. Chest x-ray was normal. The patient was treated with standard regimen of tuberculosis and was cured after 6 months of therapy.

CONCLUSION

Laryngeal tuberculosis should be considered in the differential diagnosis of patients with hoarseness without pulmonary involvement in endemic regions of tuberculosis.

Laryngeal squamous cell carcinoma in a 13 year-old child associated with human papillomaviruses 16 and 18: a case report and review of the literature

Squamous cell carcinoma (SCC) of the larynx is extremely rare in adolescents and typically has an aggressive nature. The mechanism of laryngeal oncogenesis is complex and little is known about the role that human papillomavirus (HPV) plays in SCC in adolescents. We report a case of invasive laryngeal SCC that co-expressed HPV DNA subtypes 16 and 18 in a 13 year-old boy. Detection of HPV DNA types 6, 11, 16, 18, 31, 33, and 51 was performed by in situ hybridization, with confirmation by polymerase chain reaction. Immunohistochemical staining with p16 and HPV 16/18 revealed diffusely positive staining in the tumor cells. Coinfection by HPV DNA types 16 and 18 has not been previously reported, but our case suggests that HPV is a risk factor in developing laryngeal SCC in children and adolescents. Future studies evaluating HPV in the pathogenesis of these lesions is recommended to determine its prognostic significance.