In France, the main causes for unilateral laryngeal nerve paralysis in the adult patient are surgery and malignant tumors. Most of unilateral laryngeal nerve paralysis following thyroid surgery will recover within the first six postoperative months. At the time of unilateral laryngeal nerve paralysis, swallowing impairment and dyspnea occur in around 30% and 5% of cases, respectively. In the face of a unilateral laryngeal nerve paralysis occurring without a history of trauma of surgery, the main paraclinical examination to perform is a computed laryngeal nerve examination analyzing the whole length of the nerve involved. Speech therapy efficiency is related to the degree of severity of the symptoms related to unilateral laryngeal nerve paralysis. In the vast majority of cases, laryngeal medialization approaches improve dysphonia and swallowing impairment related to unilateral laryngeal paralysis, but not dyspnea. PMID:24525308
Laccourreye, Ollivier; Malinvaud, David; Ménard, Madeleine; Bonfils, Pierre
The aim of this report is to summarize current concepts in unilateral recurrent laryngeal nerve paralysis (URLNP). Important aspects of laryngeal phylogenesis, physiology and anatomy are reviewed. Recent advances in the neurophysiology of URNLP are discussed. Revised and updated principles of diagnosis and treatment are provided. Glottic configuration and prognosis vary according to the type of neural lesion (neurapraxia, axonotmesis or neurotmesis). Therapeutic indications depend on glottic configuration and prognosis. Treatment options include voice therapy, vocal fold augmentation by intrafold injection, medialization thyroplasty, arytenoid adduction, and laryngeal reinnervation. Each treatment option is summarized, and the results reported in the medical literature are reviewed. PMID:10739996
Hartl, D M; Brasnu, D
Vocal cord paralysis is a relatively common entity, usually resulting from a pathologic process of the vagus nerve or its recurrent laryngeal branch. It is rarely caused by intralaryngeal lesions. Fourteen patients with recurrent laryngeal nerve paralysis (RLNP) were evaluated by laryngography, computed tomography (CT), or both. In the evaluation of the paramedian cord, CT was limited in its ability to differentiate between tumor or RLNP as the cause of the fixed cord, but it yielded more information than laryngography on the structural abnormalities of the larynx and pre-epiglottic and paralaryngeal spaces. Laryngography revealed distinct features of RLNP and is the procedure of choice for evaluation of functional abnormalities of the larynx until further experience with faster CT scanners and dynamic scanning of the larynx is gained. PMID:6856825
Agha, F P
Accepted 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. PMID:17892603
The clinical diagnosis of superior laryngeal nerve paralysis (SLNp) is infrequently made, because of the heterogeneity of clinical presentations and laryngoscopic findings. Laryngeal electromyography (LEMG) can provide the definitive diagnosis of this abnormality. With increasing use of LEMG in clinical practice, this condition is now more frequently appreciated by otolaryngologists. A characteristic, but infrequently reported, videostroboscopic vocal fold motion termed Gegenschlagen ("dashing-against-each-other") has previously been described to occur in unilateral SLNp. We encountered such motion in a clinical case, which we subsequently verified as unilateral SLNp by means of LEMG. This characteristic glottic motion was then verified in an in vivo canine model of phonation after unilateral SLNp. Videostrobokymography was performed to generate kymograms that illustrated this vocal fold motion clearly. Kymograms of both human and canine subjects with SLNp demonstrated an undulating motion of the horizontally shifting glottic space as the medial edges of the vocal folds chased each other 90 degrees out of phase. As one vocal fold mucosal edge was opening, the other was closing, and this repeated motion appeared as vocal folds chasing or dashing against each other. Although not uniformly seen in all cases, this vocal fold motion appears to be unique to SLNp. PMID:17388230
Mendelsohn, Abie H; Sung, Myung-Whun; Berke, Gerald S; Chhetri, Dinesh K
Laryngeal paralysis is a common cause of upper airway obstruction in older, large-breed dogs and is likely associated with a generalized polyneuropathy in most animals. Surgical therapy is frequently indicated, and UAL is currently the recommended treatment. Respiratory signs significantly improve in most patients after surgery; however, postoperative complication rates can be high, and patients have a lifelong risk of developing respiratory tract disease. PMID:19517415
Millard, Ralph P; Tobias, Karen M
Voiced speech is produced by dynamic fluid-structure interactions in the larynx. Traditionally, reduced order models of speech have relied upon simplified inviscid flow solvers to prescribe the fluid loadings that drive vocal fold motion, neglecting viscous flow effects that occur naturally in voiced speech. Viscous phenomena, such as skewing of the intraglottal jet, have the most pronounced effect on voiced speech in cases of vocal fold paralysis where one vocal fold loses some, or all, muscular control. The impact of asymmetric intraglottal flow in pathological speech is captured in a reduced order two-mass model of speech by coupling a boundary-layer estimation of the asymmetric pressures with asymmetric tissue parameters that are representative of recurrent laryngeal nerve paralysis. Nonlinear analysis identifies the emergence of irregular and chaotic vocal fold dynamics at values representative of pathological speech conditions.
Sommer, David; Erath, Byron D.; Zanartu, Matias; Peterson, Sean D.
Vocal cord paralysis is a relatively common entity, usually resulting from a pathologic process of the vagus nerve or its recurrent larynegeal branch. It is rarely caused by intralargngeal lesions. Four teen patients with recurrent laryngeal nerve paralysis (RLNP) were evaluated by laryngography, computed tomography (CT), or both. In the evaluation of the paramedian cord, CT was limited in its
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. PMID:15699602
Yeon, Seong-Chan; Lee, Hee-Chun; Chang, Hong-Hee; Lee, Hyo-Jong
Four dogs with clinical signs of laryngeal paralysis and three normal dogs were evaluated with transnasal laryngoscopy. Six of these dogs subsequently underwent standard laryngoscopy. For transnasal laryngoscopy, a video endoscope was passed through the left nasal passage after intramuscular sedation and topical anesthesia. The laryngeal opening was observed during spontaneous ventilation. Laryngeal paralysis was diagnosed in four dogs and was confirmed with traditional laryngoscopy in three dogs. Normal motion of the arytenoid cartilages was present in the other three dogs; however, two required mechanical stimulation of the laryngeal mucosa for full evaluation. Transnasal laryngoscopy provided a means for diagnosing laryngeal paralysis in dogs without general anesthesia. PMID:15131101
Radlinsky, MaryAnn G; Mason, Diane E; Hodgson, David
Background: The non-recurrent laryngeal nerve is subject to potential injury during thyroid surgery. Intra-operative identification and preservation of this nerve can be challenging. Its presence is associated with an aberrant subclavian artery and the developmental absence of the brachiocephalic trunk. This study aimed to evaluate the incidence of non-recurrent laryngeal nerves and present a new classification system for the course of these nerves. Methods: Non-recurrent laryngeal nerves were identified on the right side in 15 patients who underwent thyroidectomy. The incidence of non-recurrent laryngeal nerves (during thyroidectomy) and aberrant subclavian arteries (using neck computed tomography) was evaluated, and the course of the nerves was classified according to their travelling patterns. Results: The overall incidence of non-recurrent laryngeal nerves was 0.68 per cent. The travelling patterns of the nerves could be classified as: descending (33 per cent), vertical (27 per cent), ascending (20 per cent) or V-shaped (20 per cent). Conclusion: Clinicians need to be aware of these variations to avoid non-recurrent laryngeal nerve damage. A retroesophageal subclavian artery (on neck computed tomography) virtually assures a non-recurrent laryngeal nerve. This information is important for preventing vocal fold paralysis. Following a review of non-recurrent laryngeal nerve travelling patterns, a new classification was devised. PMID:24849584
Hong, K H; Park, H T; Yang, Y S
Acquired laryngeal paralysis (LP) is an important cause of upper airway obstruction in dogs. We hypothesize that LP may be part of a generalized polyneuropathy complex. Electro-diagnostic studies were performed in six dogs, and histopathological studies of muscle and nerve biopsies were obtained from 11 dogs diagnosed with acquired LP. Abnormalities in electrodiagnostic procedures were consistent with a generalized polyneuropathy. Loss of large-caliber nerve fibers and axonal degeneration were identified in nerve biopsies, and neurogenic atrophy was observed in muscle specimens. Abnormalities in electrodiagnostic studies and histopathology provide evidence that LP may be part of a generalized polyneuropathy. Establishing a diagnosis of a more involved disease process is relevant for long-term prognosis. PMID:20439938
Thieman, Kelley M; Krahwinkel, D J; Sims, Michael H; Shelton, G Diane
It is well accepted that recurrent laryngeal nerve paralysis is a severe complication of esophagectomy or lymphadenectomy performed adjacent to the recurrent laryngeal nerves. Herein, determination of the effectiveness of implementing continuous recurrent laryngeal nerve monitoring to reduce the incidence of recurrent laryngeal nerve paralysis after esophagectomy was sought. A total of 115 patients diagnosed with esophageal cancer were enrolled in the thoracic section of the Tangdu Hospital of the Fourth Military Medical University from April 2008 to April 2009. Clinical parameters of patients, the morbidity, and the mortality following esophageal resection were recorded and compared. After the surgery, a 2-year follow up was completed. It was found that recurrent laryngeal nerve paralysis and postoperative pneumonia were more frequently diagnosed in the patients that did not receive continuous recurrent laryngeal nerve monitoring (6/61 vs. 0/54). Furthermore, positive mediastinal lymph nodes (P = 0.015), total mediastinal lymph nodes (P < 0.001), positive total lymph nodes (P = 0.027), and total lymph nodes (P < 0.001) were more often surgically removed in the patients with continuous recurrent laryngeal nerve monitoring. These patients also had a higher 2-year survival rate (P = 0.038) after surgery. It was concluded that continuous intraoperative recurrent laryngeal nerve monitoring is technically safe and effectively identifies the recurrent laryngeal nerves. This may be a helpful method for decreasing the incidence of recurrent laryngeal nerve paralysis and postoperative pneumonia, and for improving the efficiency of lymphadenectomy. PMID:23020300
Zhong, D; Zhou, Y; Li, Y; Wang, Y; Zhou, W; Cheng, Q; Chen, L; Zhao, J; Li, X; Yan, X
Three three-month-old Siberian husky x Alaskan malamute crossbreds had suffered episodic inspiratory dyspnoea and stridor for four to eight weeks and their endurance had decreased. In two of them bilateral, and in the other unilateral, laryngeal paralysis was diagnosed by laryngoscopy. In the nucleus ambiguus of the dogs there was a depletion of motor neurons, neuronal degeneration and mild gliosis, but there were no lesions in the root and peripheral segments of the recurrent laryngeal nerves. PMID:14653342
Polizopoulou, Z S; Koutinas, A F; Papadopoulos, G C; Saridomichelakis, M N
Laryngeal paralysis is the effect of an inability to abduct the arytenoid cartilages during inspiration, resulting in respiratory signs consistent with partial airway obstruction. The aetiology of the disease can be congenital (hereditary laryngeal paralysis or congenital polyneuropathy), or acquired (trauma, neoplasia, polyneuropathy, endocrinopathy). The most common form of acquired laryngeal paralysis (LP) is typically seen in old, large breed dogs and is a clinical manifestation of a generalised peripheral polyneuropathy recently referred to as geriatric onset laryngeal paralysis polyneuropathy. Diagnosing LP based on clinical signs, breed and history has a very high sensitivity (90%) and can be confirmed bylaryngeal inspection. Prognosis after surgical correction depends on the aetiology: traumatic cases have a good prognosis, whereas tumour-induced or polyneuropathy-induced LP has a guarded prognosis. Acquired idiopathic LP is a slow progressive disease, with dogs reaching median survival times of 3-5 years after surgical correction. PMID:23718178
Kitshoff, Adriaan M; Van Goethem, Bart; Stegen, Ludo; Vandekerckhov, Peter; de Rooster, Hilde
Vocal cord paralysis associated with goiter usually indicates the presence of a malignancy. Pediatric patients retain significant thymic tissue that regresses only later in life. This thymic tissue can develop significant hyperplasia during an acute autoimmune process. We describe a case of a 17-year-old girl who presented with a goiter secondary to severe Graves' disease and a 2-month history of hoarseness, choking on liquid intake, and small-volume vomiting especially after eating. She demonstrated a left vocal cord paralysis probably secondary to a unilateral left recurrent laryngeal nerve palsy. A marked enlargement of the thymus was discovered on thoracic imaging. Treatment was initiated with methimazole, with near complete remission of her vocal cord paralysis within 3 months. Given the immunomodulatory effects of methimazole, a potential mechanism of the left recurrent laryngeal nerve palsy was autoimmune hyperstimulation of the thymus and consequent hyperplasia, resulting in distension of the nerve. Attenuation of the hyperactive immune process with methimazole may have resulted in regression of the mass effect of the thymus and associated reduction of the nerve distension. This case illustrates the unique risk of left recurrent laryngeal nerve palsy in pediatric patients with an acute immune stimulation and hyperplasia of the thymus and the reversibility in the context of mitigation of the immune hyperactivity. Methimazole may be an optimal initial treatment choice in pediatric patients with Graves' disease and left recurrent laryngeal nerve palsy. PMID:24249820
Chiu, Harvey K; Ledbetter, Daniel; Richter, Monica W; Iyer, Ramesh S; Merati, Albert L
The laryngeal mask airway (LMA) is being used with increasing frequency since its introduction into the United States in 1991. Currently, the LMA is being used in the United States in approximately one third of all operations or greater than 100 million surgeries. In Britain, where it was first introduced for use in 1988, the LMA is estimated to be used in up to 50% of cases. Not only has its use in elective cases increased, but the scope of indications for the LMA has also grown. Its use in emergent and difficult airway management has increased, and new LMA products have been introduced to address the limitations of the classic model. As the LMA has increased in popularity, however, so has the incidence of LMA-related complications. Cases of mucosal trauma, hematoma, tongue cyanosis, arytenoid dislocation, and lingual, hypoglossal, and recurrent laryngeal nerve paralyses have been documented in various anesthesia journals. Reports of these injuries are sparse in the otolaryngology literature. As otolaryngologists who will manage the sequelae of LMA-related injuries, we must remain cognizant of potential problems and their underlying mechanisms. We report a case of unilateral vocal cord paralysis, which required operative repair after the use of an LMA. We review the existing case reports, propose mechanisms of injury, and discuss practical applications of our findings. PMID:16094119
Chan, Teresa V; Grillone, Gregory
A 4 yr old spayed female Labrador retriever was referred for acute respiratory distress and was found to have bilateral laryngeal paralysis. Physical examination and biochemical testing were consistent with systemic lupus erythematosus (SLE) and did not reveal a likely alternative cause for the laryngeal paralysis. Following immunosuppressive and supportive treatment, the dog regained normal laryngeal function. At a scheduled follow-up examination 6 wk later, normal laryngeal function was confirmed via sedated laryngeal examination. Laryngeal paralysis associated with SLE has been reported in humans, but this is the first known report of acquired laryngeal paralysis associated with SLE in the dog. PMID:22186720
Kvitko-White, Heather; Balog, Kelley; Scott-Moncrieff, J Catharine; Johnson, Anthony; Lantz, Gary C
We report a patient with significant weakness of the left soft palate, paralysis of the left vocal cord, and left facial nerve palsy. Although the patient showed no herpetic eruption in the pharyngolaryngeal mucosa and auricle skin, reactivation of varicella zoster virus (VZV) was confirmed by serological examination. She was diagnosed with zoster sine herpete. After treatment with antiviral drugs and corticosteroids, her neurological disorder improved completely. When we encounter a patient with associated laryngeal paralysis, we should consider the possibility of reactivation of VZV even when no typical herpetic eruption is observed. PMID:24715925
Fujiwara, Keishi; Furuta, Yasushi; Fukuda, Satoshi
We report a patient with significant weakness of the left soft palate, paralysis of the left vocal cord, and left facial nerve palsy. Although the patient showed no herpetic eruption in the pharyngolaryngeal mucosa and auricle skin, reactivation of varicella zoster virus (VZV) was confirmed by serological examination. She was diagnosed with zoster sine herpete. After treatment with antiviral drugs and corticosteroids, her neurological disorder improved completely. When we encounter a patient with associated laryngeal paralysis, we should consider the possibility of reactivation of VZV even when no typical herpetic eruption is observed.
Fujiwara, Keishi; Furuta, Yasushi; Fukuda, Satoshi
Forty dogs with clinical signs suggestive of upper respiratory tract disease underwent echolaryngography and laryngoscopy. Laryngoscopy was used as the definitive technique to diagnose laryngeal paralysis. The ultrasound investigation accurately indicated the presence of the paralysis and confirmed the uni- or bilateral nature of the disorder. Findings indicative of laryngeal paralysis included asymmetry or absence of motion of the cuneiform processes (30/30), abnormal arytenoid movement (16/30), paradoxical movement (9/30), caudal displacement of the larynx (2/30) and laryngeal collapse (1/30). Thirty dogs were found to be afflicted with laryngeal paralysis and ten had normal laryngeal motility. PMID:11499709
Rudorf, H; Barr, F J; Lane, J G
Four cases of spontaneous laryngeal paralysis in juvenile white-coated German shepherd dogs are described. The presenting signs were typical for laryngeal paralysis, with stridor present in all four cases. Laryngoscopy revealed bilateral laryngeal paralysis in three cases, and unilateral paralysis in one. Concurrent megaoesophagus was also identified in one dog. All dogs underwent surgical treatment for laryngeal paralysis. Euthanasia was performed in one case due to intractable regurgitation and aspiration pneumonia. A possible association with white coat colour is discussed. PMID:11138855
Ridyard, A E; Corcoran, B M; Tasker, S; Willis, R; Welsh, E M; Demetriou, J L; Griffiths, L G
Vocal cord paralysis is a relatively common entity, usually resulting from a pathologic process of the vagus nerve or its recurrent larynegeal branch. It is rarely caused by intralargngeal lesions. Four teen patients with recurrent laryngeal nerve paralysis (RLNP) were evaluated by laryngography, computed tomography (CT), or both. In the evaluation of the paramedian cord, CT was limited in its ability to differentiate between tumor or RLNP as the cause of the fixed cord, but it yielded more information than laryngography on the structural abnormalities of the larynx and pre-epiglottic and paralaryngeal spaces. Laryngography revealed distinct features of RLNP and is the procedure of choice for evaluation of functional abnormalities of the larynx until further experience with faster CT scanners and dynamic scanning of the larynx is gained.
During the past seven years 347 patients have been entered into a data bank at the Duke University Medical Center for evaluation of transient neurologic ischemia. One hundred fifty eight of these patients had carotid endarterectomies of whom 24 (15.1%) developed 26 (16.4%) peripheral cranial nerve palsies. Injury to the peripheral portion of the hypoglossal nerve was noted in 13 patients, to the cervical branch of the facial nerve in five and to the recurrent laryngeal nerve branch of the vagus in eight. Complete recovery of nerve function usually occurred within four months but residual deficit was present at one year in two patients with facial nerve and four with hypoglossal nerve involvement. Even though these complications of carotid endarterectomy are generally benign and transient, the frequency of occurrence can be reduced if careful attention is given to anatomic localization of the cranial nerves during surgery. PMID:6695421
Massey, E W; Heyman, A; Utley, C; Haynes, C; Fuchs, J
Injection laryngoplasty is a common operative technique used in the management of unilateral vocal fold paralysis. Cymetra is a micronized particulate injectable form of acellular human dermis that is commonly used for vocal cord medialization procedures. We report migration of an intracordal bolus of Cymetra into the medial wall of the pyriform sinus. Histopathology from endoscopic resection of the migrated Cymetra demonstrated a localized foreign body reaction with characteristic giant cells. Specific anatomic considerations through cadaveric laryngeal dissection are presented to demonstrate the likely pathway of intralaryngeal bolus migration. PMID:17909445
Bock, Jonathan M; Lee, John H; Robinson, Robert A; Hoffman, Henry T
Contraction of the cricothyroideus muscles (CTMs), innervated by the superior laryngeal nerves (SLNs), modulates the voice by tilting the thyroid cartilage anteriorly onto the top of the cricoid and tensing the vocal cords. Either unilateral or bilateral paralysis of the SLNs is disabling for individuals with above-average voice demands. Some patients never compensate for this paralysis; there is no surgical procedure recognized to correct it. This study tested the hypothesis that surgical fusion of the thyroid and cricoid cartilages anteriorly can correct the problems of SLN injury by duplicating the mechanical tilt of the thyroid onto the cricoid cartilage normally produced by the CTMs. The SLNs were cut in 12 dogs. In six the cricoid and thyroid cartilages were fused anteriorly. Vocal cord and airway function was assessed preoperatively, immediately postoperatively, and 6 to 10 weeks after surgery. Following surgery there was no airway compromise and there appeared to be a more satisfactory compensation for the SLN paralysis in the fused larynges as compared with the unfused controls as determined by cinelaryngoscopic analysis. PMID:6438580
Thompson, J W; Ward, P H; Schwartz, I R
To emphasize the risks of recurrent laryngeal nerve lesions during transhiatal oesophagectomy an anatomical study of the course of the recurrent laryngeal nerve (RLN) was performed. Twenty RLN were dissected in their thoracic portion. This work showed the constancy of the low origin of the nerve in the adult under the aortic arch, and its course in the tracheal angle.
A. Dia; D. Valleix; B. Dixneuf; D. Philippi; B. Descottes; M. Caix; A. Ndiaye; M. L. Sow
Laryngeal paralysis is a relatively common cause of upper airway obstruction in middle-aged to older, large-breed dogs; however, it is rare in the cat. The purpose of this study is to describe a series of cats diagnosed with laryngeal paralysis treated by unilateral arytenoid lateralization. Fourteen cats met the criteria of the study. Intraoperative and postoperative complications were seen in 21% (three of 14) and 50% (seven of 14) of cases, respectively. Median duration of follow-up was 11 months (range 3 weeks to 8 years). None of these cats had recurrence of clinical signs. Based on this brief case series, unilateral arytenoid lateralization appeared to be a suitable method for treating laryngeal paralysis in cats. Additional studies are warranted to determine the type and frequency of long-term complications. PMID:21041335
Thunberg, Brian; Lantz, Gary C
Recovery from unilateral vocal-fold paralysis is lengthy, unpredictable, and often incomplete, highlighting the need for better treatments of the injured recurrent laryngeal nerve. To be able to monitor recovery of vocal-fold motion in studies with rats, we developed a procedure for quantitative video laryngoscopy. An asymmetry index was defined as a continuous and robust measure of unequal vocal-fold motion and calculated from spectral-density plots of vocal-fold displacements. In a cohort of 8 animals, unilateral vocal-fold paralysis was observed within seconds after clamping of the right recurrent laryngeal nerve and was accompanied by a markedly negative asymmetry index. Over the next month, the asymmetry index gradually returned to zero, concomitant with a visible recovery of vocal-fold motion. Our results suggest that quantitative video laryngoscopy is a sensitive and discriminating method for monitoring recovery from recurrent laryngeal nerve injury and set the stage for testing novel surgical and pharmacological treatments of unilateral vocal-fold paralysis. PMID:24486780
Mor, Niv; Naggar, Isaac; Das, Olipriya; Nakase, Ko; Silverman, Joshua B; Sundaram, Krishnamurthi; Stewart, Mark; Kollmar, Richard
The cervical branches of the vagus nerve that are pertinent to endocrine surgery are the superior and the inferior laryngeal nerves: their anatomical course in the neck places them at risk during thyroid surgery. The external branch of the superior laryngeal nerve (EB) is at risk during thyroid surgery because of its close anatomical relationship with the superior thyroid vessels and the superior thyroid pole region. The rate of EB injury (which leads to the paralysis of the cricothyroid muscle) varies from 0 to 58%. The identification of the EB during surgery helps avoiding both an accidental transection and an excessive stretching. When the nerve is not identified, the ligation of superior thyroid artery branches close to the thyroid gland is suggested, as well as the abstention from an indiscriminate use of energy-based devices that might damage it. The inferior laryngeal nerve (RLN) runs in the tracheoesophageal groove toward the larynx, close to the posterior aspect of the thyroid. It is the main motor nerve of the intrinsic laryngeal muscles, and also provides sensory innervation to the larynx. Its injury finally causes the paralysis of the omolateral vocal cord and various sensory alterations: the symptoms range from mild to severe hoarseness, to acute airway obstruction, and swallowing impairment. Permanent lesions of the RNL occur from 0.3 to 7% of cases, according to different factors. The surgeon must be aware of the possible anatomical variations of the nerve, which should be actively searched for and identified. Visual control and gentle dissection of RLN are imperative. The use of intraoperative nerve monitoring has been safely applied but, at the moment, its impact in the incidence of RLN injuries has not been clarified. In conclusion, despite a thorough surgical technique and the use of intraoperative neuromonitoring, the incidence of neurological complications after thyroid surgery cannot be suppressed, but should be maintained in a low range.
Varaldo, Emanuela; Ansaldo, Gian Luca; Mascherini, Matteo; Cafiero, Ferdinando; Minuto, Michele N.
Möbius syndrome is typified by bilateral facial nerve palsies, usually with abducens palsies. We examined an infant with Möbius syndrome who had bifacial weakness and third nerve palsies, but intact abduction of both eyes. Lower cranial nerve involvement, leading to respiratory, swallowing, and cardiac difficulties, was also present. Pathologic examination of the brainstem showed absent or hypoplastic third, seventh, tenth, and twelfth nerve nuclei. The fourth, fifth, sixth, and eighth nerve nuclei were intact. In Möbius syndrome with ocular motor palsies, rarely the sixth nerve may be spared. PMID:9858013
Tran, D B; Wilson, M C; Fox, C A; Clancy, R; Teener, J W; Golden, J A; Liu, G T
Introduction We describe a novel, clinically applicable conduction study of the laryngeal nerves. Methods 17 normal volunteer subjects were included. Activation of the sensory territory of the superior laryngeal nerve was performed by administration of low level, brief electrical stimulus. The laryngeal closure reflex (LCR) evoked by this stimulus was recorded by needle electrodes. Mean minimal latencies were calculated for each response, and proposed values for the upper limit of normal were determined. Results Uniform consistent early ipsilateral responses and late bilateral responses, which exhibit greater variation in latency and morphology, were recorded. Significant side-to-side difference in latencies is observed, consistent with the length discrepancy between right and left recurrent laryngeal nerves. Discussion This technique yields clear, quantifiable data regarding neurologic integrity of laryngeal function, heretofore unobtainable in the clinical setting. This study may yield clinically relevant information regarding severity and prognosis in patients with laryngeal neuropathic injury.
Carey, Bridget; Sulica, Lucian; Wu, Anita; Branski, Ryan
Snoring is the most obvious symptom of sleep-disordered breathing (SDB). Vibratory sound usually originates from the pharynx; however, in some circumstances, the narrowing of glottic structures can also cause nighttime breathing noise. This clinical study investigated the role of laryngeal obstruction in patients with SDB. Nine female patients with paralysis of bilateral vocal folds were enrolled in this study. All
Hsueh-Yu Li; Pa-Chun Wang; Chung-Yao Hsu; Ning-Hung Chen; Tuan-Jen Fang
Amyloidosis affecting peripheral nerves causing isolated nerve palsies is uncommon. Localised amyloidosis occurs less frequently than the reactive or immune related systemic forms, and mediastinal localisation is virtually unknown. We present a case of recurrent laryngeal nerve palsy associated with mediastinal AL amyloidosis in a middle aged man.??
Conaghan, P.; Chung, D.; Vaughan, R.
A 13-year-old neutered female Labrador retriever had inspiratory dyspnea secondary to bilateral laryngeal paralysis. Radiographically, there was pectus excavatum with a mediastinal shift to the right. Arytenoid lateralization was performed, relieving the upper respiratory obstruction, and the sternal deformity also resolved. Chronic upper respiratory obstruction should be considered in dogs with pectus excavatum. Furthermore, correction of upper respiratory obstruction has the potential to result in resolution of pectus excavatum. PMID:22145690
Kurosawa, Tsumugi Anne; Ruth, Jeffrey D; Steurer, Jeffrey; Austin, Brenda; Heng, Hock Gan
We applied a novel head-out plethysmographic (HOP) method to study awake canine responses to external resistive loading and natural laryngeal paralysis. Measurements of inspiratory and expiratory specific airway resistance (sRaw(insp), sRaw(exp)) were obtained before and after uni- and bidirectional loading (R(add) = 5 cmH(2)O/L/s) in large-breed dogs (n = 9). Mean sRaw(insp) after inspiratory, and sRaw(exp) after expiratory loading were 31.4 and 33.3 cmH(2)Os, respectively. Bidirectional loads induced a significantly greater rise in both sRaw(insp) and sRaw(exp) (55.1 and 61.3 cmH(2)Os) compared to unidirectional loading (P < 0.001). Yet, type of loading did not affect flow-volume indices. The mean R(aw) of dogs was 4.81 cmH(2)O/L/s. Expiratory loading resulted in a significant 8.8% increase in functional-residual-capacity (FRC), compared to FRC(baseline) (76.7 ml/kg). Dogs (n = 5) with laryngeal paralysis demonstrated a significant increase in sR(aw) and R(aw) compared to controls without changes in FRC. In conclusion, HOP precisely characterized sR(aw) in response to external resistive loading. Hence, we could accurately quantify airway obstruction in awake dogs with laryngeal paralysis. PMID:16055393
Bedenice, D; Rozanski, E; Bach, J; Lofgren, J; Hoffman, A M
Summary Traumatic injury resulting in isolated dysfunction of the hypoglossal nerve is relatively rare and described in few case reports. We present a patient with isolated unilateral palsy of the twelfth cranial nerve (CN XII) resulting from recurrent airway intervention following extensive burn injuries. The differential diagnosis for paralysis of the CN XII is also discussed herein. This case illustrates the significance of comprehensive diagnostic evaluation and the need for refined airway manipulation in patients that require multiple endotracheal intubations
Weissman, O.; Weissman, O.; Farber, N.; Berger, E.; Grabov Nardini, G.; Zilinsky, I.; Winkler, E.; Haik, J.
We recently began performing intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve during high-risk thyroidectomies. Neuromonitoring can detect stimulation of these nerves and thereby prevent a mechanical or thermal injury that can result in neurapraxia or axonotmesis. Monitoring is also useful during dissection in an already operated-on field, when performing thyroidectomy on patients who depend on their voice for their livelihood, and when removing a large goiter or mediastinal mass. PMID:16075865
Song, Phillip; Shemen, Larry
Unilateral vocal fold paralysis (UVFP) is one of the most serious problems in conducting surgery for thyroid cancer. Different treatments are available for the management of UVFP including intracordal injection, type I thyroplasty, arytenoid adduction, and laryngeal reinnervations. The effects of immediate recurrent laryngeal nerve (RLN) reconstruction during thyroid cancer surgery with or without UVFP before the surgery were evaluated with videostroboscopic, aerodynamic, and perceptual analyses. All subjects experienced postoperative improvements in voice quality. Particularly, aerodynamic analysis showed that the values for all patients entered normal ranges in both patients with and without UVFP before surgery. Immediate RLN reconstruction has the potential to restore a normal or near-normal voice by returning thyroarytenoid muscle tone and bulk seen with vocal fold denervation. Immediate RLN reconstruction is an efficient and effective approach to the management of RLN resection during surgery for thyroid cancer.
Sanuki, Tetsuji; Yumoto, Eiji; Minoda, Ryosei; Kodama, Narihiro
Introduction: Newly developed vagal stimulation probes permit continuous intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid resection. Complete signal loss indicates damage of the nerve. There is no other criterion so far to warn before imminent nerve function impairment. Methods: In 100 patients, thyroid resection (188 nerves at risk, 52 thyroidectomies, 21 Dunhill resections, 12 hemithyroidectomies, 5 two-sided subtotal
Objective. Laryngeal elevation protects the airway and assists opening of the esophagus during swallowing. The GH, thyrohyoid, and MH muscles provide a majority of this elevatory motion. This study applied functional electrical stimulation to the XII/C1 nerve complex using a nerve cuff electrode to determine the capabilities of neural stimulation to induce laryngeal elevation. Approach. Multi-contact FINE electrodes were implanted onto the XII/C1 nerve complex at locations proximal and distal to the thyrohyoid branching point in five anesthetized canines. Motion of the thyroid cartilage and the hyoid bone was recorded during stimulation of nerve cuffs and intramuscular electrodes. Main Results. Nerve stimulation induced 260% more laryngeal elevation than intramuscular stimulation (18.8 mm versus 5.2 mm, p ? 0.01), and 228% higher velocity (143.8 versus 43.9 mm s-1, p ? 0.01). While stimulation at all cuff and electrode locations elevated the larynx, only the proximal XII/C1 nerve cuff significantly elicited both thyroid-hyoid approximation and hyoid elevation. In all proximal XII/C1 nerve cuffs (n = 7), stimulation was able to obtain selectivity of greater than 75% of at least one elevatory muscle. Significance. These results support the hypothesis that an implanted neural interface system can produce increased laryngeal elevation, a significant protective mechanism of deglutition.
Hadley, Aaron J.; Kolb, Ilya; Tyler, Dustin J.
This study evaluated changes in respiratory function in dogs with experimentally induced laryngeal paralysis treated with either unilateral arytenoid lateralization or ventral ventriculocordectomy, and compared the effectiveness of these procedures. Evaluation consisted of clinical assessment and tidal breathing flow volume loop and upper airway resistance measurements. Carbon dioxide and doxapram hydrochloride were used as respiratory stimulants. Initially, all dogs improved clinically after corrective surgery. However, by the end of the study, laryngeal collapse had developed in 2 of 5 dogs corrected by ventral ventriculocordectomy. No statistical differences in upper airway mechanics testing were seen between the surgical procedures. With both groups combined, many measurements of upper airway obstruction improved after surgical correction. Based on this study, these surgical procedures yield comparable results, although additional studies are needed to evaluate both the cause of laryngeal collapse and the role of upper airway mechanics testing in the evaluation of canine laryngeal paralysis.
Alsup, J C; Greenfield, C L; Hungerford, L L; McKiernan, B C; Whiteley, H E
Bilateral ventriculocordectomy through a ventral median laryngotomy was performed for the treatment of idiopathic laryngeal paralysis in 88 dogs. The purpose of this retrospective analysis was to provide long-term follow-up for a large number of dogs surgically managed with this technique. A combination of medical record and completed client questionnaire information provided short-term (14 days) follow-up for 88 dogs and long-term (>6 mo) follow-up for 42 dogs. Major short-term postoperative complications were identified in 3 of 88 (3.4%) patients. Major long-term complications were identified in 3 of 42 (7.1%) patients. The results of surgery were considered to be very satisfactory in 93% and unsatisfactory in 7%. Three dogs in this series developed aspiration pneumonia. Bilateral ventriculocordectomy through a ventral median laryngotomy is associated with a low incidence of both short- and long-term complications. Due to the ease of this procedure, the minimal surgical trauma to the patient, and the satisfactory results, this surgery should be considered an option for the treatment of idiopathic laryngeal paralysis in the dog. PMID:22611210
Zikes, Cynthia; McCarthy, Timothy
The purposes of this study were to describe a modified surgical technique in which intraoperative extubation was performed to evaluate abduction of the arytenoid cartilage prior to tying the suture and to assess outcome and complication rates associated with this procedure. Medical records from 30 client-owned dogs with acquired idiopathic laryngeal paralysis were retrospectively reviewed. All clients were contacted by telephone to obtain follow-up information regarding their dog. Six of the 30 surgeries required additional dissection (primarily around the craniodorsal aspect of the cricoarytenoid joint) after the initial intraoperative laryngeal examination. The procedures in 29 of the 30 dogs were deemed a success by the owners. Three (10%) dogs developed postoperative aspiration pneumonia. One of these dogs required long-term antibiotic therapy. Twenty-nine dogs returned to normal activity, and none of the dogs had any exercise intolerance associated with respiratory difficulties. Three owners reported that their dogs were able to swim, and one dog hunted postoperatively. Results of this study suggest that intraoperative laryngeal examination may help limit postoperative complications by allowing for direct, intraoral visualization of the arytenoid cartilage. This enables a surgeon to modify the soft tissue dissection around the cricoarytenoid joint to ensure that adequate abduction is apparent. PMID:20610696
Weinstein, Jeff; Weisman, Debra
Objective To evaluate the long-term efficacy of delayed laryngeal reinnervation using the main branch of the ansa cervicalis in treatment of unilateral vocal fold paralysis (UVFP) caused by thyroid surgery. Summary of Background Data UVFP remains a serious complication of thyroid surgery. Up to now, a completely satisfactory surgical treatment of UVFP has been elusive. Methods From Jan. 1996 to Jan. 2008, a total of 237 UVFP patients who underwent ansa cervicalis main branch-to-recurrent laryngeal nerve (RLN) anastomosis were enrolled as UVFP group; another 237 age- and gender-matched normal subjects served as control group. Videostroboscopy, vocal function assessment (acoustic analysis, perceptual evaluation and maximum phonation time), and electromyography were performed preoperatively and postoperatively. The mean follow-up period was 5.2±2.7 years, ranging from 2 to 12 years. Results Analysis of videostroboscopic findings indicated that the glottic closure, vocal fold edge, vocal fold position, phase symmetry and regularity were significantly improved in the UVFP group (P<0.001, postoperative vs. preoperative). The postoperative parameters of vocal function were also significantly improved in the UVFP group (P<0.001) and showed no statistical differences compared to the control group (P>0.05, respectively). Postoperative laryngeal electromyography confirmed successful reinnervation of laryngeal muscle. Conclusions Delayed laryngeal reinnervation with the main branch of ansa cervicalis is a feasible and effective approach for treatment of thyroid surgery-related UVFP; it can restore the physiological laryngeal phonatory function to the normal or a nearly normal voice quality.
Li, Ding; Li, Meng; Xia, Siwen; Zheng, Hongliang
Existing nerve monitoring devices in thyroid surgery are - except for one - mainly intermittently working nerve identification tools. We present a new vagal electrode which allows true continuous monitoring of the recurrent laryngeal nerve (RLN). The electrode was designed as a tripolar hybrid cuff electrode consisting of polyimide, gold and platinum layers embedded in a flexible silicon cuff which can be opened at the long side for introducing the nerve. It is fully implantable and atraumatic. The evoked potentials are sensed by standard thyroid electrodes. Real-time signal analysis and audio feedback are achieved by specially designed software. Homogeneous and stable signals were recorded throughout the operations. Thus real-time computer-based signal analysis was possible. Evoked potentials reached 300-900 mV. Mean time to place the cuff electrode was 5.5 min. The nerve was stimulated a mean of 63 min (range 55-99 min). No RLN lesions were detected postoperatively. The new vagal electrode was easy to handle and led to stable and reproducible signals. The stimulation current could be kept extremely low due to the special geometry of the electrode. It offers the possibility for uninterrupted, continuous laryngeal nerve monitoring in thyroid surgery. In an ongoing clinical trial its compatibility as an add-on for existing nerve monitoring devices is being tested. PMID:17573619
Lamadé, Wolfram; Ulmer, Christoph; Seimer, Andreas; Molnar, Viktor; Meyding-Lamadé, Uta; Thon, Klaus-Peter; Koch, Klaus Peter
A retrospective evaluation of 17 dogs treated surgically for idiopathic acquired laryngeal paralysis demonstrated a marked variability in outcome, with many dogs continuing to exhibit weakness and exercise tolerance. In a subsequent prospective study, 22 consecutive affected dogs were tested for neurological deficits by neurological examination, electrodiagnostic evaluation, and blood analysis to measure thyroxine and thyroid-stimulating hormone and to detect any evidence of myasthenia gravis. Clinical neurological deficits and/or electrodiagnostic abnormalities were found in each case. There was limited evidence that specific neurological deficits were associated with a poor prognosis for full recovery of exercise tolerance. None of the dogs was positive for anti-acetylcholine receptor antibodies, and only three showed evidence of thyroid dysfunction. PMID:16400098
Jeffery, N D; Talbot, C E; Smith, P M; Bacon, N J
The larynx serves respiratory, protective, and phonatory functions. The motor and sensory innervation to the larynx controlling these functions is provided by the superior laryngeal nerve (SLN) and the recurrent laryngeal nerve (RLN). Classical studies state that the SLN innervates the cricothyroid muscle and provides sensory innervation to the supraglottic cavity, whereas the RLN supplies motor innervation to the remaining intrinsic laryngeal muscles and sensory innervation to the infraglottic cavity, but recent data suggest a more complex anatomical and functional organisation. The current neuroanatomical tracing study was undertaken to provide a comprehensive description of the central brainstem connections of the axons within the SLN and the RLN, including those neurons that innervate the larynx. The study has been carried out in 41 adult male Sprague–Dawley rats. The central projections of the laryngeal nerves were labelled following application of biotinylated dextran amines onto the SLN, the RLN or both. The most remarkable result of the study is that in the rat the RLN does not contain any afferent axons from the larynx, in contrast to the pattern observed in many other species including man. The RLN supplied only special visceromotor innervation to the intrinsic muscles of the larynx from motoneurons in the nucleus ambiguus (Amb). All the afferent axons innervating the larynx are contained within the SLN, and reach the nucleus of the solitary tract. The SLN also contained secretomotor efferents originating from motoneurons in the dorsal motor nucleus of the vagus, and special visceral efferent fibres from the Amb. In conclusion, the present study shows that in the rat the innervation of the larynx differs in significant ways from that described in other species.
Pascual-Font, Aran; Hernandez-Morato, Ignacio; McHanwell, Stephen; Vazquez, Teresa; Maranillo, Eva; Sanudo, Jose; Valderrama-Canales, Francisco J
Paralysis of the anterior interosseous nerve may occur for a variety of reasons. It has been suggested that such a malady presents clinically more often than is recognized. Some authors attribute this to a general misunderstanding or ignorance of the precise anatomical distribution and motor function of this branch of the median nerve. The neuropathy produces a clinical scenario with a characteristic disturbance of the "pinch grip." Spontaneous recovery has been reported, but is said to be delayed and incomplete. Surgical exploration of the nerve may reveal a biomechanical basis for irritation, and decompression maneuvers may result in rapid and complete recovery. It is important to recognize, however, the value of conservative measures, including mobilization and adjustive procedures, which may be specifically directed to the elbow joint and other regions of the upper extremity. Such techniques may assist in reducing restrictive influences comprising the nerve and associated tissues. The benefits of electrotherapy may prove invaluable and, perhaps, should be considered prior to more radical procedures. Therefore, the practitioner should be wary of the potential to approach such a condition from the chiropractic perspective of treatment and management, which may yield rewarding sequellae. PMID:3392477
Crawford, J P; Noble, W J
A muscle-nerve pedicle implantation to the lateral cricoarytenoid muscle as described by Tucker is an alternative to Teflon injection for treating dysphonia due to vocal cord palsy. Improvement in voice was noted in 19 of the 20 (95%) selected patients who were treated by muscle-nerve pedicle reinnervation. These patients have been followed for 6 months to 10 years. Changes in the voice were documented through assessment of high-quality audio tape recordings by three speech pathologists, results of a patient questionnaire, and evaluation by the surgeon. The improvement in voice quality was attributed to reestablishment and maintenance of vocal cord tone and mass, without the vocal cord stiffness usually associated with Teflon injection. The improvements in quality of voice with pedicle implantation are natural and lasting. This technique is proposed as an alternative to Teflon injection in selected cases. PMID:3773616
May, M; Beery, Q
In 30% of patients with epilepsy seizure control cannot be achieved with medications. When medical therapy is not effective, and epilepsy surgery cannot be performed, vagus nerve stimulator (VNS) implantation is a therapeutic option. Laryngeal patterns in vagus nerve stimulation have not been extensively studied yet. The objective was to evaluate laryngeal patterns in a cohort of patients affected by drug-resistant epilepsy after implantation and activation of a vagus nerve stimulation therapy device. 14 consecutive patients underwent a systematic otolaryngologic examination between 6 months and 5 years after implantation and activation of a vagus nerve stimulation therapy device. All patients underwent fiberoptic endoscopic evaluation, which was recorded on a portable device allowing a convenient slow-motion analysis of laryngeal patterns. All recordings were blindly evaluated by two of the authors. We observed three different laryngeal patterns. Four patients showed left vocal cord palsy at the baseline and during vagus nerve stimulation; seven showed left vocal cord palsy at the baseline and left vocal cord adduction during vagus nerve stimulation; and three patients showed a symmetric pattern at the baseline and constant left vocal cord adduction during vagus nerve stimulation. These laryngeal findings are here described for the first time in the literature and can be only partially explained by existing knowledge of laryngeal muscles and vagus nerve physiology. This might represent a new starting point for studies concerning laryngeal physiology and phonation, while the vagus nerve stimulation therapy could act as a new and ethical experimental model for human laryngeal physiology. PMID:23744179
Felisati, Giovanni; Gardella, Elena; Schiavo, Paolo; Saibene, Alberto Maria; Pipolo, Carlotta; Bertazzoli, Manuela; Chiesa, Valentina; Maccari, Alberto; Franzini, Angelo; Canevini, Maria Paola
Purpose: To model tension asymmetry caused by superior laryngeal nerve paralysis (SLNP) in excised larynges and apply perturbation, nonlinear dynamic, and aerodynamic analyses. Method: SLNP was modeled in 8 excised larynges using sutures and weights to mimic cricothyroid (CT) muscle function. Weights were removed from one side to create tension…
Devine, Erin E.; Bulleit, Erin E.; Hoffman, Matthew R.; McCulloch, Timothy M.; Jiang, Jack J.
The aim of this study was to determine the role of the superior laryngeal nerve (SLN) in the following esophageal reflexes: esophago-upper esophageal sphincter (UES) contractile reflex (EUCR), esophago-lower esophageal sphincter (LES) relaxation reflex (ELIR), secondary peristalsis, pharyngeal swallowing, and belch. Cats (N = 43) were decerebrated and instrumented to record EMG of the cricopharyngeus, thyrohyoideus, geniohyoideus, and cricothyroideus; esophageal pressure; and motility of LES. Reflexes were activated by stimulation of the esophagus via slow balloon or rapid air distension at 1 to 16 cm distal to the UES. Slow balloon distension consistently activated EUCR and ELIR from all areas of the esophagus, but the distal esophagus was more sensitive than the proximal esophagus. Transection of SLN or proximal recurrent laryngeal nerves (RLN) blocked EUCR and ELIR generated from the cervical esophagus. Distal RLN transection blocked EUCR from the distal cervical esophagus. Slow distension of all areas of the esophagus except the most proximal few centimeters activated secondary peristalsis, and SLN transection had no effect on secondary peristalsis. Slow distension of all areas of the esophagus inconsistently activated pharyngeal swallows, and SLN transection blocked generation of pharyngeal swallows from all levels of the esophagus. Slow distension of the esophagus inconsistently activated belching, but rapid air distension consistently activated belching from all areas of the esophagus. SLN transection did not block initiation of belch but blocked one aspect of belch, i.e., inhibition of cricopharyngeus EMG. Vagotomy blocked all aspects of belch generated from all areas of esophagus and blocked all responses of all reflexes not blocked by SLN or RLN transection. In conclusion, the SLN mediates all aspects of the pharyngeal swallow, no portion of the secondary peristalsis, and the EUCR and ELIR generated from the proximal esophagus. Considering that SLN is not a motor nerve for any of these reflexes, the role of the SLN in control of these reflexes is sensory in nature only. PMID:22403790
Lang, I M; Medda, B K; Jadcherla, S; Shaker, R
The aim of this study was to determine the role of the superior laryngeal nerve (SLN) in the following esophageal reflexes: esophago-upper esophageal sphincter (UES) contractile reflex (EUCR), esophago-lower esophageal sphincter (LES) relaxation reflex (ELIR), secondary peristalsis, pharyngeal swallowing, and belch. Cats (N = 43) were decerebrated and instrumented to record EMG of the cricopharyngeus, thyrohyoideus, geniohyoideus, and cricothyroideus; esophageal pressure; and motility of LES. Reflexes were activated by stimulation of the esophagus via slow balloon or rapid air distension at 1 to 16 cm distal to the UES. Slow balloon distension consistently activated EUCR and ELIR from all areas of the esophagus, but the distal esophagus was more sensitive than the proximal esophagus. Transection of SLN or proximal recurrent laryngeal nerves (RLN) blocked EUCR and ELIR generated from the cervical esophagus. Distal RLN transection blocked EUCR from the distal cervical esophagus. Slow distension of all areas of the esophagus except the most proximal few centimeters activated secondary peristalsis, and SLN transection had no effect on secondary peristalsis. Slow distension of all areas of the esophagus inconsistently activated pharyngeal swallows, and SLN transection blocked generation of pharyngeal swallows from all levels of the esophagus. Slow distension of the esophagus inconsistently activated belching, but rapid air distension consistently activated belching from all areas of the esophagus. SLN transection did not block initiation of belch but blocked one aspect of belch, i.e., inhibition of cricopharyngeus EMG. Vagotomy blocked all aspects of belch generated from all areas of esophagus and blocked all responses of all reflexes not blocked by SLN or RLN transection. In conclusion, the SLN mediates all aspects of the pharyngeal swallow, no portion of the secondary peristalsis, and the EUCR and ELIR generated from the proximal esophagus. Considering that SLN is not a motor nerve for any of these reflexes, the role of the SLN in control of these reflexes is sensory in nature only.
Medda, B. K.; Jadcherla, S.; Shaker, R.
Objectives To assess the possibilities of reinnervation in a paralyzed hemidiaphragm via an anastomosis between phrenic nerve and inferior laryngeal nerve in rabbits. Reinnervation of a paralyzed diaphragm could be an alternative to treat patients with ventilatory insufficiency due to upper cervical spine injuries. Material and method Rabbits were divided into five groups of seven rabbits each. Groups I and II were respectively the healthy and the denervated control groups. The 3 other groups were all reinnervated using three different surgical procedures. In groups III and IV, phrenic nerve was respectively anastomosed with the abductor branch of the inferior laryngeal nerve and with the trunk of the inferior laryngeal nerve. In group V, the fifth and fourth cervical roots were respectively anastomosed with the abductor branch of the inferior laryngeal nerve and with the nerve of the sternothyroid muscle (originating from the hypoglossal nerve). Animals were evaluated 4 months later using electromyography, transdiaphragmatic pressure measurements, sonomicrometry and histological examination. Results A poor inspiratory activity was found in quiet breathing in the reinnervated groups, with an increasing pattern of activity during effort. In the reinnervated groups, transdiaphragmatic pressure measurements and sonomicrometry were higher in group III with no significant differencewith groups IV and V. Conclusion Inspiratory contractility of an hemidiaphragm could be restored with immediate anastomosis after phrenic nerve section between phrenic nerve and inferior laryngeal nerve.
Derrey, Stephane; verin, Eric; Laquerriere, Annie; de Barros, Angelique Boishardy; Lacoume, Yann; Freger, Pierre; Marie, Jean Paul
Intraoperative neuro-monitoring was introduced in thyroid surgery several years ago resulting in a facilitated identification of the recurrent laryngeal nerve and less recurrent laryngeal nerve injuries. Between 1999 and 2005 data of all patients undergoing thyroid resection were recorded and analyzed yearly. The intraoperative identification of recurrent laryngeal nerve succeeded in 99.2% (1768 nerves at risk). The percentage of complete resecting surgical procedures raised from 17% to 84%. Minimal vocal cord dysfunction, associated with hematoma and edema in most cases, was diagnosed laryngoscopically in 2.9%. The permanent palsy rate of 0.8% in the first year decreased down to 0.32%. Routinely introduction of intraoperative neuro-monitoring in thyroid surgery is associated with a demonstrable decreased palsy rate. Anyway, the rate of minimal vocal cord movement disorders and transient recurrent laryngeal nerve palsies is not changed. PMID:17313730
Moroni, E; Jonas, J; Cavallaro, A; Sapienza, P; M, Colasanti; Bahr, R
Background Retained oesophageal foreign bodies must be urgently removed to prevent potentially serious complications. Recurrent laryngeal nerve palsy is rare and has not been reported in association with a foreign body in the thoracic oesophagus. Case presentation We present a case of a dental plate in the thoracic oesophagus that caused high dysphagia. Delayed diagnosis led to a recurrent laryngeal nerve palsy, which persisted despite successful surgical removal of the foreign body. Conclusion Oesophagoscopy is essential to fully assess patients with persistent symptoms after foreign body ingestion, irrespective of the level of dysphagia. Recurrent laryngeal nerve palsy may indicate impending perforation and should prompt urgent evaluation and treatment.
Sutcliffe, Robert P; Rohatgi, Ashish; Forshaw, Matthew J; Mason, Robert C
Objectives/Hypothesis To describe a novel conduction study of the laryngeal nerves, including normal values and abnormal findings. Study Design Prospective nonrandomized. Methods Seventeen healthy adult volunteers, as well as three patients with clinically identified laryngeal neuropathy, underwent low-level brief electrical stimulation of the laryngeal mucosa by means of a wire inserted via a transnasal flexible laryngoscope. Bilateral hookwire electrodes recorded the result in the laryngeal adductor muscles. Results This study yields an early response ipsilateral to the side of stimulation (LR1), which is uniform and consistent (right 5 13.2 6 0.80 msec; left 5 15.2 6 1.20 msec), and late bilateral responses (ipsilateral LR2 [LR2i] and contralateral LR2 [LR2c]), which exhibit greater variation in latency and morphology (right LR2i 5 50.5 6 3.38 msec; left LR2i 5 52.2 msec; right LR2c 5 50.7 6 4.26; left LR2c 5 50.6 6 4.07). Findings in abnormal patients differ significantly from normal, consistent with the distribution of neuropathy. Conclusions We describe a novel, clinically applicable conduction study of laryngeal nerves. Normative electrodiagnostic values and variations of the reflex responses of the laryngeal adductor muscles in response to irritative stimulation of the laryngeal mucosa (Laryngeal Closure Reflex) are proposed. By enabling the determination of electrophysiological parameters of the superior laryngeal and recurrent laryngeal branches of cranial nerve X (CN X), this procedure, which is used as an adjunct to laryngeal electromyography, may provide earlier and more accurate information regarding the extent and grade of nerve injury. Because injury grade relates directly to prognosis, the information derived from this test may have clinical relevance in determining optimal treatment. Level of Evidence 4.
Sulica, Lucian; Carey, Bridget; Branski, Ryan C.
Neurogenic compromise of vocal fold function exists along a continuum encompassing vocal cord hypomobility (paresis) to vocal fold immobility (paralysis) with varying degrees and patterns of reinnervation. Vocal fold paralysis (VFP) may result from injury to the vagus or the recurrent laryngeal nerves anywhere along their course from the brainstem to the larynx. In this article, we review the anatomy of the vagus and recurrent laryngeal nerves and examine the various etiologies of VFP. Selected cases are presented with discussion of key imaging features of VFP including radiologic findings specific to central vagal neuropathy and peripheral recurrent nerve paralysis.
Vachha, Behroze; Cunnane, Mary Beth; Mallur, Pavan; Moonis, Gul
Our aim was to describe our experience with the masseteric nerve in the reanimation of short term facial paralysis. We present our outcomes using a quantitative measurement system and discuss its advantages and disadvantages. Between 2000 and 2012, 23 patients had their facial paralysis reanimated by masseteric-facial coaptation. All patients are presented with complete unilateral paralysis. Their background, the aetiology of the paralysis, and the surgical details were recorded. A retrospective study of movement analysis was made using an automatic optical system (Facial Clima). Commissural excursion and commissural contraction velocity were also recorded. The mean age at reanimation was 43(8) years. The aetiology of the facial paralysis included acoustic neurinoma, fracture of the skull base, schwannoma of the facial nerve, resection of a cholesteatoma, and varicella zoster infection. The mean time duration of facial paralysis was 16(5) months. Follow-up was more than 2 years in all patients except 1 in whom it was 12 months. The mean duration to recovery of tone (as reported by the patient) was 67(11) days. Postoperative commissural excursion was 8(4)mm for the reanimated side and 8(3)mm for the healthy side (p=0.4). Likewise, commissural contraction velocity was 38(10)mm/s for the reanimated side and 43(12)mm/s for the healthy side (p=0.23). Mean percentage of recovery was 92(5)mm for commissural excursion and 79(15)mm/s for commissural contraction velocity. Masseteric nerve transposition is a reliable and reproducible option for the reanimation of short term facial paralysis with reduced donor site morbidity and good symmetry with the opposite healthy side. PMID:24148699
Hontanilla, Bernardo; Marre, Diego; Cabello, Alvaro
Introduction. Vagus nerve stimulation for the management of intractable seizure disorders is increasingly being used, especially in younger children. Although complications such as infection or vocal cord paralysis are uncommon, some may be unreported. Clinical presentation. A 3.5-year-old boy with intractable complex partial and generalized seizures had a left vagus nerve stimulator (VNS) successfully implanted. Two weeks later, the cervical
M. Vassilyadi; R. H. Strawsburg
In patients who show their lower teeth during smiling and facial animation, paralysis of the marginal mandibular nerve (MMN) causes a noticeable asymmetry of the lower lip due to the absence of depressor function. This paper presents a balancing technique for this lower lip asymmetry that involves resection of the depressor labii inferioris (DLI) on the nonparalysed side. The anatomy
G Hussain; R. T Manktelow; L. R Tomat
Parathyroid cysts are uncommon entities. Symptomatic parathyroid cysts are extremely rare with approximately only 200 cases\\u000a reported in the literature. Only ten cases have been reported with recurrent laryngeal nerve paralysis and none in the radiological\\u000a literature. We present a case of parathyroid cyst and recurrent laryngeal nerve paralysis with illustrations of the clinical,\\u000a radiological and pathological appearances as well
E. K. Woo; R. Simo; B. Conn; S. E. J. Connor
Introduction A non-recurrent variant of the inferior laryngeal nerve has been seldom reported. These reports are mostly based on cadaveric dissection studies or large chart review studies in which the emphasis is placed on the determination of the frequency of the variation, and not on the clinical appearance of this variant. We graphically describe the intraoperative identification of a non-recurrent inferior laryngeal nerve. Case Presentation A 44-year old Caucasian man was referred to the Head and Neck Surgery Outpatient Clinic with the diagnosis of a nodular mass in his left thyroid lobe that had been growing for one year. A fine needle aspiration puncture was compatible with thyroid papillary cancer. It was decided that the patient should undergo total thyroidectomy. During surgery, a non-recurrent right inferior laryngeal nerve was noted. This nerve emanated from the right vagus nerve, entering the larynx 3 cm after its origin. The nerve did not show a recurrent course. The nerve on the left side had a normal configuration. The surgery and post-operative period were uneventful, and the patient had no change in his voice. Conclusion This paper allows those interested to become acquainted with the normal intraoperative appearance of a non-recurrent inferior laryngeal nerve. This will undoubtedly be of significance for all of those performing invasive diagnostic and surgical procedures in the neck and upper thoracic regions, in order to minimize the risk of iatrogenic injury to this nerve. This is of extreme importance, since a unilateral lesion of this nerve may result in permanent hoarseness, and a bilateral lesion may lead to aphonia and life-threatening dyspnea.
Since the discovery of the G-type nerve agents, there have been numerous studies of Central Nervous System (CNS) involvement in the etiology of organophosphate poisoning, notably associated with status Elipticus and/or 'electrographic seizures'. Brain dam...
R. W. Bide L. Schofield D. J. Risk
Early and definite identification of the recurrent laryngeal nerve (RLN) is an important step to avoid inadvertent nerve injury during complicated thyroid operations. This study aimed to determine the feasibility of routine use of intraoperative neuromonitoring (IONM) to localize and identify the RLN at an early stage of thyroid surgery. This prospective study enrolled 220 consecutive patients (333 RLNs at risk) who underwent thyroid operations with application of IONM. The RLN was localized and identified routinely with a nerve stimulator after opening the space between the thyroid and carotid sheath. The success rates of early RLN localization and identification were evaluated. The current for localization and the amplitude of evoked laryngeal electromyographic signals were also recorded and analyzed. All RLNs, including 87 (26%) nerves that were regarded as difficult to identify, were successfully localized and identified. The stimulation level for RLN localization was 2mA in 315 nerves (95%) and 3mA in the other 18 nerves (5%). The signal obtained from RLN localization (amplitude = 932 ±436?V) showed a clear and reliable laryngeal electromyographic response that was similar to that from direct vagus (amplitude=811±389?V) or RLN stimulation (amplitude=1132±472?V). The palsy rate was 0.6% and no permanent palsy occurred. RLN injury is rare if the nerve is definitely identified early in the thyroid operation. The conclusion of this study is that IONM is a reliable tool for early RLN localization and identification, even in complicated thyroid operations. PMID:21186011
Chiang, Feng-Yu; Lu, I-Cheng; Chen, Hui-Chun; Chen, Hsiu-Ya; Tsai, Cheng-Jing; Lee, Ka-Wo; Hsiao, Pi-Jung; Wu, Che-Wei
Electrical injuries can occur as a result of contact with low- or high-voltage electricity. Low-voltage injuries are more common, as they usually occur in the home, but reports in the literature are few. After exposure to electric current, almost every organ system in the body is affected. The severity of an injury depends on many factors, including the type of current, the duration of exposure, and the resistance of the tissue involved. Reported cases of hearing loss and facial nerve paralysis associated with low-voltage electrical shock are rare, and minimal information is available about this circumstance. In this article, the author describes a case of low-voltage electrical shock in a 20-year-old man. To the best of the author's knowledge, this is the first report in the literature of a resolution of unilateral sensorineural hearing loss and facial nerve paralysis caused by a low-voltage electrical shock. PMID:24526477
The aim of this study was to assess the feasibility of implanting an existing vagus nerve stimulating (VNS) electrode around the recurrent laryngeal nerve. The stimulus response characteristics required to achieve abduction of the ipsilateral arytenoid by the VNS electrode in the normal horse could then be determined. The electrode was wound around the left recurrent laryngeal nerve at the cervical level and connected to a pulse generator. Stimulus response characteristics were obtained by measuring stimulated arytenoid displacement endoscopically in the standing, non-sedated horse. A full and sustained abduction of the arytenoid was obtained with a stimulation frequency of 25 Hz and intensity of 1 mA with a pulse width of 250 ?s. PMID:20724182
Vanschandevijl, Katleen; Nollet, Heidi; Vonck, Kristl; Raedt, Rorecht; Boon, Paul; Roost, DirkVan; Martens, Ann; Deprez, Piet
Bell's palsy is the sudden onset of unilateral transient paralysis of facial muscles resulting from dysfunction of the seventh cranial nerve. Presented here is a 26-year-old female patient with right lower motor neurone facial palsy following hepatitis B vaccination. Readers' attention is drawn to an uncommon cause of Bell's palsy, as a possible rare complication of hepatitis B vaccination, and steps taken to manage such a presentation. PMID:24457866
Paul, R; Stassen, L F A
Ethylene glycol (EG) may be consumed accidentally or intentionally, usually in the form of antifreeze products or as an ethanol substitute. EG is metabolized to toxic metabolites. These metabolites cause metabolic acidosis with increased anion gap, renal failure, oxaluria, damage to the central nervous system and cranial nerves, and cardiovascular instability. Early initiation of treatment can reduce the mortality and morbidity but different clinical presentations can cause delayed diagnosis and poor prognosis. Herein, we report a case with the atypical presentation of facial paralysis, hematuria, and kidney failure due to EG poisoning which progressed to end stage renal failure and permanent right peripheral facial nerve palsy.
Eroglu, Eray; Kocyigit, Ismail; Bahcebasi, Sami; Unal, Aydin; Sipahioglu, Murat Hayri; Kocyigit, Merva; Tokgoz, Bulent; Oymak, Oktay
Unilateral recurrent nerve paralysis leads to glottic insufficiency, significantly reducing vocal ability. Due to its unusually long course, the recurrent laryngeal nerve is prone to iatrogenic lesions involves many medical fields generally with little expertise in voice disorders. Whenever the etiology is uncertain, a complete diagnostic work-up is mandatory. Indirect laryngoscopy confirms the diagnosis. Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytenoid joint. Moreover in many cases laryngeal electromyography yields a reliable prognosis of clinical outcome. While unfavorable results can be predicted with high accuracy, correct prognosis of complete recovery is more difficult. Speech therapy is the treatment of choice in cases of unilateral recurrent nerve palsy. Patients with persistent glottal gap may express the wish for surgical voice rehabilitation. Nowadays a broad spectrum of endoscopic and open approaches are available for this purpose. This review describes advanced techniques of voice-improving surgery available in specialized centers today. PMID:18509610
Sittel, C; Bosch, N; Plinkert, P K
Previous investigations using in vivo models to study the role of intrinsic laryngeal muscles in phonation have used neuromuscular stimulation to study voice parameters. However, these studies used coarse stimulation techniques using limited levels of neuromuscular stimulation. In the current investigation, a technique for fine control of laryngeal posturing was developed using graded stimulation of the laryngeal nerves. Vocal fold strain history to graded stimulation and a methodology for establishing symmetric laryngeal activation is presented. This methodology has immediate applications for the study of laryngeal paralysis and paresis, as well as general questions of neuromuscular control of the larynx. PMID:20369979
Chhetri, Dinesh K; Neubauer, Juergen; Berry, David A
Previous investigations using in vivo models to study the role of intrinsic laryngeal muscles in phonation have used neuromuscular stimulation to study voice parameters. However, these studies used coarse stimulation techniques using limited levels of neuromuscular stimulation. In the current investigation, a technique for fine control of laryngeal posturing was developed using graded stimulation of the laryngeal nerves. Vocal fold strain history to graded stimulation and a methodology for establishing symmetric laryngeal activation is presented. This methodology has immediate applications for the study of laryngeal paralysis and paresis, as well as general questions of neuromuscular control of the larynx.
Chhetri, Dinesh K.; Neubauer, Juergen; Berry, David A.
A prospective study was carried out in patients undergoing thyroid and parathyroid surgery using a laryngeal mask airway (LMA) and electrical nerve stimulation to identify the recurrent laryngeal nerves. A total of 150 consecutive patients undergoing thyroid and parathyroid surgery by a single surgeon were assessed for suitability of anaesthesia via the LMA. Peroperatively, a fibre-optic laryngoscope was passed through the LMA to enable the anaesthetist to visualise the vocal cords while adduction of the cords was elicited by applying a nerve stimulator in the operative field. In all, 144 patients were selected for anaesthesia via the LMA. Fibre-optic laryngoscopy and nerve stimulation were performed in 64 patients (42.7%). The trachea was deviated in 51 (34.0%) and narrowed in 33 (22.0%). The recurrent laryngeal nerves were identified in all patients. There were no cases of vocal cord dysfunction resulting from surgery. The LMA can be safely used for thyroid and parathyroid surgery even in the presence of a deviated or narrowed trachea. It can assist in identification and preservation of the recurrent laryngeal nerve and is, therefore, of benefit to both patient and surgeon. Images Figure 1 Figure 2
Shah, E. F.; Allen, J. G.; Greatorex, R. A.
We examined the swallowing-related intracellular activity of motoneurons of the superior laryngeal nerve (SLN) in decerebrate, paralyzed and artificially-ventilated rats, to elucidate the neuronal mechanism of the pharyngo-esophageal and laryngo-esophageal coordination during swallowing. The majority of the SLN motoneurons exhibited respiratory rhythm (n=16; 13 inspiratory, one expiratory and two non-respiratory neurons). During fictive swallowing evoked by electrical stimulation of the
Yoshiaki Saito; Kazuhisa Ezure; Ikuko Tanaka
A 74-year-old man was referred to our hospital because of persistent cough. A chest radiograph revealed an elevation of the right diaphragm. Computed tomography (CT) images revealed a small nodule localized on the right mediastinum. Five months later, the nodule had grown and was diagnosed as malignant pleural mesothelioma (MPM) by a CT-guided needle biopsy. The patient underwent combined chemotherapy, but the disease progressed rapidly and he passed away. On autopsy, microscopic findings and immunohistological examinations supported the diagnosis of sarcomatoid mesothelioma. Therefore, we diagnosed this rare case as localized sarcomatoid MPM showing phrenic nerve paralysis as an initial presentation.
Makimoto, Go; Fujiwara, Keiichi; Fujimoto, Nobukazu; Yamadori, Ichiro; Sato, Toshio; Kishimoto, Takumi
Background The aim of this study was to evaluate the ability of intraoperative neuromonitoring in reducing the postoperative recurrent laryngeal nerve palsy rate by a comparison between patients submitted to thyroidectomy with intraoperative neuromonitoring and with routine identification alone. Methods Between June 2007 and December 2012, 2034 consecutive patients underwent thyroidectomy by a single surgical team. We compared patients who have had neuromonitoring and patients who have undergone surgery with nerve visualization alone. Patients in which neuromonitoring was not utilized (Group A) were 993, patients in which was utilized (group B) were 1041. Results In group A 28 recurrent laryngeal nerve injuries were observed (2.82%), 21 (2.11%) transient and 7 (0.7%) permanent. In group B 23 recurrent laryngeal nerve injuries were observed (2.21%), in 17 cases (1.63%) transient and in 6 (0.58%) permanent. Differences were not statistically significative. Conclusions Visual nerve identification remains the gold standard of recurrent laryngeal nerve management in thyroid surgery. Neuromonitoring helps to identify the nerve, in particular in difficult cases, but it did not decrease nerve injuries compared with visualization alone. Future studies are warranted to evaluate the benefit of intraoperative neuromonitoring in thyroidectomy, especially in conditions in which the recurrent nerve is at high risk of injury.
Non-recurrent laryngeal nerve (NRLN) is a rare anomaly which is reported in 0.3%-0.8% of people on the right side and in 0.004% (extremely rare) on the left side. Damage to this nerve during the surgical procedure may lead to severe iatrogenic morbidity and should therefore be prevented from being damaged. The best way to avoid this damage to the nerve is to identify the nerve with a systematic diligent dissection based on usual anatomical landmarks and awareness about the possibility of their existence. Hereby, we are going to present a 26-year-old woman, a case of NRLN on the right side which was identified during thyroidectomy. The nervous anomaly was accompanied with vascular abnormality which was confirmed by computerized tomography (CT) angiography, post-operatively.
Mahmodlou, Rahim; Aghasi, Mohammad Reza; Sepehrvand, Nariman
Electromyography of the larynx in the awake patient using zoom-endoscopy provides an earlier diagnosis of recurrent laryngeal nerve diseases by recording action potentials of the posterior cricoarytenoid muscle. Not in every case the type of nerve lesion (neurapraxy, neurotmesis, axonotmesis) could be determined by the EMG alone. Therefore, neurography of the laryngeal nerves was investigated. With respect to the mixed innervation of the larynx by both the more sensible superior and the motoric inferior laryngeal nerve a reflex arc can be examined. The upper laryngeal nerve was stimulated transcutaneously. The afferent reflex arc leads to the ganglions of the vagus nerve and its central nuclei, its efferent motor neurons conduct reflex activity via the recurrent and upper laryngeal nerves back to the larynx. The reflex potentials can be measured out of the various larynx muscles by electromyography under endoscopic control. The importance of this method is demonstrated in cases of vocal cord palsies. PMID:7464358
Thumfart, W; Gschwandtner, R
The recurrent laryngeal nerve (RLN) branches from the vagus cranial nerve to innervate structures important for voicing and swallowing. Damage to this nerve, commonly associated with surgery or idiopathic etiologies that largely occur with aging, results in impaired voicing and swallowing. Sunderland proposed a model of peripheral nerve damage whereby a nerve’s ability to resist damage from stretch and compression is determined by the quantity and composition of its epineurial connective tissues. Thus, it would be expected that epineurium differs depending upon the forces imposed on a nerve within its anatomical setting. The purpose of this study was to investigate RLN epineurium quantity and composition with development. A porcine model (piglet vs. juvenile) was used because of the similarity between porcine and human laryngeal innervation, anatomy, and function. The entire RLN was excised bilaterally, and stereological methods were used to quantify the composition of epineurial connective tissues. Compared to the piglet, the juvenile pig RLN was double in diameter. While the piglet had no differences in the percent of epineurial collagen and adipose between proximal and distal segments of both sides of the RLN, the juvenile pig had a greater percent of collagen in the proximal segment of both sides of the RLN and a greater percent of adipose in the distal segment of the left RLN compared to the proximal segment. In addition, unlike the piglet, the juvenile pig had a greater number of fascicles in the proximal than distal segment of the RLN, regardless of nerve side. These findings are consistent with predicted patterns associated with the different anatomical settings of the left and right RLN, show that the RLN changes with age, and support Sunderland’s model.
Campbell, Ellen O.; Samlan, Robin A.; McMullen, Nathaniel T.; Cook, Sarah; Smiley-Jewell, Suzette; Barkmeier-Kraemer, Julie
Background Previous thyroid or parathyroid surgery induces scarring or distorts anatomy, and increases the risk of recurrent laryngeal nerve (RLN) injury for a reoperation. The benefit of intraoperative nerve monitoring (IONM) for re-exploration (a second nerve exploration) and reoperation has not been established. Methods Two hundred and ten patients were given a thyroid or parathyroid reoperation at our hospital between 2001 and 2010. Using IONM, we re-explored 56 patients who had been operated on before June 2007. The injury rate in these patients was compared with that of the 15 patients re-explored without IONM between 2001 and 2006. Results Of the 70 nerves that were re-explored using IONM, only one was incidentally injured, significantly fewer than the three injured in the 15 nerves re-explored without using IONM (1.43% vs. 20%, P = 0.0164). Conclusions IONM helped prevent RLN damage when re-exploring nerves during thyroid and parathyroid surgery. We recommend the routine use of IONM in thyroid and parathyroid reoperations.
The prognosis and the recovery process of facial nerve paralysis were reviewed in 74 patients who, despite preservation of nerve continuity, showed no facial movement after acoustic neuroma resection. In 50 or 67.6% of patients, facial movement recovered sufficiently so as not to require any reanimation procedures. However, no apparent sign of remission was observed for 7–49 months in the
Takanobu Kunihiro; Jin Kanzaki; Shigemitsu Yoshihara; Yasuo Satoh
The internal branch of the superior laryngeal nerve (ibSLN) may be injured during anterior approaches to the cervical spine, resulting in loss of laryngeal cough reflex, and, in turn, the risk of aspiration pneumonia. Such a risk dictates the knowledge regarding anatomical details of this nerve. In this study, 24 ibSLN of 12 formaldehyde fixed adult male cadavers were used. Linear and angular parameters were measured using a Vernier caliper, with a sensitivity of 0.1 mm, and a 1° goniometer. The diameter and the length of the ibSLN were measured as 2.1±0.2 mm and 57.2±7.7 mm, respectively. The ibSLN originates from the vagus nerve at the C1 level in 5 cases (20.83%), at the C2 level in 14 cases (58.34%), and at the C2–3 intervertebral disc level in 5 cases (20.83%) of the specimens. The distance between the origin of ibSLN and the bifurcation of carotid artery was 35.2±12.9 mm. The distance between the ibSLN and midline was 24.2±3.3 mm, 20.2±3.6 mm, and 15.9±4.3 mm at the level of C2–3, C3–4, and at the C4–5 intervertebral disc level, respectively. The angles of ibSLN were mean 19.6±2.6° medially with sagittal plane, and 23.6±2.6° anteriorly with coronal plane. At the area between the thyroid cartilage and the hyoid bone the ibSLN is the only nerve which traverses lateral to medial. It is accompanied by the superior laryngeal artery, a branch of the superior thyroid artery. The ibSLN is under the risk of injury as a result of cutting or compression of the blades of the retractor at this level. The morphometric data regarding the ibSLN, information regarding the distances between the nerve, and the other consistent structures may help us identify this nerve, and to avoid the nerve injury.
Naderi, Sait; Ergur, Ipek; Korman, Esin
We assessed the effect of an early transfer of pronator teres to extensor carpi radialis brevis on hand function in patients with high radial nerve paralysis. Power grip and precision grip were measured preoperatively and postoperatively using a dynamometer. Fifteen patients were operated on, of which ten could be assessed at the end of 6 months. At 6 months after surgery, there was a median increase of 48% in power grip, 162% in tip pinch, 90% in key pinch and 98% in palmar pinch. Decreased palmar flexion was seen in four patients. Fraying of the periosteal extension and rupture of sutures at the junction site were each seen in one patient, leading to unsatisfactory results. Early tendon transfer quickly restored efficient grip while awaiting reinnervation of wrist extensors, avoiding the need for prolonged external splintage. PMID:20935022
Dabas, V; Suri, T; Surapuraju, P K; Sural, S; Dhal, A
The effects of CO2 on laryngeal receptors were studied in ten anaesthetized, paralysed, artificially ventilated cats using a preparation in which the upper airway was isolated in situ and artificially ventilated. This allowed CO2 to be confined to the upper airway and enabled responses to CO2 to be recorded whilst the larynx was being ventilated under physiological conditions. Single-unit afferent activity was recorded from the superior laryngeal nerve and the pressure and thermal sensitivity of receptors determined. Carbon dioxide responses were tested by switching from upper airway ventilation with room air to mixtures containing 5 and 9% CO2 with 21% O2 in N2. Fibres were classified into two broad groups, tonic and quiescent, depending on their level of activity when the larynx was not being ventilated. All tonic fibres responded to either positive or negative pressure. Quiescent fibres were either positive or negative pressure receptors, cold receptors or had no response to pressure or cold airflow. The majority of all categories of fibres were significantly affected by CO2 in a reversible and usually concentration-dependent manner. Tonic fibres were inhibited, regardless of pressure sensitivity. Quiescent negative and positive pressure receptors were excited and inhibited respectively whilst cold receptors and fibres with no response to occlusion were excited. Laryngeal hypoxia and systemic asphyxia and hypercapnia had no effect on receptor activity. We conclude that the majority of laryngeal receptors are sensitive to CO2 and that this receptivity may be important in the control of ventilation and upper airway muscle activity. PMID:8311945
Bradford, A; Nolan, P; O'Regan, R G; McKeogh, D
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. PMID:11407844
Paniello, R C; West, S E; Lee, P
We report a case of left phrenic nerve paralysis due to compression of left auricle caused by congenital partial left pericardial defect. A 56-year-old man was admitted with left phrenic nerve paralysis. His congenital partial left pericardial defect was incidentally diagnosed on video assisted thoracoscopic surgery (VATS). This case of left phrenic nerve paralysis was due to compression of the left auricle which protruded through the hole of a partial defect in the pericardium. When the patient was examined for dyspnea at our hospital, the chest X-ray revealed left diaphragmatic relaxation and chest computed tomography showed a high density mass in front of the left pulmonary artery. Electrophysiologic evaluation of the diaphragm by transcutaneous phrenic nerve stimulation indicated complete paralysis of the left phrenic nerve. VATS revealed that the phrenic nerve was compressed by the protruding left auricle due to a congenital partial left pericardial defect. Because of the complete paralysis of the left phrenic nerve, we chose to perform plication of the left diaphragm. The postoperative course was uneventful and the patient was discharged on the 23rd day after the operation. Congenital pericardial defect is an abnormality that is rarely found incidentally on thoracotomy or autopsy. However, we should perform a careful examination and consider the possibility of congenital pericardial defect in the differential diagnosis of phrenic nerve paralysis. PMID:19348266
Ogawa, Junichi; Nagashim, Hiromi; Suhara, Makoto; Yamauchi, Kohei
To acquire symmetry of the cheek when smiling, we carried out 39 free vascularised grafts of the muscle, the motor nerve of which was sutured to a stump of the ipsilateral facial nerve, for 39 patients with facial paralysis. We used two methods: an as healthy and fresh as possible facial nerve stump (method 1A, n = 17), or an
Kazuki Ueda; Kiyonori Harii; Hirotaka Asato; Kotarou Yoshimura; Atsushi Yamada
... through your mind after you've acquired a spinal cord injury or developed paralysis. You'll find your answers ... to activate nerves affected by paralysis resulting from spinal cord injury (SCI), stroke or other neurological disorders. FES can ...
Idiopathic onset of unilateral vocal fold paralysis (UVP) is caused by damage to the recurrent laryngeal nerve (RLN) and results in difficulty speaking, breathing, and swallowing. This damage may occur in this nerve as it loops around the aortic arch, which is in a dynamic biomechanical environment. The goal of this study is to determine if the location-dependent biomechanical and microstructural properties of the RLN are different in piglets versus adolescent pigs. The neck/distal and thoracic/proximal (near the aortic arch) regions of the RLN from eight adolescent pigs and six piglets were isolated and mechanically assessed in uni-axial tension. Two-photon imaging (second harmonic) data were collected at 5%, 10%, and 15% strain during the mechanical test. The tangential modulus (TM) and the strain energy density (W) were determined at each level of strain. The mean mode of the preferred fiber angle and the full width at half maximum (FWHM, a measure of fiber splay) were calculated from the imaging data. We found significantly larger values of TM, W, and FWHM in the proximal segments of the left RLN when compared to the distal segments (18.51?MPa?±?1.22 versus 10.78?MPa?±?1.22, p?0.001 for TM, 0.046?MPa?±?0.01 versus 0.026?MPa?±?0.01, p?0.003 for W, 15.52?deg?±?1.00 versus 12.98?deg?±?1.00, p?0.001 for FWHM). TM and W were larger in the left segments than the right (15.32?MPa?±?1.20 versus 11.80?MPa?±?1.20, p?0.002 for TM, 0.038?MPa?±?0.01 versus 0.028?MPa?±?0.01, p?0.0001 for W). W was larger in piglets when compared to adolescent pigs (0.042?MPa?±?0.01 versus 0.025?MPa?±?0.01, p?0.04). The proximal region of the left porcine RLN is more stiff than the distal region and has a higher degree of fiber splay. The left RLN of the adolescent pigs also displayed a higher degree of strain stiffening than the right. These differences may develop as a result of the more dynamic environment the left RLN is in as it loops around the aortic arch. PMID:24829083
Williams, Megan J; Utzinger, Urs; Barkmeier-Kraemer, Julie M; Vande Geest, Jonathan P
Among the pathological sequelae of facial paralysis is a paralytic eye. Apart from the psychological and aesthetic deficits, facial paralysis if left untreated can lead to dryness, ulceration and eventual blindness. Although numerous restorative microsurgical approaches have been introduced to address the sequelae of this problem, complete restoration of function to denervated facial muscles remains elusive.Utilizing the rat model of facial paralysis the present research has as an objective to examine a dual treatment approach. Specifically, this study combined the current microsurgical treatment of the cross-facial nerve graft with local administration of insulin-like growth factor I (IGF-I).The efficacy of this combined approach (cross-facial nerve graft + IGF-I) was assessed in the following ways: (a) behavior measurement of the blink response and (b) histomorphometry light and electron microscopy of the entire nerve graft. These data will help provide insight into the restoration of facial muscle function after trauma and assist in the future development of more potent treatment strategies.7he local adnünistration of IGF-I (50 micro g/ml) to the cross-facial nerve graft was found to restore the blink response faster and to strengthen the degree of eye closure. Light microscopy examination revealed that IGF-I significantly enhanced axonal regeneration within a nerve graft (a 22% increase in the mean number of axons), and increased the mean nerve fiber diameter and myelin thickness. Electron microscopy assessment of the nerve grafts demonstrated that the IGF-I treated grafts possessed a greater density of microtubules, which were evenly distributed within the axoplasm. PMID:12671244
Thanos, Panayotis K.; Okajima, Seiichiro; Tiangco, David A.; Terzis, Julia K.
Sensorimotor responses to repeated electrical stimulation of the superior laryngeal nerve were compared in 8 patients with adductor spasmodic dysphonia (ADSD) and 11 normal controls to determine if adductor response disinhibition occurred in ADSD. Pairs of electrical pulses were presented at interstimulus intervals varying from 100 to 5,000 milliseconds (ms). Three responses were measured in thyroarytenoid muscles: ipsilateral R1 responses at 17 ms and ipsilateral and contralateral R2 responses between 60 and 75 ms. Conditioned response characteristics, the percent occurrence and percentage amplitude of initial responses, were measures of response inhibition. As a group, the patients had reduced response inhibition: their conditioned ipsilateral R1 response amplitudes were increased, as was the frequency of their conditioned contralateral muscle responses (p < or = .002) compared to normal. However, the patients' initial responses were normal in latency and frequency characteristics, demonstrating that the brain stem mechanisms for these responses were intact. These results suggest a central disinhibition of laryngeal responses to sensory input in ADSD. PMID:7492063
Ludlow, C L; Schulz, G M; Yamashita, T; Deleyiannis, F W
Neuronal vacuolation and spinocerebellar degeneration in young Rottweiler dogs is a neurodegenerative condition characterized by neuronal vacuolation of several nuclei in the central nervous system and degeneration of the spinal cord white matter. Here, we describe the morphologic and ultrastructural findings in laryngeal muscles and peripheral nerves of a 16-week-old female and a 32-week-old female Rottweiler dog affected by progressive ataxia and tetraparesis associated with laryngeal paralysis. Lesions were characterized by neurogenic muscle atrophy of the intrinsic laryngeal muscles, and a loss of large myelinated fibers in the recurrent laryngeal nerve, accompanied by demyelinating/remyelinating features affecting the small myelinated fibers. No significant changes were detected in the cranial laryngeal, vagus, phrenic, ulnar, or peroneal nerves. These findings were indicative of a selective distal neuropathy of the recurrent laryngeal nerve with early severe axonal degeneration, mainly of the large myelinated fibers. PMID:16301586
Salvadori, C; Tartarelli, C L; Baroni, M; Mizisin, A; Cantile, C
This study is a morphologic description of the recurrent laryngeal nerve (RLN) and of the number and size of motor units (MUs) in the thyroarytenoid (TA) muscle bilaterally of a human fetus aged 25 weeks. A quantitative analysis of RLN and MUs is presented to investigate similarities with equivalent structures in adults. In the fetus used in our study, the morphologic organization of the RLN was similar to that commonly described in the adult RLN. Moreover, as is observed in adult TA, the TA of the analyzed fetus, particularly the right TA, showed MUs typical of muscles with great motor accuracy. These results may be used to increase our knowledge of the features of the voice in adults and newborns. PMID:24128892
Ellwanger, Joel Henrique; da Costa Rosa, Joăo Paulo; dos Santos, Iuri Pereira; da Rosa, Helen Tais; Jotz, Geraldo Pereira; Xavier, Léder Leal; de Campos, Deivis
The most common disease process involving the larynx is laryngeal paralysis, which occurs much more frequently in dogs than in cats. Diagnosis of laryngeal paralysis requires close attention to anesthetic plane and coordination of respiratory effort with laryngeal motion. Surgical arytenoid lateralization improves respiration and quality of life in dogs with laryngeal paralysis; however, aspiration pneumonia is a recognized complication, and generalized neuropathy can progress. Laryngeal collapse can result from any cause of chronic upper airway obstruction, but is most often associated with unaddressed brachycephalic airway syndrome. Laryngeal neoplasia, while generally uncommon, occurs more frequently in cats than in dogs. PMID:24268331
Changes in motoneurons innervating laryngeal muscles after section and regeneration of the recurrent laryngeal nerve (RLN) are far from being understood. Here, we report the somatotopic changes within the nucleus ambiguus (Amb) after the nerve injury and relates it to the resulting laryngeal fold impairment. The left RLN of each animal was transected and the stumps were glued together using surgical fibrin glue. After several survival periods (1, 2, 4, 8, 12, 16 weeks; at least six rats at each time point) the posterior cricoarytenoid (PCA) and thyroarytenoid (TA) muscles were injected with fluorescent-conjugated cholera toxin and the motility of the vocal folds evaluated. After section and subsequent repair of the RLN, no movement of the vocal folds could be detected at any of the survival times studied and the somatotopy and the number of labeled motoneurons changed. From 4 wpi award, the somatotopy was significantly disorganized, with the PCA motoneurons being located rostrally relative to their normal location. A rostrocaudal overlap between the two pools of motoneurons supplying the PCA and TA muscles was observed from 2 wpi onwards. Hardly any labeled neurons were found in the contralateral Amb in any of the experimental groups. An injury of the RLN leads to a reinnervation of the denervated motor endplates of PCA and TA. However, misdirected axons sprout and regrowth from the proximal stump to the larynx. As a result, misplaced innervation of muscles results in a lack of functional recovery of the laryngeal folds movement following a RLN injury. PMID:24458941
Hernández-Morato, Ignacio; Berdugo-Vega, Gabriel; Sańudo, Jose R; McHanwell, Stephen; Vázquez, Teresa; Valderrama-Canales, Francisco J; Pascual-Font, Arán
The aim of this retrospective multicenter study was to verify whether the substernal goiter and the type of surgical access could be risk factors for recurrent laryngeal nerve palsy during total thyroidectomy. Between 1999-2008, 14,993 patients underwent total thyroidectomy. Patients were divided into three groups: group A (control; n=14.200, 94.7%), cervical goiters treated through collar incision; group B (n=743, 5.0%) substernal goiters treated by cervical approach; group C (n=50, 0.3%) in which a manubriotomy was performed. Transient and permanent unilateral palsy occurred significantly more frequently in B+C vs. A (P?.001) and in B vs. A (P?.001). Transient bilateral palsy was significantly more frequent in B+C vs. A (P?.043) and in C vs. A (P?.016). Permanent bilateral palsy was significantly more frequent in B+C vs. A (P?.041), and in B vs. A (P?.037). Extension of the goiter into the mediastinum was associated to increased risk of recurrent nerve palsy during total thyroidectomy. PMID:24880605
Testini, M; Gurrado, A; Bellantone, R; Brazzarola, P; Cortese, R; De Toma, G; Fabiola Franco, I; Lissidini, G; Pio Lombardi, C; Minerva, F; Di Meo, G; Pasculli, A; Piccinni, G; Rosato, L
Recurrent laryngeal nerve injury remains one of the main complications in thyroid and parathyroid surgery. When this injury is bilateral, an acute upper airway obstruction may occur, leading to a potentially life-threatening situation for the patient. The visual identification of the nerve during surgery is the best way to preserve its integrity. However identification of the nerves by means of electromyographic stimuli through electrodes attached to endotracheal tubes could help in decreasing nerve injury. In these cases the experience and role of the anesthetist is essential to correctly place the electromyographic endotracheal tube and ensure that the electrodes are in touch with the vocal cords during the surgery. Moreover, the results of the electromyography can be affected by the neuromuscular blocking agents. Therefore, the choice and dose must be adapted, in order to ensure a suitable anesthetic depth, and adequate response. PMID:23886448
Martín Jaramago, J; Tamarit Conejeros, M; Escudero Torrella, M; Solaz Roldán, C
INTRODUCTION The aims of this study were to assess and compare vocal cord functions before and after thyroid surgery after intra-operative identification of recurrent laryngeal nerve. PATIENTS AND METHODS Recurrent laryngeal nerve (RLN) is seen intra-operatively in all cases undergoing thyroid surgeries. Vocal cord functions including any voice change were evaluated by indirect laryngoscopy (I/L) and direct laryngoscopy (D/L) before and after surgery. RESULTS Prospective study on 100 patients over 18 months with a total of 146 nerves at risk (NAR). Majority were women (n = 86) with mean age of 37.48 years (range, 13–60 years). RLN was seen in all patients and 19 patients complained of some change in quality of their voice after surgery. Evaluation by I/L and D/L at 6 weeks showed recurrent laryngeal nerve palsy (RLNP) in nine (47.36%) and five (26%) of these 19 patients respectively. Analysed according to total NAR, the incidence of voice change and temporary RLN palsy (I/L and D/L) at 6 weeks was still less at 13.01%, 6.16% and 3.42%, respectively. Voice change improved in all cases at 3 months with no RLNP palsy by I/L or D/L. All these 19 patients had undergone difficult or extensive surgery for malignancy, large gland, extratyhroidal spread or fibrosis. CONCLUSIONS Despite identification and preservation of RLN, patients can develop postoperative voice change and RLNP although all voice change cannot be attributed to damaged RLN. Proper assessment of vocal cord functions by I/L and D/L laryngoscopy is required to rule out injuries to these nerves. Risk of damage is higher in patients undergoing more difficult surgery.
Mohil, Ravindra Singh; Desai, Pragnesh; Narayan, Nitisha; Sahoo, Maheswar; Bhatnagar, Dinesh; Venkatachalam, VP
Patients with medically intractable seizures who are not candidates for epilepsy surgery are left with few options. Vagal nerve stimulation therapy is often a viable alternative for these patients and can have a positive impact on quality of life. Rarely complications may occur. We report a case of mild blunt neck trauma resulting in VNS malfunction and delayed vocal cord paralysis. A systematic review of the literature on VNS malfunction, self-inflicted injuries, vagal nerve injury, and common side effects including voice changes was performed. Only a handful of relevant publications were found. Symptoms following VNS dysfunction include pain, dyspnea, and dysphonia. These symptoms are usually nonspecific, and in many cases, do not help differentiate from vagal nerve traction, lead breakage, or pulse generator malfunction. In our case, lead fracture and visible traction injury to the left vagus nerve were seen during surgical exploration. The vocal cord function completely recovered after revision of the leads. Prompt medical attention including appropriate diagnostic studies and early surgical exploration is necessary in cases of delayed vocal cord dysfunction and can help prevent long-term complications such as neuroma formation. The authors present a unique case of reversible vocal cord injury from blunt neck trauma leading to left vagus nerve damage. PMID:21397256
Tran, Yvan; Shah, Aashit K; Mittal, Sandeep
To determine the intra-examiner intertrial reproducibility of normal facial motor nerve conduction studies (FNCS) and their relevance in electrophysiological assessments of peripheral facial paralysis, 52 patients with acute unilateral Bell's palsy were examined on two separate occasions 1 months apart. Three electroneurographic methods were assessed. On the unaffected side of the face, FNCS are reliable when performed by a single examiner over time. Nevertheless, compound muscle action potential (CMAP) baseline-to-peak and peak-to-peak amplitude showed a rather high intertrial variability. Reproducibility of the assessed surface electrode recording procedures was similar. Regarding the affected side, in patients with mild axonotmesis of the facial nerve variations of electroneurographic parameters 1 months apart fell within the range of normal intertrial variability. In patients with severe or moderate axonotmesis, the distal latency and the M wave amplitude variations showed significant intertrial variations. Reproducibility of FNCS appears to be similar to that found in limb motor nerves. Normal variability curtails the sensitivity of FNCS in detecting mild facial nerve axonotmesis, although this technique remains useful in severe cases. PMID:9350062
Di Bella, P; Logullo, F; Lagalla, G; Sirolla, C; Provinciali, L
265 carotid endarterectomies in 210 patients (all vein patch in the carotid bifurcation) were investigated postoperatively for the presence and reversibility of cranial nerve palsy especially for N. facialis, N. hypoglossus, and N. vagus paresis. Additionally, the anatomical relationship between the affected cranial nerve and the carotid artery and the influence of surgical case load on the incidence of cranial nerve paresis were investigated. Altogether 28 (10.5%) cranial nerve injuries were registered. In 6 (2.2%) cases the hypoglossus nerve was injured, in 13 (4.9%) the vagal nerve (N. laryngeus recurrens) and in 9 (3.4%) facial nerve paresis occurred. Cranial nerves VII and X, which are not directly connected with the area operated on, show significantly more injuries than the hypoglossal nerve (p < 0.01), which is located closer to the carotid artery. Significantly lower rates of cranial nerve injuries (p < 0.01) were recorded in cases operated on by surgeons with greater experience (> 30 cases) than by surgeons with a case load below this threshold. Although different reasons for cranial nerve injuries such as direct pressure, retraction or edema are known, all pareses show an excellent spontaneous recovery rate within the period of one year. PMID:7785277
Krennmair, G; Moser, G; Pachinger, O; Deutsch, M
The stimulation of the vagus nerve has been used as an anti-epileptic treatment for over a decade, and its use for depression and chronic heart failure is currently under investigation. Co-activation of the intrinsic laryngeal muscles may limit the clinical use of vagal stimulation, especially in the case of prolonged activation. To prevent this, the use of a selective stimulation paradigm has been tested in seven acute pig experiments. Quasi-trapezoidal pulses successfully blocked the population of the largest and fastest vagal myelinated fibers being responsible for the co-activation. The first response in the vagus compound action potential was reduced by 75 ± 22% (mean ± SD) and the co-activated muscle action potential by 67 ± 25%. The vagal bradycardic effects remained unchanged during the selective block, confirming the leading role of thin nerve fibers for the vagal control of the heart. Quasi-trapezoidal pulses may be an alternative to rectangular pulses in clinical vagal stimulation when the co-activation of laryngeal muscles must be avoided.
Tosato, M.; Yoshida, K.; Toft, E.; Struijk, J. J.
Eighteen cases of tendon transfer for isolated radial or posterior interosseous nerve palsy have been carried out in our unit over a period of 21 years. Fifteen patients were reviewed with a mean follow-up of 9.5 years. Nine had sustained high and six low radial nerve injury. We achieved 11 excellent, two good, one fair and one bad result. The main problems were loss of power of gripping and the occurrence of radial deviation, particularly in patients with flexor carpi ulnaris transfer to the extensor digitorum communis. During this time, our technique has evolved, including changes of the tendons transferred. Our final preference is a modified Tsuge procedure, using the pronator teres to restore extension of the wrist, the flexor carpi radialis for extension of the fingers and the palmaris longus for extension of the thumb. Abduction of the thumb is restored by a tenodesis of the abductor pollicis longus to the brachioradialis. This review justifies the final policy, in particular the preservation of flexor carpi ulnaris to maintain wrist stability and flexion. PMID:16928411
Ropars, M; Dréano, T; Siret, P; Belot, N; Langlais, F
We report 20 children admitted to the paediatric ward of a public general hospital for acute flaccid paralysis, which was bilaterally symmetrical in all cases and was associated with bulbar involvement in eight of them. Recovery was partial. Nerve conduction studies showed motor axonal neuropathy. This new disease, variously termed as non-inflammatory neuropathy/Chinese paralysis syndrome must be differentiated from Guillain-Barré syndrome (GBS) and poliomyelitis. Both GBS and Asian paralysis syndrome have bilaterally symmetrical flaccid paralysis but GBS tends to have sensory involvement, full recovery occurs in 90% of cases and nerve conduction shows demyelinating neuropathy. Asian paralysis syndrome and poliomyelitis are pure motor lesions without sensory changes and partial recovery, but poliomyelitis differs in that paralysis is asymmetrical and unequal, muscle spasm is always present in the initial stage and there are prodromal symptoms. Nerve conduction studies show anterior horn cell disease. This new entity, common in Asian populations, assumes public health importance when it mimics poliomyelitis in a country that has tried to eliminate poliomyelitis by universal immunization. To the best of our knowledge, this is the first report of Asian paralysis syndrome in children in our area. PMID:10716023
Phadke, M A; Gambhir, P S; Deshpande, A S; Kurlekar, S U; Godbole, K G
The possible mechanisms contributing to the generation of R2-like response were investigated in 19 patients with complete facial nerve paralysis, where the efferent limb of the reflex arc is absent. The first possibility that potentials produced by the unaffected orbicularis oculi (0.0c) are conducted to the reference electrode taped over the nose was confirmed as the amplitude of R2 on the affected side was significantly reduced when the reference electrode was removed from the nose and taped on the ear lobule. The second possibility of volume conducted potentials produced by muscular generator in temporalis and masseter muscles through trigemino-trigeminal reflex was suggested in some patients based on three reproducible observations: (1) EMG activity of high amplitude could be recorded with electrodes taped over the affected 0.0c muscle during voluntary teeth clenching, (2) R2-like responses were recorded in patients with bilateral complete facial paralysis, (3) R2-like responses were recorded from temporalis and masseter muscles. The contribution of extraocular muscles could be discounted as R2 could be recorded from patients with Möbius's syndrome who had complete bilateral facio-ocular paralysis. The results of the present study further support the greater value of R1--rather than R2--in predicting clinical outcome of patients with peripheral facial nerve palsy. PMID:9187869
Ibrahim, I K; el-Abd, M A
Left vagus nerve stimulation (VNS) by means of an implanted electrode has proven to reduce seizure frequency in epileptic patients with medically refractory seizures. This technique is now widely applied over the world. Voice changes appear to be one of the major side effects. The morphodynamic changes in the larynx and the acoustic impacts have been analyzed in detail in
Willem Kersing; Philippe H Dejonckere; Hans E van der Aa; Hendrik P. J Buschman
"C3, 4, 5 Keeps the Diaphragm Alive." Is phrenic nerve palsy part of the pathophysiological mechanism in strangulation and hanging? Should diaphragm paralysis be excluded in survived cases?: A review of the literature.
The phrenic nerve arises in the neck. It is formed from C3, C4, and C5 nerve fibers and descends along the anterior surface of the scalenus anterior muscle before entering the thorax to supply motor and sensory input to the diaphragm. Its anatomic location in the neck leaves the nerve vulnerable to traumatic injury. Phrenic nerve injury can arise as a result of transection, stretching or compression of the nerve, and may result in paralysis of the diaphragm. Consequences of diaphragm paralysis include respiratory compromise, gastrointestinal obstruction, and cardiac arrhythmias. There may be serious morbidity and onset of symptoms may be delayed. Cases of diaphragm paralysis occurring as a consequence of neck trauma are documented in the literature. In some cases, the forces involved are relatively minor and include whiplash injury, occurring in minor motor vehicle collisions, chiropractic manipulation, and compression of neck structures, including a case involving external neck compression by industrial machinery. It is concluded that phrenic nerve palsy might be part of the pathophysiological mechanism in strangulation and hanging, and clinical investigation to exclude diaphragm paralysis in survived cases should be considered. PMID:19935388
Davies, Susan J
Background: Vocal cord paralysis continues to be an important issue in laryngology and is considered as a sign of underlying disease; the etiologies of this problem are varied and changing. Aims: The study was to carry out a retrospective analysis of patients with unilateral vocal fold paralysis diagnosed. Materials and Methods: The medical records of 53 patients diagnosed and treated for unilateral vocal fold paralysis were studied retrospectively. Data regarding age, sex, duration of symptoms, etiology, and side of paralysis were recorded. Results: Out of the 53 cases, 36 were females and 17 males with a ratio of 2.1:1. The age of the patients ranged from 17-75 years. In 18.9% the cause was idiopathic. Surgical trauma (iatrogenic) problems was the most encountered etiology (66%), others included malignancy (non laryngeal) (7.5%), central (3.8%), external neck trauma (1.9%) and radiation therapy 1.9%. Thyroid surgery was the most commonly reported neck surgery in 50.9%. Conclusions: Thyroidectomy continues to be the single most common surgical procedure responsible for unilateral vocal cord paralysis. For this reason, routine pre and postoperative laryngoscopy should be considered in all patients undergoing surgeries with a potential risk for recurrent nerve paralysis to reduce the postoperative morbidity.
Al-Khtoum, Nemer; Shawakfeh, Nabil; Al-Safadi, Eyad; Al-Momani, Osama; Hamasha, Khalid
A progressive and sustained increase in inspiratory-related motor output ("long-term facilitation") and an augmented ventilatory response to hypoxia occur following acute intermittent hypoxia (AIH). To date, acute plasticity in respiratory motor outputs active in the postinspiratory and expiratory phases has not been studied. The recurrent laryngeal nerve (RLN) innervates laryngeal abductor muscles that widen the glottic aperture during inspiration. Other efferent fibers in the RLN innervate adductor muscles that partially narrow the glottic aperture during postinspiration. The aim of this study was to investigate whether or not AIH elicits a serotonin-mediated long-term facilitation of laryngeal abductor muscles, and if recruitment of adductor muscle activity occurs following AIH. Urethane anesthetized, paralyzed, unilaterally vagotomized, and artificially ventilated adult male Sprague-Dawley rats were subjected to 10 exposures of hypoxia (10% O(2) in N(2), 45 s, separated by 5 min, n = 7). At 60 min post-AIH, phrenic nerve activity and inspiratory RLN activity were elevated (39 ± 11 and 23 ± 6% above baseline, respectively). These responses were abolished by pretreatment with the serotonin-receptor antagonist, methysergide (n = 4). No increase occurred in time control animals (n = 7). Animals that did not exhibit postinspiratory RLN activity at baseline did not show recruitment of this activity post-AIH (n = 6). A repeat hypoxia 60 min after AIH produced a significantly greater peak response in both phrenic and RLN activity, accompanied by a prolonged recovery time that was also prevented by pretreatment with methysergide. We conclude that AIH induces neural plasticity in laryngeal motoneurons, via serotonin-mediated mechanisms similar to that observed in phrenic motoneurons: the so-called "Q-pathway". We also provide evidence that the augmented responsiveness to repeat hypoxia following AIH also involves a serotonergic mechanism. PMID:22241052
Bautista, Tara G; Xing, Tao; Fong, Angelina Y; Pilowsky, Paul M
We examined the effects of orexins on the reflex swallowing using anesthetized rats. Orexins were administered into the fourth ventricle. Swallowing was induced by repeated electrical stimulation of the central cut end of the superior laryngeal nerve (SLN) and was identified by the electromyogram lead penetrated the mylohyoid muscle through bipolar electrodes. The frequency of swallowing during the electrical stimulation of the SLN decreased after the administration of orexin-A in a dose-dependent manner. The latency of the first swallowing tended to be extended after the administration of orexin-A. The administration of orexin-B did not affect swallowing frequency. Pre-administration of SB334867, an orexin-1 receptor antagonist, attenuated the degree of inhibition of swallowing frequency induced by the administration of orexin-A. To identify the effective site of orexin-A, the effect of a microinjection of orexin-A into the dorsal vagal complex (DVC) was evaluated. Orexin-A was injected into one of the lateral DVC, the intermediate DVC, or the medial DVC. Microinjection of orexin-A into the medial DVC but not the other two sites decreased swallowing frequency. Pre-injection of SB334867 into the medial DVC disrupted the inhibitory response induced by fourth ventricular administration of orexin-A. The electrical lesion of the commissural part of the NTS, but not ablation of the AP, abolished the inhibition of reflex swallowing induced by fourth ventricular administration of orexin-A. These results suggest that orexin-A inhibits reflex swallowing via orexin-1 receptors situated in the commissural part of the NTS and/or its vicinity. PMID:24637063
Kobashi, Motoi; Mizutani, Satoshi; Fujita, Masako; Mitoh, Yoshihiro; Shimatani, Yuichi; Matsuo, Ryuji
Hypokalaemic paralysis is a relatively uncommon but potentially life-threatening clinical syndrome. If recognised and treated appropriately, patients recover without any clinical sequellae. The syndrome of hypokalaemic paralysis represents a heterogenous group of disorders characterised clinically by hypokalaemia and acute systemic weakness. Most cases are due to familial or primary hypokalaemic periodic paralysis; sporadic cases are associated with numerous other conditions including barium poisoning, hyperthyroidism, renal disorders, certain endocrinopathies and gastrointestinal potassium losses. The age of onset, race, family history, medications, and underlying disease states can help in identifying the cause of hypokalaemic paralysis. Initial therapy of the patient with hypokalaemic paralysis includes potassium replacement and search for underlying aetiology. Further management depends on the aetiology of hypokalaemia, severity of symptoms, and duration of disease. This review presents the differential diagnosis for hypokalaemic paralysis and discusses management of the syndrome.???Keywords: hypokalaemia; periodic paralysis
Ahlawat, S.; Sachdev, A.
Progressive bulbar paralysis of childhood is characterised by progressive paralysis of muscles innervated by cranial nerves.\\u000a The authors report a case of progressive bulbar paralysis of childhood in a 12-year-old child. Child was admitted with the\\u000a complaints of drooping of eyelids, difficulty in swallowing and hoarse voice. She had involvement of III, VII, IX, X, XI and\\u000a XII cranial nerves
Taruna Gulati; Vivek Dewan; Praveen Kumar; Bina Ahuja I; V. K. Anand
Background/Aims Rehabilitation of the bilaterally paralyzed human larynx remains a complex clinical problem. Conventional treatment generally involves surgical enlargement of the compromised airway, but often with resultant dysphonia and risk of aspiration. In this retrospective study, we compared one such treatment, posterior cordotomy, against unilateral laryngeal pacing: reanimation of vocal fold opening by functional electrical stimulation of the posterior cricoarytenoid muscle. Methods Post-operative peak inspiratory flow (PIF) values and overall voice grade ratings were compared between the two surgical groups, and pre and post-operative PIF were compared within the pacing group. Results There were five patients in the unilateral pacing group and 12 patients in the unilateral cordotomy group. Within the pacing group, post-operative PIF values were significantly improved from pre-operative PIF values (p=0.04) without significant effect on voice (grade) (p=0.62). Within the pacing group, the mean post-operative PIF value was significantly higher than that in the cordotomy group (p=0.05). Also, the mean post-operative overall voice grade values in the pacing group were significantly lower (better) than that of cordotomy group (p=0.03). Conclusion Unilateral pacing appears to be an effective and superior treatment to posterior cordotomy with respect to post-operative ventilation and voice outcome measures.
Li, Yike; Pearce, Elizabeth C.; Mainthia, Rajshri; Athavale, Sanjay M.; Dang, Jennifer; Ashmead, Daniel H; Garrett, C. Gaelyn; Rousseau, Bernard; Billante, Cheryl R.; Zealear, David L.
Injury to the bilateral internal branch of superior laryngeal nerve (ibSLN) brings on an impairment of the laryngeal cough reflex that could potentially result in aspiration pneumonia and other respiratory illnesses. We describe a patient with traumatic cervical injury who underwent bilateral ibSLN palsy after anterior cervical discectomy with fusion (ACDF). An 75-year-old man visited with cervical spine fracture and he underwent ACDF through a right side approach. During the post-operative days, he complained of high pitched tone defect, and occasional coughing during meals. With a suspicion of SLN injury and for the work up for the cause of aspiration, we performed several studies. According to the study results, he was diagnosed as right SLN and left ibSLN palsy. We managed him for protecting from silent aspiration. Swallowing study was repeated and no evidence of aspiration was found. The patient was discharged with incomplete recovery of a high pitched tone and improved state of neurologic status. The SLN is an important structure; therefore, spine surgeons need to be concerned and be cautious about SLN injury during high cervical neck dissection, especially around the level of C3-C4 and a suspicious condition of a contralateral nerve injury.
Shin, Dong-Uk; Nam, Kyung-Hun; Cho, Dae-Chul
Introduction: Nimodipine has been shown to be beneficial for recovery from acute vocal fold paralysis (AVFP) in an animal model. Methods: prospective, open-label trial of patients with AVFP was performed using nimodipine. Consecutive patients were evaluated and offered nimodipine therapy. Results: Fifty-three patients were considered for treatment with nimodipine. Thirteen did not qualify for inclusion, 5 were lost to follow-up, and 7 had side effects requiring cessation of treatment. Thus 28 patients (30 paralyzed vocal folds) were analyzed. Eighteen of the paralyzed vocal folds experienced recovery of purposeful motion (60%). Historical controls and laryngeal electromyography meta-analysis suggest no more than a 20% recovery rate from AVFP. Conclusions: This open label study using nimodipine for treatment of AVFP demonstrates tripling of the recovery rate of vocal fold motion compared with historical controls. Further study in a randomized, controlled manner is warranted. Muscle Nerve 50: 114-118, 2014. PMID:24639294
Rosen, Clark A; Smith, Libby; Young, Vyvy; Krishna, Priya; Muldoon, Matthew F; Munin, Michael C
Partial chemical neurolysis by means of a peripheral nerve block induced with a phenol solution can result in decreasing local muscle hypertonia of central origin. In case of a walking disability resulting from a spastic or dystonic equinovarus position of the ankle the phenol block of the tibial nerve may be a valuable treatment that improves walking ability. The technique of the procedure is explained. A phenol block is induced only after a favourable result of a trial block with a local anaesthetic. In the group of 19 patients who underwent tibial nerve block given by the author in the period 1987-1989 there appears to exist a correlation between the functional results and the extent to which the patient had been active in walking prior to the nerve block. A group of 6 'sitters' and 'hardly walking' patients had poor to moderate results, a group of 13 'walkers' had moderate, good and excellent results. The difference in functional outcome is ascribed by the author to a better possibility to actually utilise a muscular balance improved by the phenol block. In the early--recovery--phase of stroke rehabilitation a phenol block of the tibial nerve may well be useful in cases with equinovarus position of the ankle which interferes with therapeutic exercise and functional progress. PMID:2046769
Wichers, M J
A massive goiter may constrict the trachea resulting in shortness of breath. Recurrent laryngeal nerve compression may cause vocal cord paralysis. We highlight a case of a 62- year-old female with a 30 year history of an anterior neck swelling gradually increasing in size. She presented with acute symptoms of upper airway obstruction and voice changes. Emergency thyroidectomy was performed by dividing the middle part of the gland using ultrasonic scissors. The recovery was uneventful and the patient regained normal vocal cord function post operatively. PMID:23629575
M, Irfan; Yaroko, Ali Ango; S M, Najeb; Periasamy, Centilnathan
The one tick-borne disease that rarely comes under the auspices of the infectious disease specialist is not caused by an infectious agent, but is tick paralysis. This condition is caused by tick bite and typically presents as a flaccid ascending paralysis. This article discusses this entity partly because of completeness, but also because tick paralysis, or tick toxicosis as it is sometimes called, is worth the infectious disease consultant's consideration. The differential diagnosis includes entities that are infectious or caused by toxins of infectious agents, such as epidural abscess, some causes of transverse myelitis, and botulism. Lastly, in an era of antibiotic toxicity, multidrug-resistant bacteria, antigen-switching viruses, and complex antibiotic regimens, the cure for tick paralysis-removing the tick-is as simple as it is gratifying. PMID:18755381
Edlow, Jonathan A; McGillicuddy, Daniel C
To compare quantitatively the results obtained after hemihypoglossal nerve transposition and microvascular gracilis transfer associated with a cross facial nerve graft (CFNG) for reanimation of a paralysed face, 66 patients underwent hemihypoglossal transposition (n = 25) or microvascular gracilis transfer and CFNG (n = 41). The commissural displacement (CD) and commissural contraction velocity (CCV) in the two groups were compared using the system known as Facial clima. There was no inter-group variability between the groups (p > 0.10) in either variable. However, intra-group variability was detected between the affected and healthy side in the transposition group (p = 0.036 and p = 0.017, respectively). The transfer group had greater symmetry in displacement of the commissure (CD) and commissural contraction velocity (CCV) than the transposition group and patients were more satisfied. However, the transposition group had correct symmetry at rest but more asymmetry of CCV and CD when smiling. PMID:22455573
Hontanilla, Bernardo; Vila, Antonio
The larynx is the "bottleneck" of the human airway. For this reason, the effects of stenosing laryngeal pathologies on the vital factor respiratory gas exchange are particularly critical. Internal stabilization is a prerequisite for recovery of the laryngeal respiratory function in severe forms of inspiratory collapse (laryngomalacia). Effective laser surgery techniques have been developed to this end in recent years. Glottis-dilating surgery in cases of bilateral vocal cord motion impairment is now moving in the direction of endoscopic laser cordotomy or cordectomy, whereas arytenoidectomy and open surgical procedures are now used only rarely due to higher secondary morbidity rates. In individual cases, in particular if functional recovery is expected, temporary laterofixation of a vocal cord using an endoscopic suturing technique can be a helpful approach. Extensive laryngeal defects can be covered by means of composite grafts with mucosal lining, a supporting skeleton and their own vascularization. Autologous transplantation of the larynx, with its complex surgical and immunological problems, has become a manageable procedure. The problems of post-transplantation reinnervation and risk assessment of immunosuppression-induced recurrence of the tumor are still under consideration. Reanimation of the bilaterally paralyzed larynx by means of neurorrhaphy (neurosuture), neural grafting and, more recently, functional electrostimulation (pacemaker) represents a challenge for the coming years. In most cases of paralysis of the recurrent laryngeal nerve, a part of the muscles is maintained by synkinetic reinnervation when therapy is carried out, which however also prevents effective vocal cord movement due to simultaneous activity of agonists and antagonists. Modulation of reinnervation by means of electrostimulation and modern genetic therapy approaches justify hopes of better outcomes in the future.
Organophosphorus poisoning is a major global cause of health problems and the leading cause of mortality and morbidity in the developing countries. In this, the inhibition of acetyl-choline esterase and neurotoxic esterase along with nicotinic receptor involvement produces three well-identified and documented clinical phases: The initial cholinergic phase, which is a medical emergency often requiring management in an intensive care unit; the intermediate syndrome, during which prolonged ventilator care is necessary; and finally delayed neurotoxicity. Vocal cord paralysis is rare and leads to aphonia. Role of physiotherapy rehabilitation is substantial in all three stages and aims at early weaning off from mechanical ventilator until the functional independence and community integration of the patient. PMID:24678153
Shetye, Jaimala Vijay; Surkar, Swati M; Karnik, Niteen D; Mehta, Amita A
Background Recurrent laryngeal nerve (RLN) lymph node metastasis used to be shown a predictor for poor prognosis in esophageal squamous cell carcinoma. The purpose of this study was to evaluate the prognostic impact of RLN node metastasis and the number of metastatic lymph nodes in node-positive patients with squamous cell carcinoma of middle thoracic esophagus. Methods A cohort of 235 patients who underwent curative surgery for squamous cell carcinoma of middle thoracic esophagus was investigated. The prognostic impact was evaluated by univariate and multivariate analyses. Results Lymph node metastasis was found in 133 patients. Among them, 81 had metastatic RLN nodes, and 52 had at least one positive node but no RLN nodal involvement. The most significant difference in survival was detected between patients with metastatic lymph nodes below and above a cutoff value of six (P?0.001). Multivariate analysis revealed that the number of metastatic lymph nodes was a significant factor associated with overall survival (P?0.001), but RLN lymph node metastasis was not (P?=?0.865). Conclusions RLN Lymph node metastasis is not, but the number of metastatic nodes is a prognostic predictor in node-positive patients with squamous cell carcinoma of the middle thoracic esophagus.
Case 1. This is believed to be the first report of acupuncture treatment for traumatic radial nerve paralysis in a wild fox. From the first treatment, improvement in the range of mobility and sensation of the limb was evident. Additionally, the attitude of this wild animal changed from fear and aggression to complete cooperation: he lay peacefully during every treatment in a calm, drowsy state. Case 2. This reports the calming effects of acupuncture on a fox which had been showing aggressive behaviour and obsessive circling following toxoplasma infection. PMID:16430128
Lloret, Lorena; Hayhoe, Simon
At the recent Forty-fourth Annual Meetings of the American Public Health Association, Cincinnati, Ohio, there was held a Round Table Discussion on Infantile Paralysis, in which health authorities throughout the country took part. This discussion was held under the auspices of the Section on Public Health Administration. Dr. George W. Goler, Health Officer of Rochester, N. Y., Chairman of this Section, presided. We take great pleasure in being able to reproduce for readers of the Journal what took place at this most important session.
Nerve preservation is an important issue during most surgery because accidental transection or injury results in significant morbidity, including numbness, pain, weakness, or paralysis. Currently, nerves are still identified only by gross appearance and anatomical location during surgery, without intraoperative image guidance. Near-infrared (NIR) fluorescent light, in the wavelength range of 650-900 nm, has the potential to provide high-resolution, high-sensitivity, and real-time avoidance of nerve damage, but only if nerve-specific NIR fluorophores can be developed. In this study, we evaluated a series of Oxazine derivatives to highlight various peripheral nerve structures in small and large animals. Among the targeted fluorophores, Oxazine 4 has peak emission near into the NIR, which provided nerve-targeted signal in the brachial plexus and sciatic nerve for up to 12 h after a single intravenous injection. In addition, recurrent laryngeal nerves were successfully identified and highlighted in real time in swine, which could be preserved during the course of thyroid resection. Although optical properties of these agents are not yet optimal, chemical structure analysis provides a basis for improving these prototype nerve-specific NIR fluorophores even further.
Park, Min Ho; Hyun, Hoon; Ashitate, Yoshitomo; Wada, Hideyuki; Park, GwangLi; Lee, Jeong Heon; Njiojob, Costyl; Henary, Maged; Frangioni, John V.; Choi, Hak Soo
Nerve preservation is an important issue during most surgery because accidental transection or injury results in significant morbidity, including numbness, pain, weakness, or paralysis. Currently, nerves are still identified only by gross appearance and anatomical location during surgery, without intraoperative image guidance. Near-infrared (NIR) fluorescent light, in the wavelength range of 650-900 nm, has the potential to provide high-resolution, high-sensitivity, and real-time avoidance of nerve damage, but only if nerve-specific NIR fluorophores can be developed. In this study, we evaluated a series of Oxazine derivatives to highlight various peripheral nerve structures in small and large animals. Among the targeted fluorophores, Oxazine 4 has peak emission near into the NIR, which provided nerve-targeted signal in the brachial plexus and sciatic nerve for up to 12 h after a single intravenous injection. In addition, recurrent laryngeal nerves were successfully identified and highlighted in real time in swine, which could be preserved during the course of thyroid resection. Although optical properties of these agents are not yet optimal, chemical structure analysis provides a basis for improving these prototype nerve-specific NIR fluorophores even further. PMID:24955143
Park, Min Ho; Hyun, Hoon; Ashitate, Yoshitomo; Wada, Hideyuki; Park, GwangLi; Lee, Jeong Heon; Njiojob, Costyl; Henary, Maged; Frangioni, John V; Choi, Hak Soo
Bilateral vocal fold paralysis (BVCP) is a life threatening condition and appears to be a good candidate for therapy using functional electrical stimulation (FES). Developing a working FES system has been technically difficult due to the inaccessible location and small size of the sole arytenoid abductor, the posterior cricoarytenoid (PCA) muscle. A naturally-occurring disease in horses shares many functional and etiological features with BVCP. In this study, the feasibility of FES for equine vocal fold paralysis was explored by testing arytenoid abduction evoked by electrical stimulation of the PCA muscle. Rheobase and chronaxie were determined for innervated PCA muscle. We then tested the hypothesis that direct muscle stimulation can maintain airway patency during strenuous exercise in horses with induced transient conduction block of the laryngeal motor nerve. Six adult horses were instrumented with a single bipolar intra-muscular electrode in the left PCA muscle. Rheobase and chronaxie were within the normal range for innervated muscle at 0.55±0.38 v and 0.38±0.19 ms respectively. Intramuscular stimulation of the PCA muscle significantly improved arytenoid abduction at all levels of exercise intensity and there was no significant difference between the level of abduction achieved with stimulation and control values under moderate loads. The equine larynx may provide a useful model for the study of bilateral fold paralysis.
Cheetham, Jon; Regner, Abby; Jarvis, Jonathan C.; Priest, David; Sanders, Ira; Soderholm, Leo V.; Mitchell, Lisa M.; Ducharme, Norm G.
Background. Laryngeal dystonia (LD) is a form of focal dystonia, involving laryngeal muscles and causing disturbed phonation. Adductor, abductor and mixed forms of LD are described. Methods. Largely unsuccessful treatments include voice the- rapy, psychotherapy, biofeedback, section of the laryngeal re- current nerve, laryngeal framework surgery and the use of centrally acting drugs. Botulinum toxin proved to be the most
Sarcoidosis is a chronic granulomatous disease that tends to involve the lungs, hilar and mediastinal lymph nodes, liver, eyes, skin, bones, and nervous system. Sarcoidosis involves the larynx less commonly than it afflicts these other sites. Laryngeal sarcoidosis may occur in isolation or as a component of systemic sarcoidosis and it may produce hoarseness, dysphagia, and dyspnea. Life-threatening airway obstruction
Carole M Dean; Robert Thayer Sataloff; Mary J Hawkshaw; Edmund Pribitkin
The authors report a case where a woman presents a right jugular bulb procidence already known and responsible of a perception deafness. Secondarily, a right facial paralysis is appeared progressively and not regressive even with medical treatment. When the computed tomography as shown an intrapetrous diverticular, the facial paralysis treatment was surgical to decompress the facial nerve. The literature study shoes the rarity of this association facial paralysis and jugular bulb procidence (only two cases), more often responsible of deafness, tinnitus, and vertigo. The diagnosis is given by computed tomography. M.R.I. has not still be evaluated. Then the authors insist on the progressive character of the facial paralysis and on the necessity of a surgical treatment. PMID:10371865
Gal, M; Darrouzet, V; Pescio, P; Vincey, P; Bébéar, J P
Objectives To determine whether immediate (less than 3 months from time of nerve injury), early (from 3 to 6 months from time of nerve injury) or late (more than 6 months from time of nerve injury) vocal fold injection influences the long-term outcomes for patients with permanent unilateral vocal fold paralysis. Methods A total of 250 patients with documented unilateral vocal fold paralysis were identified in this retrospective chart review. 66 patients met the inclusion criteria, having undergone awake trancervical injection with gelfoam™, collagen, perlane™ or a combination. Patients with documented recovery of vocal fold mobility, or patients with less than one year of follow-up after the onset of paralysis were excluded. Patients were stratified into immediate (<3 months), early (3-6 months) and late (>6 months) groups denoting the time from suspected injury to injection. The need for open surgery as determined by a persistently immobile vocal fold with insufficient glottic closure following injection was the primary outcome. Results 1 out of 21 (4.8%) in the immediate group, 2 out of 17 (11.8%) in the early group and 20 out of 28 (71.4%) in the late group required type 1 thyroplasty procedures to restore glottic competence. There was significance when comparing late injection to both early and immediate injection (p?0.001). No statistically significant differences were seen when comparing the number of injections needed to restore glottic competence. Conclusions This 10-year longitudinal assessment revealed that early medialization of a permanent paralyzed, abducted vocal fold with a temporary material appears to diminish the likelihood of requiring permanent laryngeal framework surgery.
Introduction Several lesions have been described as post-intubation complications. Most frequent are injuries of the pharynx/larynx or trachea. Cranial nerve injury following routine endo-tracheal intubation appears to be rare, and most reports describe Tapia's syndrome with hypoglossus/recurrent laryngeal nerve paralysis; cases that describe only bilateral hypoglossus palsy are infrequent. The cause is attributed to neuropathy of the nerve, provoked by compression following inflation of the cuff within the larynx or damage after neck hyperextension during a difficult intubation. However, similar cases after non-traumatic intubation have not been reported. Case presentation We report here a case of bilateral hypoglossus palsy in a young man undergoing a diagnostic anterior mediastinotomy that was attributed to prolonged non-complicated oro-tracheal intubation. Progressive recovery of function by the patient supports neuropraxic damage as the cause. Conclusion To avoid such problems, special attention should be paid to the correct positioning of the head during surgery or during rapidly performed tracheostomy if prolonged intubation is anticipated.
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…
Stager, Sheila V.; Bielamowicz, Steven A.
Tuberculosis (TB) accounts for the highest number of mortalities among infectious diseases worldwide. Laryngeal TB is an extremely rare presentation of TB. It has many similarities to laryngeal carcinoma, one of the three most common cancers among males in the city, with an age standardized rate of 8.6. The associated risk factors of laryngeal carcinoma i.e. smoking, paan, betel nut
Anwar Suhail; Muhammad Sheharyar Ahmed; Zain-ul-Abdeen Sobani; Shahzad Ghaffar
Hyperkalemia manifests clinically with acute neuromuscular paralysis, which can simulate Guillain Barré syndrome (GBS) and other causes of acute flaccid paralysis. Primary hyperkalemic paralysis occurs from genetic defects in the sodium channel, and secondary hyperkalemic paralysis (SHP) from diverse causes including renal dysfunction, potassium retaining drugs, Addison's disease, etc. Clinical characteristics of SHP have been addressed in a number of publications. However, electrophysiological evaluations of these patients during neuromuscular paralysis are infrequently reported and have demonstrated features of demyelination. The clinical features and electrophysiological abnormalities in secondary hyperkalemia mimic GBS, and pose diagnostic challenges. We report the findings of nerve conduction studies in a middle-aged man who was admitted with rapidly reversible acute quadriplegia resulting from secondary hyperkalemic paralysis.
Naik, Karkal R.; Saroja, Aralikatte O.; Khanpet, Mallikarjun S.
Summary A patient with sleep paralysis is discussed in view of the paucity of such reports in current American literature. It is believed, however, that this disability is more common than realized and reported heretofore. This case is of additional interest in view of the still less frequent presentation of patients with sleep paralysis in the absence of narcolepsy or
Jerome M. Schneck
Diaphragm paralysis may occur after traumatic phrenic nerve injury. Here we report three patients in whom right hemi-diaphragmatic paralysis developed after cardiac radiofrequency ablation. We hypothesise that local focused thermal energy at the time of the ablation may have caused direct neuronal damage by axonal coagulation necrosis. The prognosis for this type of injury may be reasonably good; two of the three patients fully recovered diaphragm function by 1 year. PMID:16488125
Swallow, E B; Dayer, M J; Oldfield, W L; Moxham, J; Polkey, M I
A 10-year-old Yorkshire Terrier with suspected laryngeal paralysis was referred for further examination and surgical treatment. The dog displayed severe dyspnoea and dysphonia. Ventrolateral to the larynx a soft-elastic mass of 2 cm diameter was palpated and confirmed by radiography. Histopathological examination of the resected mass revealed an infiltrative lipoma/lipoma. Although the dog totally recovered after surgery, the prognosis remains guarded due to the high risk of a recurrence. Tumours of the larynx in general and an infiltrative lipoma specifically should be added to the list of differential diagnosis in dogs presented with clinical signs that could be misinterpreted as laryngeal paralysis. PMID:23403788
Brunnberg, M; Cinquoncie, S; Burger, M; Plog, S; Nakladal, B
Hypokalemic periodic paralysis is a rare genetic disorder characterized by recurrent attacks of skeletal muscle weakness with associated hypokalemia which is precipitated by stress, cold, carbohydrate load, infection, glucose infusion, hypothermia, metabolic alkalosis, anesthesia, and steroids. We encountered one such incidence of prolonged recovery after general anesthesia, which on further evaluation revealed a case of hypokalemic paralysis. The key to successful management of such a patient was vigilant pre-operative evaluation, perioperative monitoring, and aggressive treatment of hypokalemia when it occurs.
Abbas, Haider; Kothari, Nikhil; Bogra, Jaishri
This paper describes a series of patients with a petrous temporal bone cholesteatoma paying particular attention to the complications and their management. Sixteen patients who underwent surgery in our department were reviewed. Topographically, the petrous bone cholesteatomas were grouped into five categories according to the classification proposed by Sanna et al. There were five massive labyrinthine; five infralabyrinthine; one apical; four supralabyrinthine; and one infralabyrinthine-apical. Clinically, the presenting symptom of these lesions were facial nerve paralysis (10 patients) and unilateral deafness (13 patients). Total removal of the cholesteatomas was achieved in all patients using different surgical approaches according to their site and extent. Recurrences were observed in two patients after 8 months and 24 months, respectively. The facial nerve was infiltrated and compressed by the cholesteatoma in eight patients. Seven were managed with cable grafts using sural nerve. One of these patients was treated using a facial-hypoglossal anastomosis because of the failure of the graft. In the remaining patient, a baby-sitter procedure was employed. In the other two patients, the preoperative facial paralysis was due to compression by the cholesteatoma, and its removal allowed partial recovery of facial function. The rationale of the surgical management of petrous bone cholesteatoma is its radical and total removal. Our present policy is to prefer approaches which result in a closed cavity obliterating the eustachian tube and closing the auditory canal as a blind sac. Facial nerve function is the main complication of these lesions, Facial nerve involvement requires rapid management because the duration of the paralysis is directly related to poor recovery of facial function. PMID:9669076
Magliulo, G; Terranova, G; Sepe, C; Cordeschi, S; Cristofar, P
A bilateral and symmetrical neuronal vacuolation associated with spinal cord white matter degeneration and laryngeal neuropathy was observed in a 12-week-old male mixed-breed dog with a history of progressive pelvic limbs ataxia. On clinical examination, signs included inspiratory stridor, spinal ataxia, tetraparesis, and proprioceptive deficits more severe in the pelvic limbs. Examination of the larynx showed bilateral laryngeal paralysis and electromyography revealed fibrillation potentials restricted to the intrinsic laryngeal muscles. Clinical and pathological findings resembled the syndrome of neuronal vacuolation and spinocerebellar degeneration described in Rottweiler dogs. This is the first report of a similar disorder in a dog different from Rottweiler. PMID:17877588
Salvadori, C; Tartarelli, C L; Baroni, M; Arispici, M; Cantile, C
This cross sectional descriptive study was done to find out common clinical presentations, etiologies and laboratory investigation abnormalities in patients of periodic paralysis. Study was carried out in 30 patients with an age range from 8 to 70 years who were enrolled from July 2008 to June 2009 in Mymensingh Medical College Hospital (MMCH) medicine unit. Individuals who were admitted with sudden onset generalized muscle weakness, had history of previous attack and serum potassium level <3mmol/l or >5.5mmol/l were included in this study. In this series, majority of the patients were male (66.67%). Male: female ratio was approximately 2:1. The mean age of the patients was 27.4±4.5 years. Majority (26.67%) of them were in age range of 31-40 years. About 30% of the patients experienced the first attack of paralysis at the age of 20-24 years. Majority of patients (53%) were from middle class family with occupation of private service (26.66%) and farmer (20%). Positive family history was reported in 20% of patients. Regarding the precipitating factors, majority of patients (83.3%) were related to high carbohydrate meal, 56.67% related to temperature, 41.67% to exercise. Flaccid muscle weakness with variables muscle power (MRC grade 4/5 to 2/5 in 60% and 1/5 to 0/5 in 40%) was found. Cerebellar functions, all modalities of sensations and functions of cranial nerves were intact in all patients. In this series, laboratory investigations revealed reduced serum potassium level (<3mmol/l) in 90% of patients. Serum potassium value >5.5mmol/l was found in only 3.33% of patients. Creatine kinase (MM) was raised in 23% of the patients and Thyroid stimulating hormone (TSH) level was 0.8-2mmol/l in 6% of the patients. More than half of the patients (56%) showed variable ECG changes. Impaired nerve conduction function was found in 28.00%. So, careful history taking, meticulous clinical examination and simple laboratory investigations is sufficient to make a prompt diagnosis and rapid management of patients with periodic paralysis. PMID:22314450
Khan, N A; Khan, A U; Hasan, M I; Datta, P K; Rahman, M W; Akter, M; Rahman, S; Ferdous, J; Miah, A H; Sarker, C B
Injury to the greater auricular, hypoglossal and superior laryngeal nerves during carotid endarterectomy is preventable. A knowledge of regional anatomy and the mechanisms of such injury allows prevention of this complication. Unilateral individual nerve injury is generally well tolerated, but bilateral or combined nerve injuries can pose a serious threat to life. Minor modifications in technique aid greatly in avoiding nerve injury. PMID:836092
Verta, M J; Applebaum, E L; McClusky, D A; Yao, J S; Bergan, J J
Injection laryngoplasty is one of the procedures for treating unilateral vocal fold paralysis. This is a preliminary report on modified injection laryngoplasty, ie, injection of liposuctioned autologous fat into the larynx and hypopharynx of patients who have aspiration and voice disorders after vocal fold paralysis. Lipoinjection was performed in 3 patients with these complaints with the endolaryngeal microsurgical technique under general anesthesia. The locations of fat injection were the vocal fold, the false vocal fold, the aryepiglottic fold of the larynx, and the medial wall of the pyriform sinus of the hypopharynx. Lipoinjection into the vocal fold, false vocal fold, and aryepiglottic fold strengthened laryngeal closure. Lipoinjection, performed into the thyroarytenoid muscle lateral to the oblong fovea of the arytenoid cartilage, made arytenoid cartilage rotation possible, and consequently strengthened laryngeal closure. Lipoinjection into the medial wall of the pyriform sinus of the hypopharynx reduced its capacity; consequently, the amount of residual food retained in it was reduced and pharyngeal clearance on the affected side was improved. The longest follow-up among the 3 patients has been 24 months. Their aspiration and glottal incompetence have been improved by this operation. We conclude that modified injection laryngoplasty (laryngohypopharyngoplasty) is one of the surgical options for preventing aspiration after vocal fold paralysis. PMID:14994760
Sato, Kiminori; Umeno, Hirohito; Nakashima, Tadashi
Functional electrical stimulation (FES) of the posterior cricoarytenoid muscle (PCA) to restore respiratory function of the larynx may become an option for the treatment of bilateral recurrent laryngeal nerve paralysis (RLNP) in the near future. The feasibility of this has been shown in several animal trials and in a human pilot study. The common open surgical inferolateral approach for electrode insertion into the PCA for FES has a risk of damaging the recurrent laryngeal nerve (RLN) and may result in postoperative swelling and scaring of the larynx. Therefore, a minimal invasive electrode insertion technique is needed. A new miniaturized bipolar spiral tip electrode and a new electrical stimulatable insertion needle were tested in a short-term trial for an endoscopically guided and functionally controlled transcricoidal electrode insertion in eight Göttingen minipigs with bilateral normal RLN function. The feasibility of this technique was evaluated and the achieved positions of the electrodes in the PCA were analyzed using intraoperative stimulation threshold data and 3D-CT reconstructions. In seven cases it was possible to place two well-performing electrodes into the PCA. They were positioned one on either side. In one animal no functioning electrode position could be achieved because the PCA was missed. Thresholds of the electrode tips varied between 0.2 and 2.5 mA (mean 0.71 mA). In any case maximal glottal opening could be reached before adductors were co-activated. The majority of electrodes were placed into the central lower part of the PCA with no apparent correlation between threshold and electrode position. Surgical trauma might be further reduced by using endoscopy via a laryngeal mask avoiding the temporary tracheostomy used in this trial. If the implanted electrodes remain stable in long-term tests, we suggest that this method could soon be transferred into human application. PMID:22875064
Förster, Gerhard; Arnold, Dirk; Bischoff, Sabine J; Schubert, Harald; Scholle, Hans-Christoph; Müller, Andreas H
This paper presented a novel approach to objective assessment of facial nerve paralysis based on infrared thermography and formal concept analysis. Sixty five patients with facial nerve paralysis on one side were included in the study. The facial temperature distribution images of these 65 patients were captured by infrared thermography every five days during one-month period. First, the facial thermal images were pre-processed to identify six potential regions of bilateral symmetry by using image segmentation techniques. Then, the temperature differences on the left and right sides of the facial regions were extracted and analyzed. Finally, the authors explored the relationships between the statistical averages of those temperature differences and the House-Brackmann score for objective assessment degree of nerve damage in a facial nerve paralysis by using formal concept analysis. The results showed that the facial temperature distribution of patients with facial nerve paralysis exhibited a contralateral asymmetry, and the bilateral temperature differences of the facial regions were greater than 0.2 degrees C, whereas in normal healthy individuals these temperature differences were less than 0.2 degrees C. Spearman correlation coefficient between the bilateral temperature differences of the facial regions and the degree of facial nerve damage was an average of 0.508, which was statistically significant (p < 0.05). Furthermore, if one of the temperature differences of bilateral symmetry on facial regions was greater than 0.2 degrees C, and all were less than 0.5 degrees C, facial nerve paralysis could be determined as for the mild to moderate; if one of the temperature differences of bilateral symmetry was greater than 0.5 degrees C, facial nerve paralysis could be determined as for serious. In conclusion, this paper presents an automated technique for the computerized analysis of thermal images to objectively assess facial nerve related thermal dysfunction by using formal concept analysis theory, which may benefit the clinical diagnosis and treatment of facial nerve paralysis. PMID:25007603
Liu, Xu-Long; Hong, Wen-Xue; Liu, Jie-Min
This survey investigated how individuals with facial paralysis resulting from acoustic neuroma surgery manage self-care needs of daily living. Facial paralysis was defined to include damage from surgery to other cranial nerves located in the same area as the facial nerve. The 40 patients surveyed had surgery performed at the Neurosurgical Department, National Hospital of Norway, Oslo, during a four-year period. The instrument used was a questionnaire based on Orem's universal self-care requisites. Results showed that problems related to eating and drinking and certain physiological problems were accepted over time, while pain, eye problems, and hearing loss remained difficult for patients to cope with. Social and psychological problems related to the facial paralysis were ongoing for many patients and seemed to be mitigated by self-acceptance and acceptance by others. PMID:2956334
Lohne, V; Bjřrnsborg, E; Westerby, R; Heiberg, E
Phrenic nerve injury is a recognized and severe complication after cardiac surgery. Diaphragmatic paralysis leads to difficulty of weaning the child from the ventilator surgical plication is an easy and safe procedure that result in early clinical and physiological improvements. PMID:15929450
Abid, Abdelfettah; Dhiab, Mounir; Ben Omrane, Skander; Meddeb, Inçaf; Gharsallah-Slama, Nadia; Kalfat, Taoufik; Khayati, Adel
Previously, we demonstrated that patients with adductor spasmodic dysphonia (ADSD) have a disinhibition of laryngeal responses to sensory input. In this study, sensorimotor responses to stimulation of the superior laryngeal nerve were compared between 10 subjects with abductor spasmodic dysphonia (ABSD) and 15 normal volunteers. The groups had similar latency and frequency characteristics of their unconditioned adductor responses (p>.05). The conditioned R1 (early) responses of the subjects with ABSD were greater and more variable in amplitude than those of the normal volunteers (p< or =.008). Similar R2 (late) conditioning effects were found in both groups, with a nonsignificant trend toward reduced inhibition of contralateral R2 responses at lower interstimulus intervals (p = .01) in the patient group. Thus, inhibitory mechanisms that modulate the R1 laryngeal sensorimotor pathway in the brain stem may be abnormal in subjects with ABSD. Abnormal modulation of laryngeal sensorimotor responses seems present in both types of spasmodic dysphonia. PMID:10378532
Deleyiannis, F W; Gillespie, M; Bielamowicz, S; Yamashita, T; Ludlow, C L
Ramsay Hunt syndrome is defined by herpes zoster oticus and peripheral facial nerve palsy which is often associated with otalgia. The syndrome is, in rare cases, associated with other cranial nerve paralyses including the vagal nerve causing unilateral vocal cord paralysis. Vocal cord paralysis is more often seen as a symptom of various other diseases, that is, malignant tumours, neurodegenerative illness, cerebrovascular assaults, inflammatory processes or as a result of intubation or surgical procedures. The symptoms of unilateral vocal cord paralysis are mainly hoarseness, dyspnoea and dysphagia. We present a case of Ramsay Hunt syndrome combined with unilateral hearing loss and left vocal cord paralysis. The patient underwent MRI, CT and a lumbar puncture causing anxiety in the patient and delaying the initiation of antiviral and anti-inflammatory treatment, which is only efficient when initiated within 72 h. We hope to raise the awareness of this disease. PMID:24503657
Rasmussen, Eva Rye; Mey, Kristianna
In order to determine the incidence of cranial nerve injury during carotid endarterectomy, preoperative and postoperative otolaryngologic examinations were performed in a prospective series of 240 operations. Thirty patients experienced a total of 38 cranial nerve injuries, involving the recurrent laryngeal nerve in 14, the hypoglossal nerve in 13, the marginal mandibular nerve in six and the superior laryngeal nerve in five. Postoperative dysfunction affected one cranial nerve in 25 patients, two nerves in four and three nerves in one patient. Most cranial nerve injuries were asymptomatic or mild in severity, resolved in one to 12 months and probably were caused by intraoperative retraction. PMID:7444729
Hertzer, N R; Feldman, B J; Beven, E G; Tucker, H M
Rationale: Paralyzed human volunteers (n?=?6) participated in several studies the primary one of which required full neuromuscular paralysis while awake. After the primary experiment, while still paralyzed and awake, subjects undertook studies of humor and of attempted eye-movement. The attempted eye-movements tested a central, intentional component to one’s internal visual model and are the subject of this report. Methods: Subjects reclined in a supportive chair and were ventilated after paralysis (cisatracurium, 20?mg intravenously). In illumination, subjects were requested to focus alternately on the faces of investigators standing on the left and the right within peripheral vision. In darkness, subjects were instructed to look away from a point source of light. Subjects were to report their experiences after reversal of paralysis. Results: During attempted eye-movement in illumination, one subject had an illusion of environmental movement but four subjects perceived faces as clearly as if they were in central vision. In darkness, four subjects reported movement of the target light in the direction of attempted eye-movements and three could control the movement of the light at will. Conclusion: The hypothesis that internal visual models receive intended ocular-movement-information directly from oculomotor centers is strengthened by this evidence.
Whitham, Emma M.; Fitzgibbon, Sean P.; Lewis, Trent W.; Pope, Kenneth J.; DeLosAngeles, Dylan; Clark, C. Richard; Lillie, Peter; Hardy, Andrew; Gandevia, Simon C.; Willoughby, John O.
Background Dengue is considered one of the most common mosquito borne illnesses in the world. Although its clinical course is usually uneventful, complications have rarely been known to arise. These include neurological manifestations such as neuropathies. Case presentation We report a middle aged patient from urban Sri Lanka who developed diaphragmatic paralysis secondary to phrenic neuropathy a month after recovering from dengue fever. He was managed conservatively and made a full recovery subsequently. Conclusion Isolated phrenic nerve palsy causing diaphragmatic paralysis should be considered a recognized complication of Dengue fever. A patient usually gains full recovery with conservative management.
Conservation laryngeal surgery is an increasingly available alternative for treatment of laryngeal cancer. In addition to\\u000a the traditional techniques of vertical partial laryngectomy (hemilaryngectomy) and supraglottic laryngectomy, new techniques\\u000a are now in practice that extend the indications to a far greater number of patients. The carbon dioxide laser is used to resect\\u000a both glottic and supraglottic cancers. This procedure is
Steven C. Marks
We report on the history and clinical findings of an injecting drug abuser in the Canton of Zurich who presented with multiple deep abscesses in the arms and legs. A diagnosis of wound botulism was made based on his clinical presentation with a rapidly progressing descending paralysis starting at the cranial nerves, a neuromuscular junction disorder on neurophysiologic testing, and normal findings on lumbar puncture. Several cases of wound botulism have occurred in i.v. drug abuse in Switzerland since 1997. We suspect subcutaneous injections of contaminated heroin containing Clostridium spores as sites of entry. Wound botulism caused by Clostridium botulinum is a rare cause of rapidly progressing, generalized, flaccid paralysis and should be considered in patients with a history of i.v. drug abuse presenting with descending paralysis. PMID:10703015
Hiersemenzel, L P; Jermann, M; Waespe, W
Abstract Conclusion: To achieve good facial reanimation in cases with facial paralysis resulting from temporal bone fractures, the ideal timing for surgical intervention is at least within 1 month of injury and an appropriate surgical approach should be selected depending on the site of facial nerve injury. Objective: This paper aimed to address the ideal time for surgical intervention and the appropriate surgical approach for patients with facial paralysis resulting from temporal bone fractures. Methods: We retrospectively investigated 60 patients with facial paralysis due to temporal bone fractures who underwent facial nerve decompression via different operative approaches within 1 month after trauma, of which 48 were surgically treated by the middle cranial fossa approach (80%), 8 by a pure transmastoid approach (13.3%), and four by a combined transmastoid and middle cranial fossa approach (6.7%). The House-Brackmann (H-B) grading system was used to evaluate the recovery of facial nerve function. Results: The follow-up period for all the patients was 1 year. Among 60 patients who were surgically treated, 39 achieved grade I of facial nerve function, 18 achieved grade II, two achieved grade III, and one achieved grade IV according to the H-B grading system. PMID:24665853
Liu, Yiqing; Han, Jie; Zhou, Xuanchen; Gao, Kun; Luan, Deheng; Xie, Fengyang; Wang, Xiaoting; Zong, Guangxin; Ding, Ling
The objective of the present overview was to analyse the available data on etiology, pathogenesis, diagnostics, and treatment of laryngeal papillomatosis. It is shown that the pathogenetic mechanism underlying the development of this pathology is related to cell proliferation mechanisms. The human papilloma virus is most effectively identified by the polymerase chain reaction technique in combination with in situ hybridization. It is expected that new and more informative criteria for diagnostics, treatment,and prognosis of laryngeal papillomatosis will be proposed based on recent progress in molecular biology, morphology,and immunology. Different variants of the therapeutic strategy for the treatment of laryngeal papillomatosis are described.Modern practice of the management of laryngeal papillomatosis takes advantage of the three main approaches and/or their combination. First, further improvement of surgical techniques, such as the application of endoscopic devices and surgical lasers.Second, the search for new pharmaceutical agents (indole-3-carbinol, cidofovir, antiviral medicines, etc.) most frequently used for adjuvant therapy. Third, the development of new vaccination methods. Besides these three approaches, photodynamic therapy and the use of ionizing radiation are currently being studied as the tools for the treatment of extensive and recurrent laryngeal papillomatosis as well as the methods of laser-induced interstitial thermotherapy. PMID:23814808
Svistushkin, V M; Mustafaev, D M
Familial periodic paralyses are typical channelopathies (i.e., caused by functional disturbances of ion channel proteins). The episodes of flaccid muscle weakness observed in these disorders are due to underexcitability of sarcolemma leading to a silent electromyogram and the lack of action potentials even upon electrical stimulation. Interictally, ion channel malfunction is well compensated, so that special exogenous or endogenous triggers are required to produce symptoms in the patients. An especially obvious trigger is the level of serum potassium (K+), the ion responsible for resting membrane potential and degree of excitability. The clinical symptoms can be caused by mutations in genes coding for ion channels that mediate different functions for maintaining the resting potential or propagating the action potential, the basis of excitability. The phenotype is determined by the type of functional defect brought about by the mutations, rather than the channel effected, because the contrary phenotypes hyperkalemic periodic paralysis (HyperPP) and hypokalemic periodic paralysis (HypoPP) may be caused by point mutations in the same gene. Still, the common mechanism for inexcitability in all known episodic-weakness phenotypes is a long-lasting depolarization that inactivates sodium ion (Na+) channels, initiating the action potential. PMID:11898585
Lehmann-Horn, Frank; Jurkat-Rott, Karin; Rüdel, Reinhardt
We report the use of endoscopic laser excision of a marginal laryngeal tumor, radical neck dissection, and laterofixation\\u000a of a paralyzed vocal cord in a 66-year-old man who had an early-stage right supraglottic endolaryngeal tumor and ipsilateral\\u000a neck metastasis. He had a left vocal cord paralysis after a left pneumonectomy that was performed 5 years previously. The\\u000a primary laryngeal tumor
M. Csanády; László Rovó; József Jóri
In the last 10 years, wound botulism has increasingly been reported and nearly all of these new cases have occurred in injecting-drug abusers. After absorption into the bloodstream, botulinum toxin binds irreversibly to the presynaptic nerve endings, where it inhibits the release of acetylcholine. Diplopia, blurred vision, dysarthria, dysphagia, respiratory failure and paresis of the limbs are common symptoms of this intoxication. Surprisingly and despite the well-known blocking action of the botulinum toxin on the autonomic nerve system, little attention has been paid to changes in the lower urinary tract following acute botulinum toxin poisoning. Here we report a case of bladder paralysis following wound botulism. Early diagnosis and adequate management of bladder paralysis following botulism is mandatory to avoid urologic complications. Accordingly, the prognosis is usually favorable and the bladder recovery complete. PMID:11464047
Sautter, T; Herzog, A; Hauri, D; Schurch, B
After reporting the pathophysiology of denervation the authors deal with the changes that affect nerves while going through reinnervation. A review of the drugs that may help healing and general care to be adopted in order to avoid sequential pathological phenomena related to paralysis are shown. Rehabilitative treatment is discussed, the Authors dwell upon rehabilitation of neurogenous bladder of patients with spina bifida and rehabilitation of patients with paralysis of brachial plexus. Facial paralysis has been discussed before dealing with benefits and complications of electrotherapy. The use of electromagnetotherapy and electromyography are shown with a rich photographic and bibliographic support. PMID:9410662
Grasso, A; Arena, M; Sofia, V; La Bua, V; Biondi, R; Sicurella, L; Patti, F
Acute hypokalemic paralysis is characterized by muscle weakness or paralysis secondary to low serum potassium levels. Neurogenic diabetes insipidus (DI) is a condition where the patient excretes large volume of dilute urine due to low levels of antidiuretic hormone. Here, we describe a patient with neurogenic DI who developed hypokalemic paralysis without a prior history of periodic paralysis. A 30-year-old right-handed Hispanic male was admitted for refractory seizures and acute DI after developing a dental abscess. He had a history of pituitary adenoma resection at the age of 13 with subsequent pan-hypopituitarism and was noncompliant with hormonal supplementation. On hospital day 3, he developed sudden onset of quadriplegia with motor strength of 0 of 5 in the upper extremities bilaterally and 1 of 5 in both lower extremities with absent deep tendon reflexes. His routine laboratory studies revealed severe hypokalemia of 1.6 mEq/dL. Nerve Conduction Study (NCS) revealed absent compound motor action potentials (CMAPs) with normal sensory potentials. Electromyography (EMG) did not reveal any abnormal insertional or spontaneous activity. He regained full strength within 36 hours following aggressive correction of the hypokalemia. Repeat NCS showed return of CMAPs in all nerves tested and EMG revealed normal motor units and normal recruitment without myotonic discharges. In patients with central DI with polyuria, hypokalemia can result in sudden paralysis. Hypokalemic paralysis remains an important differential in an acute case of paralysis and early recognition and appropriate management is key.
Nguyen, Frederic N.; Kar, Jitesh K.; Verduzco-Gutierrez, Monica; Zakaria, Asma
The posttraumatic cholesteatoma is a rare complication of different types of the temporal bone damage. Its diagnosis is often done after several years of evolution, sometimes even at the stage of complications. A case of posttraumatic cholesteatoma is presented that was revealed by a facial nerve paralysis 23 years after a crash of the external auditory canal underlining the importance of the otoscopic and radiological regular monitoring of the patients with a traumatism of the temporal bone.
Chihani, M.; Aljalil, A.; Touati, M.; Bouaity, B.; Ammar, H.
Injury to the greater auricular, hypoglossal and superior laryngeal nerves during carotid endarterectomy is preventable. A knowledge of regional anatomy and the mechanisms of such injury allows prevention of this complication. Unilateral individual nerve injury is generally well tolerated, but bilateral or combined nerve injuries can pose a serious threat to life. Minor modifications in technique aid greatly in avoiding nerve injury. Images Fig. 1.
Verta, M J; Applebaum, E L; McClusky, D A; Yao, J S; Bergan, J J
... laryngeal SCCA are smokers. Smoking contributes to cancer development by causing mutations or changes in genes, impairing clearance of carcinogens from the respiratory tract, and decreasing the body?s immune response. Tobacco use is measured in pack-years, where ...
The laryngeal adductor response (LAR) is a protective reflex that prevents aspiration and can be elicited either by electrical stimulation of afferents in the superior laryngeal nerve (SLN) or by deflection of mechanoreceptors in the laryngeal mucosa. We hypothesized that because this reflex is life-sustaining, laryngeal muscle responses to sensory stimuli would not be suppressed during volitional laryngeal tasks when compared to quiet respiration. Unilateral electrical superior laryngeal nerve stimulation was used to elicit early (R1) and late (R2) responses in the ipsilateral thyroarytenoid muscle in 10 healthy subjects. The baseline levels of muscle activity before stimulation, R1 and R2 response occurrence and the integrals of responses were measured during each task: quiet inspiration, prolonged vowels, humming, forced inhalation and effort closure. We tested whether R1 response integrals during tasks were equal to either: (1) baseline muscle activity during the task added to the response integral at rest; (2) the response integral at rest minus the baseline muscle activity during the task; or (3) the response integral at rest. R1 response occurrence was not altered by task from rest while fewer R2 responses occurred only during effort closure and humming compared to rest. Because the R1 response integrals did not change from rest, task increases in motor neuron firing did not alter the LAR. These findings demonstrate that laryngeal motor neuron responses to sensory inputs are not gated during volitional tasks confirming the robust life-sustaining protective mechanisms provided by this airway reflex.
Henriquez, Victor M; Schulz, Geralyn M; Bielamowicz, Steven; Ludlow, Christy L
Traditional and contemporary Inuit concepts of sleep paralysis were investigated through interviews with elders and young people in Iqaluit, Baffin Island. Sleep paralysis was readily recognized by most respondents and termed uqumangirniq (in the Baffin region) or aqtuqsinniq (Kivalliq region). Traditional interpretations of uqumangirniq referred to a shamanistic cosmology in which the individual's soul was vulnerable during sleep and dreaming. Sleep paralysis could result from attack by shamans or malevolent spirits. Understanding the experience as a manifestation of supernatural power, beyond one's control, served to reinforce the experiential reality and presence of the spirit world. For contemporary youth, sleep paralysis was interpreted in terms of multiple frameworks that incorporated personal, medical, mystical, traditional/shamanistic, and Christian views, reflecting the dynamic social changes taking place in this region. PMID:15881270
Law, Samuel; Kirmayer, Laurence J
The clinical data of 3 cases of Ramsay-Hunt syndrome concurrent with ipsilateral vocal cord paralysis were retrospectively analyzed, and the relevant literatures were also reviewed. Ramsay-Hunt syndrome is a kind of disease characterized by heavy ear pain, herpes zoster oticus and inner ear neurologic symptoms, which can also affect the vocal cords and give rise to vocal cords paralysis. Ramsay-Hunt syndrome can cause multiple in flammation of cranial nerves. The viral infection can also involve the 3rd and 10th cranial nerves. It mainly damage the facial nerve, followed by the involvement of vestibulocochlear nerve. The vagus nerve damage is rare, so the relevant clinical reports are less. It is important to take the objective data as well as subjective symptoms of the patients into consideration to make a definite diagnosis, so that we can treat it as soon as possible to achieve better curative effect. PMID:25007684
Zhan, Jiabin; Fu, Zheng; Wei, Xin
The clinical use of the laryngeal electromyography is still scanty; nevertheless, in our experience it has been shown to be an efficient and objective test in the study of the neurological disorders of the larynx and in the prognosis of recovery after vocal cord paralysis. We have performed conventional electromyography of the thyroarytenoid and cricothyroid muscles in 25 patients with laryngoscopically--confirmed vocal cord paralysis of different etiology. Positive sharp waves, fibrillation potentials and decreased or absent activity on maximal voluntary effort provided enough evidence of denervation in those cases of neurogenic origin. An increased number of polyphasic potentials and increased length of the motor unit potentials recruited in reduced interference patterns were considered suggestive of reinervation, which has an outstanding prognostic value on laryngeal neuropathy. Voluntary motor units, even in some clinically non-mobile vocal cords, were identified in recruitment patterns. Laryngeal electromyography can be done as an office procedure with a minimum of discomfort. It gives objective evaluation of the neuromuscular status, and shows direct evidence of cord function, being useful to distinguish from supranuclear and mechanical disorders of the larynx. It has also shown to be efficient as recovery predictor after vocal cord paralysis. PMID:7619556
Canals Ruiz, P; Villoslada Prieto, C; López Catalá, F; Peris Beaufils, J L; Marco Peiro, A; Marco Algarra, J
Vocal cord paralysis remains a frustrating condition. The etiology can be subdivided roughly into surgically induced, neoplastic and idiopathic paralysis. In the surgical group, thyroidectomy is the most common cause. In unilateral vocal cord paralysis most patients suffer from a change in voice quality described as hoarseness or breathiness with or without aspiration and dysphagia. Laryngeal examination usually reveals the paralyzed cord shorter than the normal side and mostly in the paramedian position. Endostroboscopic examination shows invariably incomplete closure of the vocal cords with marked decrease in the mucosal waves of the folds during phonation. Several procedures for vocal cord medialization such as endoscopic injection of different materials, medialization thyroplasty, arytenoids adduction and re-innervation procedures have been described in the literature. Laryngoplastic phonosurgery for surgical rehabilitation of the paralyzed vocal cord has markedly evolved over the last few decades. This is a review of patients with unilateral vocal cord paralysis treated by medialization laryngoplasty at the American University of Beirut, Department of Otolaryngology Head and Neck Surgery, between 1994 and 2003. The etiology of the paralysis, symptomatology, endostroboscopic and acoustic findings will be presented together with a description of the surgical technique. PMID:16432970
Hamdan, Abdul-Latif; Mokarbel, Roger; Dagher, Walid
Our experience with patients undergoing carotid endoarteriectomy over a 10 year period has been retrospectively reviewed. Nerve injuries were detected by reviewing postoperative progress and clinical notes. One hundred thirty-four procedures were performed on 120 patients, to 15 of whom (9%) occurred major nerve injuries. These included seven vagal nerve injuries causing ipsilateral vocal cord paralysis and hoarseness, five injuries of the marginal mandibular nerve and three injuries of the hypoglossal nerve. None of the patients with nerve injury had a stroke as a result of carotid operation. Vocal cord paralysis was documented by laryngoscopy. The incidence of cranial nerve injury during carotid endoarteriectomy appears to be higher than expected, particularly if asymptomatic patients are controlled. PMID:2234452
Pegoraro, M; Barile, C; Nessi, F; Bertoldo, U
The term 'laryngeal neuropathy' (LN) has first been used in veterinary medicine to describe an idiopathic and typically exercise induced inspiratory noise in horses.Nowadays, the term is often used in relation with intermittent vocal cord pareses in humans. Some authors use the term 'irritable larynx syndrome' (ILS) in a similar context. This article reviews the state of knowledge regarding LN and ILS and discusses the somewhat confusing terminology.For this systematic review a selective literature research in PubMed has been carried out.35 articles were found, which report on LN in animals and 17 articles reported on humans. 4 of these articles used the term 'irritable larynx syndrome'.Laryngeal neuropathy in horses usually affects the left recurrent laryngeal nerve and results in decreased vocal cord abduction and an inspiratory roaring or whistling noise, particularly during exercise. In dogs LN has been reported to also occur bilaterally. In association with humans LN has not been defined clearly in the literature. The term ILS on the other hand has only been used in relation to humans. The term describes a hypersensitivity of the laryngeal structures towards external stimuli, which causes symptoms such as dyspnea or cough among others. Sufficient knowledge does not exist for either of the 2 diseases, ILS or LN. As of yet, the term LN should not be used in human medicine to describe according symptoms of unknown aetiology. The term 'laryngeal movement disorder' seems a lot more appropriate. The symptom oriented term irritable larynx syndrome also seems suitable to describe laryngeal hypersensitivity appropriately. PMID:22638931
Meyer, S; Ptok, M
Seventeen dogs with clinical signs attributable to nonneoplastic obstruction of the larynx, trachea, or large bronchi underwent computed tomography (CT) imaging. In 16 of the 17 dogs, CT was performed without general anesthesia using a positioning device. Fifteen of these 16 dogs were imaged without sedation or general anesthesia. Three-dimensional (3D) internal rendering was performed on each image set based on lesion localization determined by routine image planes. Visual laryngeal examination, endoscopy, video fluoroscopy, and necropsy were used for achieving the cause of the upper airway obstruction. The CT and 3D internal rendering accurately indicated the presence and cause of upper airway obstruction in all dogs. CT findings indicative of laryngeal paralysis included failure to abduct the arytenoid cartilages, narrowed rima glottis, and air-filled laryngeal ventricles. Laryngeal collapse findings depended on the grade of collapse and included everted laryngeal saccules, collapse of the cuneiform processes and corniculate processes, and narrowed rima glottis. Trachea abnormalities included hypoplasia, stenosis, or collapse syndrome. The CT findings in tracheal hypoplasia consisted of a severely narrowed lumen throughout the entire length. Tracheal stenosis was represented by a circumferential decrease in tracheal lumen size limited to one region. Tracheal collapse syndrome was diagnosed by severe asymmetric narrowing. Lobar bronchi collapse appeared in CT images as a narrowed asymmetric lumen diameter. CT imaging of unanesthetized dogs with upper airway obstruction compares favorably with traditional definitive diagnostic methods. PMID:21447037
Stadler, Krystina; Hartman, Susan; Matheson, Jodi; O'Brien, Robert
Objective: The goal of this study was to review decision factors and overall results regarding surgical and nonsurgical management of post-traumatic facial nerve paralysis (FP). Study design: A retrospective study and literature review were performed. Methods: Between 1984 and 1990, 115 cases of post-traumatic FP were handled. Patients were evaluated through clinical, audiologic, radiologic, and electromyogram assessment. Depending on examination
Vincent Darrouzet; Jean-Yves Duclos; Dominique Liguoro; Yves Truilhe; Camille De Bonfils; Jean-Pierre Bebear
Objective Disordered voices are often associated with abnormal changes in aerodynamic parameters of subglottal pressure and airflow. Phonation instability pressure (PIP) has been previously proposed to evaluate subglottal pressure at the onset of chaotic phonation. We propose the concept of and measure phonation instability flow (PIF), the airflow at which phonation becomes chaotic. Phonation flow range (PFR), PIF minus phonation threshold flow (PTF), is proposed to assess the range over which normal vocal fold vibration occurs. Study Design Repeated measures with each ex vivo larynx serving as its own control. Methods Pressure and airflow were measured at phonation onset and chaos onset in seven excised canine larynges under three experimental conditions: 0% elongation with no glottal gap; 20% elongation with no glottal gap; 20% elongation with a 3 mm posterior glottal gap. Paired t-tests were performed to determine if experimental measurements differed between elongations (0% and 20%) or degrees of abduction (20% elongation with and without a 3 mm glottal gap). Results Both PIF and PFR were dependent on abduction but not elongation. PIP was not significantly dependent on either condition. PIF and PFR showed greater differences for abduction than either phonation threshold pressure (PTP) or PTF. Conclusions PIF and PFR may be useful parameters in the experimental or clinical settings, particularly when evaluating disorders characterized by a glottal gap such as vocal fold paralysis and presbylaryngis.
Hoffman, Matthew R.; Rieves, Adam L.; Budde, Adam J.; Surender, Ketan; Zhang, Yu; Jiang, Jack J.
In open or video-assisted thoracic surgery, injury to one to four intercostal sensory nerves is a well-recognized complication. This nerve damage is a well-defined cause for chronic postoperative pain. In this discussion, the motor innervation of the rectus abdominis muscle with the T7 to T12 intercostal nerves has been neglected. Paralysis of rectus abdominis might pose significant burden on patients, delay recovery, and thus warrants exploration. PMID:19766836
Pätilä, Tommi; Sihvo, Eero I; Räsänen, Jari V; Ramstad, Raimo; Harjula, Ari; Salo, Jarmo A
Tuberculosis otitis media is a very rare cause of otorrhea, so that it is infrequently considered in differential diagnosis because clinical symptoms are nonspecific, and standard microbiological and histological tests for tuberculosis often give false-negative results. We present a rare case presenting as a rapidly progressive facial paralysis with severe dizziness and hearing loss on the ipsilateral side that was managed with facial nerve decompression and anti-tuberculosis therapy. The objective of this article is to create an awareness of ear tuberculosis, and to consider tuberculosis in the differential diagnosis of chronic otitis media with complications.
Hwang, Gyu Ho; Jung, Jong Yoon; Yum, Gunhwee
In a series of 109 carotid arterial reconstructions cranial nerve injury was observed in 14 of 102 patients. Ipsilateral peripheral hypoglossal nerve injury occurred in nine patients with carotid occlusive disease. The marginal mandibular nerve was injured in three patients and recurrent laryngeal nerve dysfunction was noted in four patients. Two cranial nerves were injured in two patients. Full recovery of hypoglossal dysfunction was seen within 2-52 weeks (average 20 weeks). The nerves are injured by retraction to clear the operative field or by postoperative haematoma. Risk factors include crossing of the hypoglossal nerve close to the carotid bifurcation or procedures requiring long arteriotomy or skeletonization of the internal carotid artery. Unilateral cranial nerve injury is usually mild but will require delay of controlateral carotid reconstruction to avoid severe bilateral cranial nerve palsy. PMID:6196459
Schmidt, D; Zuschneid, W; Kaiser, M
Facial paralysis is a frequently-occurring disease, which causes the loss of the voluntary muscles on one side of the face due to the damages the facial nerve and results in an inability to close the eye and leads to dropping of the angle of the mouth. There have been few objective methods to quantitatively diagnose it and assess this disease for clinically treating the patients so far. The skin temperature distribution of a healthy human body exhibits a contralateral symmetry. Facial paralysis usually causes an alteration of the temperature distribution of body with the disease. This paper presents the use of the histogram distance of bilateral local binary pattern (LBP) in the facial infrared thermography to measure the asymmetry degree of facial temperature distribution for objective assessing the severity of facial paralysis. Using this new method, we performed a controlled trial to assess the facial nerve function of the healthy subjects and the patients with Bell's palsy respectively. The results showed that the mean sensitivity and specificity of this method are 0.86 and 0.89 respectively. The correlation coefficient between the asymmetry degree of facial temperature distribution and the severity of facial paralysis is an average of 0.657. Therefore, the histogram distance of local binary pattern in the facial infrared thermography is an efficient clinical indicator with respect to the diagnosis and assessment of facial paralysis. PMID:23488134
Liu, Xulong; Hong, Wenxue; Zhang, Tao; Wu, Zhenying
Squamous cell carcinoma of the larynx continues to be the commonest head and neck cancer in many Western countries. The larynx plays a key role for many essential functions, including breathing, voice production, airway protection, and swallowing. The goals of laryngeal cancer treatment are thus to provide best possible oncologic control, while optimizing functional outcomes. In recent decades, the treatment paradigm for advanced laryngeal cancer has shifted from one of primary surgery (total laryngectomy) as gold standard, toward non-surgical organ-preserving treatment using radiotherapy or chemoradiotherapy. However, concerns have emerged regarding functional outcomes after chemoradiotherapy, as well as possible decreased overall survival in patients with laryngeal cancer. The purpose of the present review is to review surgical and non-surgical options for treatment of advanced laryngeal cancer, as well as the evidence supporting each of these.
Prenatal diagnosis of congenital atresia of the larynx is difficult but is possible by the findings of increased lung echogenicity and size coexisting with fetal ascites in ultrasonography. Sonographic findings may not always be typical. We report on a case of congenital laryngeal atresia diagnosed prenatally by the findings of fetal hydrops and hyperechogenic lungs. Our case presented with oligohydramnios. We also review syndromes that demonstrate laryngeal anomalies. PMID:12673628
Onderoglu, L; Saygan Karamürsel, B; Bulun, A; Kale, G; Tunçbilek, E
Nontraumatic laryngeal fractures are exceedingly rare disease entities. Only 3 prior instances have been described in the medical literature (Br Med J 1950;1:1052; Acta Otorrinolaringol Esp 2007;58:73-4; Otolaryngol Head Neck Surg 2012;147:801-2). We present a case of thyroid cartilage fracture and associated phlegmon formation after a vigorous coughing spell in a 47-year-old man. On presentation, the patient's symptoms included the triad of odynophagia, dysphagia, and dysphonia as well as diffuse swelling and tenderness over the thyroid cartilage. Computed tomography and magnetic resonance imaging revealed a mildly displaced anterior thyroid cartilage fracture as well as a phlegmon in the strap muscle compartment adjacent to the fracture (Figs. 1 and 2). Intravenous dexamethasone and antibiotics were initiated, and the patient was admitted to the medical intensive care unit. On fiberoptic examination with the flexible laryngoscope, the patient was found to have slightto-moderate watery edema of the right aryepiglottic fold and right greater than left arytenoid cartilages. After 48 hours, the patient's neck swelling and pain significantly improved. On hospital day 4, the patient was discharged with a course of oral antibiotics. One week later, the patient reported only mild odynophagia and persistent dysphonia. He otherwise felt well and was tolerating fluids and soft food without difficulty. A preexisting, congenital abnormality resulting in a focal weakness in the thyroid cartilage might predispose patients to nontraumatic fractures (Otolaryngol Head Neck Surg 2012;147:801-2). Patients in prior case reports of nontraumatic laryngeal fractures presented with similar symptoms (Table). The triad of odynophagia, dysphagia, and dysphonia after a severe coughing or sneezing episode should raise the clinician's suspicion of a thyroid cartilage fracture. PMID:23806730
Fenig, Mark; Strasberg, Stephen; Cohen, Justin C; Almadi, Rami; Gold, Menachem
Evidence is presented to indicate that evoked potentials in the recurrent laryngeal, the cervical sympathetic, and the phrenic nerve, commonly reported as being elicited by vestibular nerve stimulation, may be due to stimulation of structures other than the vestibular nerve. Experiments carried out in decerebrated cats indicated that stimulation of the petrous bone and not that of the vestibular nerve is responsible for the genesis of evoked potentials in the recurrent laryngeal and the cervical sympathetic nerves. The phrenic response to electrical stimulation applied through bipolar straight electrodes appears to be the result of stimulation of the facial nerve in the facial canal by current spread along the petrous bone, since stimulation of the suspended facial nerve evoked potentials only in the phrenic nerve and not in the recurrent laryngeal nerve. These findings indicate that autonomic components of motion sickness represent the secondary reactions and not the primary responses to vestibular stimulation.
Tang, P. C.
To evaluate the results of facial nerve reanimation after facial nerve injury by means of hypoglossal to facial nerve anastomosis. Retrospective case review. Private neuro-otologic and cranial base quaternary referral center. Sixty patients underwent hypoglossal to facial nerve anastomosis for facial nerve reanimation between April 1987 and December 2010. Only forty patients completed a minimal follow up of 24 months at the time of evaluation and were included in the study population. Facial nerve paralysis was present for a mean duration of 11.3 months (range 2-42 months) and all the patients had a HB grade VI prior their surgery. Final facial nerve motor function. The most common cause of facial paralysis was vestibular Schwannoma surgery. All the patients achieved a postoperative HB grade III or IV after a mean follow-up time of 20 months. The facial movements were detected after a period that ranged from ranged from 5 to 9 months. Only 4 patients suffered from difficulties during eating and drinking and three of them had associated lower cranial nerve deficit. Despite the various techniques in facial reanimation following total facial nerve paralysis, the end to end of hypoglossal to facial nerve anastomosis remains one of the best treatments in cases of viable distal facial stump and nonatrophic musculature. PMID:24427588
Tanbouzi Husseini, Sami; Kumar, David Victor; De Donato, Giuseppe; Almutair, Tamama; Sanna, Mario
Thyrotoxic periodic paralysis (TPP), a disorder most commonly seen in Asian men, is characterized by abrupt onset of hypokalemia and paralysis. The condition primarily affects the lower extremities and is secondary to thyrotoxicosis. The underlying hyperthyroidism is often subtle causing difficulty in early diagnosis. Factors like high-carbohydrate meal exercise, steroid, and stress can precipitate an attack of TPP. Evidence is building up showing role of genetic mutations in Kir2.6 channel in the pathogenesis of TPP. Loss of function of Kir2.6 together with increased activity of Na(+)/K(+) ATPase may trigger a positive feed-forward cycle of hypokalemia. Biochemical hyperthyroidism with normal urinary potassium excretion and ECG changes are characteristic of TPP. Treatment with low-dose potassium supplements and nonselective beta-blockers should be initiated upon diagnosis, and the serum potassium level should be frequently monitored to prevent rebound hyperkalemia. PMID:24695373
Vijayakumar, Abhishek; Ashwath, Giridhar; Thimmappa, Durganna
Schwannomas are benign tumours, rare among tumours of the larynx. They normally present as supraglottic masses (because they may arise from the internal branch of the superior laryngeal nerve), most commonly involving aryepiglottic folds or false vocal folds. Most patients present with a globus sensation, dysphagia or hoarseness. Conservative surgery is the treatment of choice. We report a case of a laryngeal asymptomatic neuroma that was diagnosed accidentally in an imaging test. Complete excision of the tumour was performed through a transoral CO? laser microsurgery without resorting to a tracheotomy. We discuss the clinical, pathologic and imaging findings and the management of this neoplasm. We also try to update the knowledge on the management of these tumours. PMID:22197446
López-Álvarez, Fernando; Gómez-Martínez, Justo R; Suárez-Nieto, Carlos; Llorente-Pendás, José L
... extensive surgery may be recommended. Stage III and IV laryngeal cancers Stage III and IV laryngeal cancers ... remaining, surgery is done. Stages II, III, and IV hypopharyngeal cancers There are 3 main options to ...
Advances in high-performance computing are enabling a new generation of software tools that employ computational modeling for surgical planning. Surgical management of laryngeal paralysis is one area where such computational tools could have a significant impact. The current paper describes a comprehensive effort to develop a software tool for planning medialization laryngoplasty where a prosthetic implant is inserted into the larynx in order to medialize the paralyzed vocal fold (VF). While this is one of the most common procedures used to restore voice in patients with VF paralysis, it has a relatively high revision rate, and the tool being developed is expected to improve surgical outcomes. This software tool models the biomechanics of airflow-induced vibration in the human larynx and incorporates sophisticated approaches for modeling the turbulent laryngeal flow, the complex dynamics of the VFs, as well as the production of voiced sound. The current paper describes the key elements of the modeling approach, presents computational results that demonstrate the utility of the approach and also describes some of the limitations and challenges. PMID:21556320
Mittal, Rajat; Zheng, Xudong; Bhardwaj, Rajneesh; Seo, Jung Hee; Xue, Qian; Bielamowicz, Steven
Papillomatous lesions intruding into the laryngeal airway were identified in an imported polo pony during a routine neurological examination for partial quadriplegia. Histological examination established a diagnosis of laryngeal besnoitiosis but it is unlikely that the laryngeal parasitism was associated with the cerebellar neuropathy which was also present. PMID:3101272
Lane, J G; Lucke, V M; Wright, A I
Paramyotonia congenita (PC), first described in 1886 by Eulenberg, is characterized by cold and exercise-induced muscle stiffness and intermittent flaccid paresis not necessarily related to cold or myotonia. Several authors segregated a pure form of PC, which has no periodic paralysis, even after cold exposure. The existence of this phenotype has been debated in the literature. We describe electrophysiological and molecular genetic features of a patient with PC who had no history of periodic paralysis. Immersion in cold water or potassium load could not induce clinical paralysis. However, repetitive nerve stimulation and exercise test demonstrated a drop in compound muscle action potential amplitude. Genetic analysis revealed the substitution of valine for glycine on the human skeletal muscle sodium channel (SCN4A) gene. The G1306V mutation is rare in the classic form of PC, and moreover might be the first in pure paramyotonia. PMID:20445432
Park, Jeong Ho; Lee, Young Wha; Park, Sun Ah; Lee, Tae Kyeong; Rho, Hak Jae; Sung, Ki Bum
The results of acute laryngeal trauma sustained by 44 patients are reported. Three major aetiological groups are identified: road traffic accidents, blunt injury and penetrating injury. Road traffic accidents appear to produce severe injury, but the long-term follow-up results are similar to those laryngeal injuries which were not recognized initially and who developed a chronic stenosis. The blunt injury group sustained less forceful trauma; 14 of the 18 were treated conservatively and all patients had a good result. The majority of the penetrating injury group developed good breathing and a good voice following operation. Some of the technical expertise normally used to treat chronic laryngeal stenosis has been included in this series to good effect.
Maran, A G; Murray, J A; Stell, P M; Tucker, A
A free-ranging male red wolf (Canis rufus) in North Carolina (USA), exhibiting paresis, anorexia and heavy tick infection was diagnosed with tick paralysis. The wolf recovered completely following the removal of all ticks. This is the first record of tick paralysis in the red wolf. PMID:9391981
Beyer, A B; Grossman, M
In a case-control analysis, we studied the effects of type of employment on laryngeal cancer risk using the interview data from the Third National Cancer Survey. Effects were measured relative to the risk for those employed in a group of arbitrarily defined industries and occupations with low risk. We excluded females and controlled for age, tobacco use, alcohol use, and
W. D. Flanders; K. J. Rothman
The present review gives a survey of rehabilitative measures for disorders of the motor function of the mimetic muscles (facial nerve), and muscles innervated by the spinal accessory and hypoglossal nerves. The dysfunction can present either as paralysis or hyperkinesis (hyperkinesia). Conservative and surgical treatment options aimed at restoring normal motor function and correcting the movement disorders are described. Static reanimation techniques are not dealt with. The final section describes the use of botulinum toxin in the therapy of dysphagia.
Laskawi, R.; Rohrbach, S.
The Office of Health Technology Assessment (OHTA) emphasizes three basic principles in its assessment activities: (1) broad and open participation both within and outside of the Federal government, (2) reliance onthe expertise and research abilities of ou...
We report the case of a 17-month-old female with tick paralysis presenting to an urban Los Angeles emergency department. The tick was later identified as the North American wood tick, Dermacentor andersoni, and was likely obtained while the family was vacationing on a dude ranch in Montana. We discuss the epidemiology of tick paralysis, a differential diagnosis for health care providers, and methods of detection and removal. Given the increasing popularity of outdoor activities and ease of travel, tick paralysis should be considered in cases of acute or subacute weakness, even in an urban setting. PMID:14984905
Gordon, Brent M; Giza, Christopher C
The authors describe the development of bladder paralysis in a child with acute lymphoblastic leukemia undergoing maintenance chemotherapy. Immediately before the adverse clinical event, the child had received vincristine intravenously and triple therapy with hydrocortisone, cytosine arabinoside, and methotrexate intrathecally and had begun a 5-day pulse of prednisolone. The authors conclude that the ensuing reversible bladder paralysis was related to the vincristine. The clinical event resolved, and vincristine was deleted from the child's subsequent therapy until full recovery was achieved. The authors advise recognition of this problem and discontinuation of the vincristine if transient bladder paralysis develops until symptoms completely disappear. PMID:15891567
El Hayek, Mohammed; Trad, Omar; Jamil, Altaf
This paper reports a case of left hemidiaphragmatic paralysis in an instructor pilot and his later recuperation. This incident was provoked by a failure in the anti-G suit, which remained inflated after the aircraft completed the maneuver that had originated the inflation. The spontaneous recuperation of both the respiratory functional test and the neurophysiological pattern are consistent with a Type II Seddon's axonotmesis of the phrenic nerve. Considering the short time of regeneration (6 months), this lesion must have involved the distal portion of the phrenic nerve. PMID:2053907
Moreno Vazquez, J M; Garcia Alcon, J L; Fuentes Otero, F; Murga Oporto, L; Campillo Alvarez, J E
Chronic laryngeal signs and symptoms associated with gastroesophageal reflux disease (GERD) are often referred to as reflux laryngitis or laryngopharyngeal reflux (LPR). It is estimated that up to 15% of all visits to otolaryngology offices are because of manifestations of LPR. Damage to laryngeal mucosa may be the result of reflux of gastroduodenal contents, whether chronic or a single incident. The most common presenting symptoms of LPR include hoarseness, sore throat, throat clearing, and chronic cough. The diagnosis of LPR is usually made on the basis of presenting symptoms and associated laryngeal signs, including laryngeal edema and erythema. The current recommendation for managing these patients is empiric therapy with twice-daily proton pump inhibitors for 1 to 2 months. Other causes of laryngeal irritation are considered in most of those who are unresponsive to such therapy. Surgical fundoplication is most effective in those who are responsive to acid-suppressive therapy. PMID:18625138
Vaezi, Michael F
While examining a patient with myotonia congenita, it was found that stimulation of the ulnar nerve with frequencies of 5 or 8 cps caused the amplitude of the muscle action potential to decrease rapidly to the base line. During the following lapse, the muscle was paralyzed. After about 20 sec the amplitude increased again, and the strength of the muscle
K. Ricker; H.-M. Meinck
Symptomatic otologic involvement by leukemic infiltration is unusual, most often occurring in the already-diagnosed leukemic patient as postauricular mass, acute hemorrhagic otitis media, mastoiditis, cranial neuropathy, vertigo, hearing loss, or leptomeningitis. We think ours is the first reported patient whose leukemia presented as atypical mastoiditis and facial paralysis due to granulocytic sarcoma (chloroma). At mastoidectomy, tan lobulated rubbery tumor filled the mastoid antrum and middle ear cleft. Complete remission and full return of facial nerve function was achieved with 2500 R local radiation and systemic chemotherapy. We discuss the role and extent of surgery in atypical acute mastoiditis when unsuspected middle ear and mastoid tumor, with inconclusive intra-operative histopathologic data, is found. PMID:6589214
Todd, N W; Bowman, C A
Management of unilateral vocal fold paralysis continues to generate controversy. Polytetrafluoroethylene (Teflon) injection remains the most popular procedure for medialization; however, there are problems involved with its use. Endoscopic assessment of patients treated with medialization laryngoplasty revealed a normal mucosal wave form in contrast to the stiff vocal fold observed with Teflon injection. Medialization laryngoplasty is also considered a reversible procedure. Based on these findings, medialization laryngoplasty should be considered the procedure of choice for unilateral vocal fold paralysis. PMID:7733552
Odland, R M; Wigley, T; Rice, R
The management of head and neck cancer has evolved into a multidisciplinary approach in which patients are evaluated before treatment and decisions depend on prospective multi-institutional trials, as well as retrospective outcome studies. The choice of one or more modalities to use in a given case varies with the tumor site and extent, as exemplified in the treatment of laryngeal squamous cell carcinomas. The goals of treatment include cure, laryngeal voice preservation, voice quality, optimal swallowing, and minimal xerostomia. Treatment options include transoral laser excision, radiotherapy (both definitive and postoperative), open partial laryngectomy, total laryngectomy, and neck dissection. The likelihood of local control and preservation of laryngeal function is related to tumor volume. Patients who have a relatively high risk of local recurrence undergo follow-up computed tomography scans every 3-4 months for the first 2 years after radiotherapy. Patients with suspicious findings on computed tomography might benefit from fluorodeoxyglucose positron emission tomography to differentiate post-radiotherapy changes from tumor.
Mendenhall, William M. [Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL (United States)], E-mail: email@example.com; Mancuso, Anthony A. [Department of Diagnostic Radiology, University of Florida College of Medicine, Gainesville, FL (United States); Hinerman, Russell W.; Malyapa, Robert S. [Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL (United States); Werning, John W. [Department of Otolaryngology, University of Florida College of Medicine, Gainesville, FL (United States); Amdur, Robert J. [Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL (United States); Villaret, Douglas B. [Department of Otolaryngology, University of Florida College of Medicine, Gainesville, FL (United States)
Our experience with patients undergoing carotid endarterectomy over a 10 year period has been retrospectively reviewed. Nerve injuries were detected by reviewing postoperative progress and clinic notes. One hundred twenty-nine procedures were performed on 112 patients, 12 of whom (9.3 percent) sustained major nerve injuries. These included five vagal nerve injuries causing ipsilateral vocal cord paralysis and hoarseness, four injuries of the marginal mandibular nerve, and three injuries of the hypoglossal nerve. Evidence of nerve dysfunction was not present preoperatively. None of the patients with nerve injury sustained a stroke as a result of carotid operation. Vocal cord paralysis was documented by indirect laryngoscopy. The incidence of cranial nerve injury during carotid endarterectomy appears to be higher than expected, particularly if asymptomatic patients are investigated; however, most injuries are transient and result not from transection but from trauma during dissection, retraction, and clamping of the vessels. The pertinent anatomy and techniques for preventing these injuries have been reviewed. PMID:3674303
Knight, F W; Yeager, R M; Morris, D M
Paralysis of the hypoglossal nerve, the twelfth (XII) cranial nerve, leads to atrophy, deviation of the tongue to the affected side, and varying degrees of fasciculation. The injury to the nerve can occur from its origin to the tongue itself. The causes of hypoglossal nerve palsy are well documented, but idiopathic, isolated nerve palsy that does not recover, is rare. To our knowledge we describe the first case that failed to resolve, and discuss the importance of meticulous investigation to make a diagnosis and rule out sinister disease. PMID:24834809
Sayan, Anna; Abeysinghe, A H M K; Brennan, Peter A; Ilankovan, Velupillai
Late presentation of head trauma is rare. A young boy presented with a traumatic facial paralysis after head trauma. A CT scan of the head showed temporal bone fracture without intracranial insult. Facial nerve decompression was performed and paralysis started improving. However, he presented with vertigo and sensorineural hearing loss after 2 months. Clinical examination also showed cerebellar sign. We suspected iatrogenic injury to the cochlea; however, brain MRI showed haemorrhage in the area of anterior inferior cerebellar artery. The patient was managed conservatively and the vertigo improved. This case stresses on unusual late presentation of head trauma and cerebellar artery injury that complicated the outcome of facial nerve paralysis. PMID:23964046
Thakur, J S; Shekar, Vidya; Saluja, Manika; Mohindroo, N K
Acute bee paralysis virus (ABPV), Kashmir bee virus (KBV) and Israeli acute paralysis virus (IAPV) are part of a complex of closely related viruses from the Family Dicistroviridae. These viruses have a widespread prevalence in honey bee (Apis mellifera) colonies and a predominantly sub-clinical etiology that contrasts sharply with the extremely virulent pathology encountered at elevated titres, either artificially induced
Joachim R. de Miranda; Guido Cordoni; Giles Budge
Summary The risk of laryngeal cancer associated with occupational exposure to asbestos was evaluated by a review of published reports. In only two of 13 cohort studies was the standardized mortality ratio (SMR) significantly increased. Smoking (a risk factor for laryngeal cancer) may have been more prevalent among asbestos workers than among the comparison populations. This was not taken into
David A. Edelman
In Belgium and even in northern Europe Rhinosporidium seeberi has not been reported in autochtonous people or animals. In this paper, the authors report the first observation of laryngeal masses, caused by Rhinosporidium seeberi, in a Belgian Warmblood horse. Moreover, laryngeal rhinosporidiosis is extremely rare since this localisation is only described in four human cases. PMID:18454748
Nollet, H; Vercauteren, G; Martens, A; Vanschandevijl, K; Schauvliege, S; Gasthuys, F; Ducatelle, R; Deprez, P
This is a descriptive exploratory study of 9 parent-dyads who experienced pharmacologic paralysis of their newborn within a prior 6-month period. Perceptual responses included feelings, values, and needs related to the pharmacologic paralysis therapy. Newborns receiving pharmacologic paralysis had direct dependence to the caretaker for mechanical ventilation, precise monitoring of physiological parameters, and extensive life support due to altered sensory-motor function and breathing. The appearance of the immobile newborn and the protocols for the administration of paralyzing agents, which eliminate excessive stimulation and handling, were suspected of impacting parental interaction. The convenience sample of parents was representative of three newborn critical care units. Open-ended, retrospective interviews were completed in either the parents' home or in a private room of the critical care complex. Physiologic complications precluded use of a prospective interview technique. Chart reviews and a background questionnaire provided demographic data. Data collection consisted of a parent-directed interview. Data were subjected to content analysis and descriptive statistics. The mother's and father's responses were coded separately. The identified common perceptual themes within the pharmacologic paralysis experience were empathy, normalcy, acceptance, and sedative association. Ancillary experiences include the perinatal period and newborn illness. Analysis of ancillary experiences revealed continued themes of empathy and normalcy as well as guilt, separation, shock and anxiety, and uncertainty. Nurses may provide parents whose ill newborn undergoes pharmacologic paralysis a supportive team approach and guidance within a framework of their feelings, values, and needs. PMID:2152103
Rudek, M E
Simian retrovirus type D (SRVD) is a naturally occurring betaretrovirus in nonhuman primates of the genus Macaca. Infection can lead to a variety of clinical, hematologic, and histopathologic abnormalities. We report an unusual clinical presentation of facial paralysis and histologic lymphocytic neuritis in an SRVD type 2 (SRVD2)-infected rhesus macaque (Macaca mulatta) with a catheter-associated vena caval thrombus, anemia, thrombocytopenia, and multisystemic lymphoid hyperplasia. At initial presentation, a right atrial mass was detected by echocardiography. The macaque was clinically asymptomatic but had persistent anemia, thrombocytopenia, hyperglobulinemia, and later neutropenia. It was seropositive for SRV and PCR-positive for SRVD 2. Approximately 1 mo after initial presentation, the macaque developed right facial paralysis and was euthanized. Histologic lesions included lymphoplasmacytic aggregates affecting multiple organs, consistent with SRV-related lymphoid hyperplasia. The right facial nerve showed lymphoplasmacytic inflammation. The nerve itself was negative immunohistochemically for SRV antigen, but antigen was present infrequently in pericapillary lymphoid cells within the facial nerve and abundantly within lymphoid aggregates in the adjacent parotid salivary gland, bone marrow, and soft tissue. Known neurotropic viruses could not be identified. Given the widespread inflammation in this macaque, particularly in the area surrounding the facial nerve, lymphocytic neuritis and facial paralysis likely were an indirect effect of SRV infection due to local extension of SRV-related inflammation in the surrounding tissue. PMID:22330582
Hampton, Anna L; Colby, Lesley A; Bergin, Ingrid L
Simian retrovirus type D (SRVD) is a naturally occurring betaretrovirus in nonhuman primates of the genus Macaca. Infection can lead to a variety of clinical, hematologic, and histopathologic abnormalities. We report an unusual clinical presentation of facial paralysis and histologic lymphocytic neuritis in an SRVD type 2 (SRVD2)-infected rhesus macaque (Macaca mulatta) with a catheter-associated vena caval thrombus, anemia, thrombocytopenia, and multisystemic lymphoid hyperplasia. At initial presentation, a right atrial mass was detected by echocardiography. The macaque was clinically asymptomatic but had persistent anemia, thrombocytopenia, hyperglobulinemia, and later neutropenia. It was seropositive for SRV and PCR-positive for SRVD 2. Approximately 1 mo after initial presentation, the macaque developed right facial paralysis and was euthanized. Histologic lesions included lymphoplasmacytic aggregates affecting multiple organs, consistent with SRV-related lymphoid hyperplasia. The right facial nerve showed lymphoplasmacytic inflammation. The nerve itself was negative immunohistochemically for SRV antigen, but antigen was present infrequently in pericapillary lymphoid cells within the facial nerve and abundantly within lymphoid aggregates in the adjacent parotid salivary gland, bone marrow, and soft tissue. Known neurotropic viruses could not be identified. Given the widespread inflammation in this macaque, particularly in the area surrounding the facial nerve, lymphocytic neuritis and facial paralysis likely were an indirect effect of SRV infection due to local extension of SRV-related inflammation in the surrounding tissue.
Hampton, Anna L; Colby, Lesley A; Bergin, Ingrid L
In a case-control analysis, we studied the effects of type of employment on laryngeal cancer risk using the interview data from the Third National Cancer Survey. Effects were measured relative to the risk for those employed in a group of arbitrarily defined industries and occupations with low risk. We excluded females and controlled for age, tobacco use, alcohol use, and race in the analysis. We found ratio estimates above 3.0 for workers in the railroad industry and the lumber industry; and for sheetmetal workers, grinding wheel operators, and automobile mechanics.
Flanders, W.D.; Rothman, K.J.
In a case-control analysis, we studied the effects of type of employment on laryngeal cancer risk using the interview data from the Third National Cancer Survey. Effects were measured relative to the risk for those employed in a group of arbitrarily defined industries and occupations with low risk. We excluded females and controlled for age, tobacco use, alcohol use, and race in the analysis. We found ratio estimates above 3.0 for workers in the railroad industry and the lumber industry; and for sheetmetal workers, grinding wheel operators, and automobile mechanics. PMID:7065314
Flanders, W D; Rothman, K J
Purpose Vocal fold medialization laryngoplasty (ML) and laryngeal reinnervation (LR) as treatments for unilateral vocal fold paralysis (UVFP) were compared in a multicenter, prospective, randomized clinical trial. Methods Previously untreated patients with UVFP were randomized to undergo either ML or LR. Voice results were compared pre-treatment and at 6 and 12 months post-treatment using perceptual ratings by untrained listeners (RUL), blinded speech pathologist GRBAS scores, and voice-related quality of life (VRQOL) scores. Other secondary data included maximum phonation time (MPT), cepstral analysis, and EMG findings. Results 24 patients from 9 sites completed the study, 12 in each group. There were no significant intergroup differences in pre-treatment variables. At 12 months, both study groups showed significant improvement in RUL, GRBAS and VRQOL scores, but no significant differences were found between the two groups. However, patient age significantly affected the LR, but not the ML, group results. The age<52 LR subgroup had significantly (p<0.05) better scores than the age>52 LR subgroup, and had better RUL and GRBAS scores than the age<52 ML subgroup. The age>52 ML subgroup results were significantly better than the age>52 LR subgroup. The secondary data generally followed the primary data, except that the MPTs for the ML patients were significantly longer than for the LR patients. Conclusion ML and LR are both effective surgical options for patients with UVFP. Laryngeal reinnervation should be considered in younger patients, while medialization laryngoplasty should be favored in older patients.
Paniello, Randal C.; Edgar, Julia D.; Kallogjeri, Dorina; Piccirillo, Jay F.
Hypokalemic periodic paralysis (hypoPP), the most common form of periodic paralysis, is a disorder characterized by attacks of transient muscle weakness associated with a drop in serum potassium level.The mainstay of treatment is potassium supplementation and drugs that inhibit the enzyme carbonic anhydrase. In this report we describe 11-year-old twins with hypoPP who were treated with topiramate, an anti-epileptic drug known to have carbonic anhydrase inhibitory properties. The patients experienced a decrease in the severity of their attacks upon initiation of treatment. Topiramate may warrant further investigation as a treatment option in hypoPP. PMID:21171065
Fiore, Darren M; Strober, Jonathan B
Transoral laser microsurgery (TLM) was pioneered in the early 1970s as an approach to treat laryngeal pathology with precision and minimal thermal damage to the vocal cords. Over the last four decades, TLM has become an integral part of the treatment paradigm for patients with laryngeal cancer. TLM is one of the primary treatment options for early-stage laryngeal tumors. However, in recent years, surgeons have begun to develop TLM into a more versatile approach which can be used to address advanced laryngeal tumors. Although functional outcomes following TLM for advanced laryngeal disease are scarce, survival outcomes appear to be comparable with those reported for organ preservation strategies employing external beam radiation therapy (EBRT) and chemotherapy. In addition, TLM plays an important role in the setting of recurrent laryngeal cancer following primary irradiation. TLM has been demonstrated to decrease the need for salvage total laryngectomy resulting in improved functionality while retaining comparable oncologic outcomes. The aim of this review is to elucidate the indications, techniques, and oncological outcomes of TLM for advanced laryngeal cancers.
Sandulache, Vlad C.; Kupferman, Michael E.
Purpose People frequently present to voice clinics with complaints of irritating laryngeal sensations. Clinicians attempt to reduce the irritating sensations and their common sequela, coughing and throat clearing, by advocating for techniques that remove the irritation with less harm to the vocal fold tissue. Despite the prevalence of patients with these complaints, it is not known if the less harmful techniques recommended by clinicians are effective at clearing irritating laryngeal sensations or that irritating laryngeal sensations are, in fact, more frequent in people with voice disorders than people without voice disorders. Method Assessments of participant reported laryngeal sensation, pre- and post- clearing task, were obtained from 22 people with and 24 people without a voice disorder. Six clearing tasks were used to preliminarily evaluate the differing effects of tasks believed to be deleterious and ameliorative. Results People with and without voice disorders reported pre-clear laryngeal sensation at a similar rate. Post-clear sensation was less likely to be completely or partially removed in people with voice disorders than in the non-voice disordered group. Hard throat clear and swallow with water were the most effective techniques at removing laryngeal sensation. Conclusions The findings provide initial evidence for some of the clinical practices common to treating patients with voice disorders and chronic clearing such as advocating for swallowing a sip of water as a replacement behavior instead of coughing or throat clearing. However, the findings raise questions about other practices such as associating irritating laryngeal sensation with a voice disorder.
Bonilha, Heather Shaw; Gerlach, Terri Treman; Sutton, Lori Ellen; Dawson, Amy Elizabeth; Nietert, Paul J
The role of epithelial ion transport in the activation of water-responsive laryngeal afferent was investigated in anesthetized, spontaneously breathing cats. Single-fiber recordings from the peripheral cut-end of the superior laryngeal nerve were carried out to identify water-responsive laryngeal afferent. Substitution of chloride ions (Cl-) of the Krebs solution with gluconate activated the water-responsive endings when the gluconate concentration was > or = 50 mM. Amiloride (10(-4), 10(-3) and 10(-2) M), an inhibitor of epithelial sodium channels, reduced the water-responsiveness of these afferents, whereas EIPA (5 x 10(-5) M), an amiloride analogue which inhibits Na+/H+ exchange, had no effect. Both ouabain (10(-4) M), an inhibitor of Na+/K+ ATPase, and bumetanide (10(-4) M), an inhibitor of Na(+)-K(+)-2Cl- cotransport, reduced the water response, but no significant reduction in the response was observed with DIDS and DPC, two chloride channel inhibitors. These findings suggest that the epithelium modulates the water-responsiveness of laryngeal afferent but is not the primary determinant of the response. PMID:8931175
Ghosh, T K; Van Scott, M R; Mathew, O P
In neonatal mammals of many species, including human infants, apnea and other reflex responses frequently arise from stimulation of laryngeal receptors by ingested or regurgitated liquids. These reflexes, mediated by afferents in the superior laryngeal nerves (SLNs), are collectively known as the laryngeal chemoreflex (LCR) and are suspected to be responsible for some cases of the sudden infant death syndrome (SIDS). The LCR is strongly enhanced by mild increases in body temperature in decerebrate piglets, a finding that is of interest because SIDS victims are often found in overheated environments. Because of the experimental advantages of studying reflex development and mechanisms in neonatal rodents, we have developed methods for eliciting laryngeal apnea in anesthetized rat pups and have examined the influence of mild hyperthermia in animals ranging in age from 3 to 21 days. We found that apnea and respiratory disruption, elicited either by intralaryngeal water or by electrical stimulation of the SLN, occurred at all ages studied. Raising body temperature by 2-3 degrees C prolonged the respiratory disturbance in response to either stimulus. This effect of hyperthermia was prominent in the youngest animals and diminished with age. We conclude that many studies of the LCR restricted to larger neonatal animals in the past can be performed in infant rodents using appropriate methods. Moreover, the developmental changes in the LCR and in the thermal modulation of the LCR seem to follow different temporal profiles, implying that distinct neurophysiological processes may mediate the LCR and thermal prolongation of the LCR. PMID:17962578
Xia, Luxi; Leiter, James C; Bartlett, Donald
This is a study of the laryngeal chemoreflex (LCR) and the trigeminal diving reflex (TDR) responses in the unanesthetized newborn lamb and of the changes in these responses produced by administration of intravenous bupivacaine. It was determined that both 1 mg and 10 mg bupivacaine significantly reduced the LCR. The responses to water and saline stimulation were similar after bupivacaine suggesting a complete blocking effect on the chemoreceptors. When the LCR was initiated by electrical stimulation of the cut superior laryngeal nerve the response was not reduced by bupivacaine indicating that the most likely site of action of bupivacaine is the chemoreceptors in the laryngeal mucosa. The trigeminal diving reflex was significantly reduced after 10 mg bupivacaine, whereas 1 mg was ineffective. PMID:12760402
Corks, B C; Marchal, F; Sundell, H
It is important to consider a differential diagnosis between paralysis on an organic basis and paralysis and disability due to psychological mechanisms in people with physical impairment secondary to trauma, without evidence of organic etiology. We review the most dramatic type of conversion disorder (CD)–‘Conversion Motor Paralysis’. Recent important medical literature concerning the accepted treatment and rehabilitation management will be
RJ Heruti; A Levy; A Adunski; A Ohry
The consequences of phrenic nerve paralysis vary from a considerable reduction in respiratory function to an apparently normal state. Acoustic analysis of lung sound intensity (LSI) could be an indirect non-invasive measurement of respiratory muscle function, comparing activity on the two sides of the thoracic cage. Lung sounds and airflow were recorded in ten males with unilateral phrenic paralysis and ten healthy subjects (5 men/5 women), during progressive increasing airflow maneuvers. Subjects were in sitting position and two acoustic sensors were placed on their back, on the left and right sides. LSI was determined from 1.2 to 2.4 L/s between 70 and 2000 Hz. LSI was significantly greater on the normal (19.3±4.0 dB) than the affected (5.7±3.5 dB) side in all patients (p?=?0.0002), differences ranging from 9.9 to 21.3 dB (13.5±3.5 dB). In the healthy subjects, the LSI was similar on both left (15.1±6.3 dB) and right (17.4±5.7 dB) sides (p?=?0.2730), differences ranging from 0.4 to 4.6 dB (2.3±1.6 dB). There was a positive linear relationship between the LSI and the airflow, with clear differences between the slope of patients (about 5 dB/L/s) and healthy subjects (about 10 dB/L/s). Furthermore, the LSI from the affected side of patients was close to the background noise level, at low airflows. As the airflow increases, the LSI from the affected side did also increase, but never reached the levels seen in healthy subjects. Moreover, the difference in LSI between healthy and paralyzed sides was higher in patients with lower FEV1 (%). The acoustic analysis of LSI is a relevant non-invasive technique to assess respiratory function. This method could reinforce the reliability of the diagnosis of unilateral phrenic paralysis, as well as the monitoring of these patients.
Fiz, Jose Antonio; Jane, Raimon; Lozano, Manuel; Gomez, Rosa; Ruiz, Juan
Background To prevent endothelium and nerve lesions, tracheal tube and laryngeal mask cuff pressure is to be maintained at a low level and yet be high enough to secure air sealing. Method In a prospective quality-control study, 201 patients undergoing surgery during anaesthesia (without the use of nitrous oxide) were included for determination of the cuff pressure of the tracheal tubes and laryngeal masks. Results In the 119 patients provided with a tracheal tube, the median cuff pressure was 30 (range 8 - 100) cm H2O and the pressure exceeded 30 cm H2O (upper recommended level) for 54 patients. In the 82 patients provided with a laryngeal mask, the cuff pressure was 95 (10 - 121) cm H2O and above 60 cm H2O (upper recommended level) for 56 patients and in 34 of these patients, the pressure exceeded the upper cuff gauge limit (120 cm H2O). There was no association between cuff pressure and age, body mass index, type of surgery, or time from induction of anaesthesia to the time the cuff pressure was measured. Conclusion For maintenance of epithelia flow and nerve function and at the same time secure air sealing, this evaluation indicates that the cuff pressure needs to be checked as part of the procedures involved in induction of anaesthesia and eventually checked during surgery.
1. The reflex responses to chemical and mechanical irritation of the laryngeal mucosa have been studied by applying stimuli to the open larynx of tracheostomized cats while monitoring ventilatory and circulatory variables. The responses were studied before and after vagotomy and before and after denervation of the larynx by transection of the superior and recurrent laryngeal nerves. 2. The immediate response to laryngeal irritation was not consistent. The most frequent responses were coughing, and slowing and deepening of breathing without coughing. Less common were expiratory apnoea and sustained, simultaneous inspiratory and expiratory activity. 3. A consistent late change in the pattern of breathing occurred. Slower, deeper breathing with increased total lung resistance (bronchoconstriction) was seen after the immediate response abated. 4. The slowing of breathing was due to prolongation of both the time for inspiration and the time for expiration. The rate of increase in phrenic nerve activity was also slowed. 5. Vagotomy did not alter qualitatively the reflex changes in the pattern of breathing, although bronchoconstriction no longer occurred. 6. The responses were abolished by denervation of the larynx. ImagesFig. 1Fig. 2Fig. 3Fig. 4Fig. 5Fig. 6
Boushey, H. A.; Richardson, P. S.; Widdicombe, J. G.
Beta-bungarotoxin, a neurotoxic phospholipase A2 is a major fraction of the venom of kraits. The toxin was inoculated into one hind limb of young adult rats. The inoculated hind limb was paralysed within 3 h, and remained paralysed for 2 days. The paralysis was associated with the loss of synaptic vesicles from motor nerve terminal boutons, a decline in immunoreactivity of synaptophysin, SNAP-25 and syntaxin, a loss of muscle mass and the upregulation of NaV(1.5) mRNA and protein. Between 3 and 6 h after the inoculation of toxin, some nerve terminal boutons exhibited clear signs of degeneration. Others appeared to be in the process of withdrawing from the synaptic cleft and some boutons were fully enwrapped in terminal Schwann cell processes. By 12 h all muscle fibres were denervated. Re-innervation began at 3 days with the appearance of regenerating nerve terminals, a return of neuromuscular function in some muscles and a progressive increase in the immunoreactivity of synaptophysin, SNAP-25 and syntaxin. Full recovery occurred at 7 days. The data were compared with recently published clinical data on envenoming bites by kraits and by extrapolation we suggest that the acute, reversible denervation caused by beta-bungarotoxin is a credible explanation for the clinically important, profound treatment-resistant neuromuscular paralysis seen in human subjects bitten by these animals. PMID:16195243
Prasarnpun, S; Walsh, J; Awad, S S; Harris, J B
Fifty nine cases of vocal cords in abduction following recurrent nerve paralysis has been treated with teflon paste injection. Most of them were secondary to pulmonary neoplasms. All injections are done under general anesthesia and direct laryngoscopy. Our technique give good results in 78/100 of the case with minimal complication (5/100). In the future, more physiological implants are to be used even if reinervation of tyroarytenoid muscle with neuro-muscular flaps could be used sometimes. PMID:7340688
Freche, C; Abitbol, J; Drweski, P; Yana, M
Facial paralysis is either congenital or acquired, and of varying severity, which leads to an asymmetrical or absent facial expression. It is an important disability both from the aesthetic and functional points of view. Between 2003 and 2008, at the Department of Maxillofacial Surgery, University of Parma, Italy, 21 patients with facial paralysis had their faces reanimated with a gracilis transplant reinnervated by the masseter motor nerve. All free-muscle transplants survived the transfer, and no flap was lost. Facial symmetry at rest and while smiling was excellent or good in most cases, and we found an appreciable improvement in both speech and oral competence. We consider that the masseter motor nerve is a powerful and reliable donor nerve, which allows us to obtain movement of the commissure and upper lip similar to those of the normal site for degree and direction. There may be a role for the masseter motor nerve in innervation of patients with facial paralysis. PMID:21885172
Bianchi, Bernardo; Copelli, Chiara; Ferrari, Silvano; Ferri, Andrea; Sesenna, Enrico
Facial nerve palsy results in the loss of facial expression and is most commonly caused by a benign, self-limiting inflammatory condition known as Bell palsy. However, there are other conditions that may cause facial paralysis, such as neoplastic conditions of the facial nerve, traumatic nerve injury, and temporal bone lesions. We present a case of facial nerve palsy concurrent with a benign cystic lesion of the temporal bone, adjacent to the tympanic segment of the facial nerve. The patient's symptoms subsided after facial nerve decompression via a transmastoid approach. PMID:24652558
Kim, Na Hyun; Shin, Seung-Ho
We report a 44 year-old, American Society of Anesthesiologist Class I (ASA I), female patient scheduled for elective excision of a small lipoma of the left thigh. She went into a 90 minute apnea and complete muscle paralysis as evidenced by the absence of all stimulatory responses by a peripheral nerve stimulator after receiving midazolam (1.0 mg) and fentanyl (100 ?g) intravenously for sedation and analgaesia. The patient made an uneventful recovery after 90 minutes. No cause and effect relationship could be established between the administered drugs and this unusual response.
Khan, Rashid M; Kaul, Naresh; Neelakanthan, Punnuvella H
Breathing is a vegetative function that is altered during more complex behaviours such as exercise, vocalisation and respiratory protective reflexes. Recent years have seen recognition of the importance of respiratory pattern generation in addition to rhythm generation. Respiratory-modulated cranial motoneurons (laryngeal, pharyngeal, hypoglossal, facial) offer a unique insight into the control of respiration since: (1) they receive rhythmic respiratory inputs but; (2) their respiratory-modulated firing pattern differs to that of phrenic neurons to suit their function, (for example, hypoglossal motoneurons begin firing and thus the tongue depresses before the onset of phrenic nerve discharge and diaphragmatic during inspiration) and; (3) their activity is often altered in parallel with changes in respiration during stereotypical non-respiratory behaviours such as coughing, swallowing and sneeze. Here we review some mechanisms that modulate the respiratory-related activity of laryngeal motoneurons with an emphasis on the generation of post-inspiratory activity. PMID:20217338
Bautista, Tara G; Burke, Peter G R; Sun, Qi-Jian; Berkowitz, Robert G; Pilowsky, Paul M
Long-standing peripheral monolateral facial paralysis in the adult has challenged otolaryngologists, neurologists and plastic surgeons for centuries. Notwithstanding, the ultimate goal of normality of the paralyzed hemi-face with symmetry at rest, and the achievement of a spontaneous symmetrical smile with corneal protection, has not been fully reached. At the beginning of the 20(th) century, the main options were neural reconstructions including accessory to facial nerve transfer and hypoglossal to facial nerve crossover. In the first half of the 20(th) century, various techniques for static correction with autologous temporalis muscle and fascia grafts were proposed as the techniques of Gillies (1934) and McLaughlin (1949). Cross-facial nerve grafts have been performed since the beginning of the 1970s often with the attempt to transplant free-muscle to restore active movements. However, these transplants were non-vascularized, and further evaluations revealed central fibrosis and minimal return of function. A major step was taken in the second half of the 1970s, with the introduction of microneurovascular muscle transfer in facial reanimation, which, often combined in two steps with a cross-facial nerve graft, has become the most popular option for the comprehensive treatment of long-standing facial paralysis. In the second half of the 1990s in France, a regional muscle transfer technique with the definite advantages of being one-step, technically easier and relatively fast, namely lengthening temporalis myoplasty, acquired popularity and consensus among surgeons treating facial paralysis. A total of 111 patients with facial paralysis were treated in Caen between 1997 and 2005 by a single surgeon who developed 2 variants of the technique (V1, V2), each with its advantages and disadvantages, but both based on the same anatomo-functional background and aim, which is transfer of the temporalis muscle tendon on the coronoid process to the lips. For a comprehensive treatment of the paralysis, the eyelids are usually managed by Paul Tessier's technique to lengthen the levator muscle of the upper eyelid by aponeurosis interposition, combined with external blepharorrhaphy with Krastinova-Lolov's technique. Facial reanimation using lengthening temporalis myoplasty is a dynamic procedure that has its roots in the techniques of Gillies and McLaughlin. This method is a true lengthening myoplasty procedure using no intermediate grafts. In general, the results with a 1-stage combination of lengthening temporalis myoplasty and static correction of the lagophthalmos appear comparable with the major series in the literature using free microneurovascular transfers combined with cross-facial nerve grafts for longstanding peripheral monolateral facial paralysis. The obvious advantages of temporalis elongation myoplasty consist in its technical ease, a single step, low incidence of complications and markedly reduced operating time. PMID:22767978
Labbč, D; Bussu, F; Iodice, A
Cauda equina and conus medullaris forms of spinal cord injury result in paralysis, sensory impairment, and autonomic dysfunction. This study investigates the effects of neural repair in nonhuman primates using a GDNF- releasing nerve guidance channel. The...
A. Hoke K. Christe L. Havton
We report a case of hypoglossal nerve damage after shoulder hemiarthroplasty with the patient in «beach chair» position, performed with general anesthesia with orotracheal intubation, and without complications. An ultrasound-guided interscalene block was previously performed in an alert patient. After the intervention, the patient showed clinical symptomatology compatible with paralysis of the right hypoglossal nerve that completely disappeared after 4 weeks. Mechanisms such as hyperextension of the neck during intubation, endotracheal tube cuff pressure, excessive hyperextension, or head lateralization during surgery have been described as causes of this neurological damage. We discuss the causes, the associated factors and suggest preventive measures. PMID:23787368
Pariente, L; Camarena, P; Koo, M; Sabaté, A; Armengol, J
Peripheral nerve lesions are uncommon but serious injuries which may delay or preclude an athlete's safe return to sports. Early, accurate anatomical diagnosis is essential. Nerve lesions may be due to acute injury (e.g. from a direct blow) or chronic injury secondary to repetitive microtrauma (entrapment). Accurate diagnosis is based upon physical examination and a knowledge of the relative anatomy. Palpation, neurological testing and provocative manoeuvres are mainstays of physical diagnosis. Diagnostic suspicion can be confirmed by electrophysiological testing, including electromyography and nerve conduction studies. Proper equipment, technique and conditioning are the keys to prevention. Rest, anti-inflammatories, physical therapy and appropriate splinting are the mainstays of treatment. In the shoulder, spinal accessory nerve injury is caused by a blow to the neck and results in trapezius paralysis with sparing of the sternocleidomastoid muscle. Scapular winging results from paralysis of the serratus anterior because of long thoracic nerve palsy. A lesion of the suprascapular nerve may mimic a rotator cuff tear with pain a weakness of the rotator cuff. Axillary nerve injury often follows anterior shoulder dislocation. In the elbow region, musculocutaneous nerve palsy is seen in weightlifters with weakness of the elbow flexors and dysesthesias of the lateral forearm. Pronator syndrome is a median nerve lesion occurring in the proximal forearm which is diagnosed by several provocative manoeuvres. Posterior interosseous nerve entrapment is common among tennis players and occurs at the Arcade of Froshe--it results in weakness of the wrist and metacarpophalangeal extensors. Ulnar neuritis at the elbow is common amongst baseball pitchers. Carpal tunnel syndrome is a common neuropathy seen in sport and is caused by median nerve compression in the carpal tunnel. Paralysis of the ulnar nerve at the wrist is seen among bicyclists resulting in weakness of grip and numbness of the ulnar 1.5 digits. Thigh injuries include lateral femoral cutaneous nerve palsy resulting in loss of sensation over the anterior thigh without power deficit. Femoral nerve injury occurs secondary to an iliopsoas haematoma from high energy sports. A lesion of the sciatic nerve may indicate a concomitant dislocated hip. Common peroneal nerve injury may be due to a direct blow or a traction injury and results in a foot drop and numbness of the dorsum of the foot. Deep and superficial peroneal nerve palsies could be secondary to an exertional compartment syndrome. Tarsal tunnel syndrome is a compressive lesion of the posterior tibial nerve caused by repetitive dorsiflexion of the ankle--it is common among runners and mountain climbers.(ABSTRACT TRUNCATED AT 400 WORDS) PMID:8378668
Lorei, M P; Hershman, E B
An analysis of postoperative injuries to the recurrent laryngeal, hypoglossal, marginal mandibular, and superior laryngeal nerves was undertaken in 517 patients who underwent 535 carotid endarterectomies between April 1978 and March 1981 at The Cleveland Clinic Foundation. A review of the literature is presented followed by the results of this analysis and a discussion of the findings. Suggestions for decreasing or avoiding such injuries are made. Conclusions are drawn to help the otolaryngologist identify the endarterectomized patient with an impaired upper aerodigestive tract. PMID:6643076
Astor, F C; Santilli, P; Tucker, H M
Although laryngeal electromyography (LEMG) is commonly performed, there are no data confirming its efficacy. We evaluated 40 patients with a laryngoscopic diagnosis of unilateral vocal-fold immobility who underwent LEMG of the thyroarytenoid (TA) and cricothyroid (CT) muscle, with the immobile side of each muscle being compared to the normal side. The immobile side compared to the normal side showed more fibrillation potentials and positive sharp waves for the TA (p=0.04), longer MUAP duration for the TA (p=0.04) and CT (p=0.01), more polyphasic potentials for the TA (p=0.002), and more frequent decreased recruitment for the TA (p<0.01) and CT (p=0.008). Specificity and positive predictive value were around 90%. Sensitivity, negative predictive value and accuracy were around 50%. These results suggest that altered LEMG findings are reliable and they can be used to determine the innervation status of an immobile muscle. Conversely, when the LEMG is normal, the results should be reviewed. PMID:21315601
Gavazzoni, Fabiano Bleggi; Scola, Rosana Herminia; Lorenzoni, Paulo José; Kay, Cláudia Suemi Kamoi; Werneck, Lineu Cesar
... laryngeal and hypopharyngeal cancers? What are the key statistics about laryngeal and hypopharyngeal cancers? The American Cancer ... 725 in men and 675 in women). Survival statistics for these cancers are discussed in the section “ ...
... Additional resources for laryngeal and hypopharyngeal cancers What’s new in laryngeal and hypopharyngeal cancers research and treatment? ... to better tests for early detection and to new targeted treatments. Chemoprevention Chemoprevention is the use of ...
We report on two cases of hypokaliemic periodic paralysis due to a potassium shift from the extracellular to the intracellular compartment of skeletal muscle cells. The first case occurred in a 15-year-old boy who experienced rapid onset flaccid tetraplegia without neurological abnormalities. Physical exam revealed facial dysmorphy, and EKG a long QT. Biology evidenced shift hypokalemia that was quickly reversible after administration of intravenous potassium. After exclusion of Andersen-Tawil syndrom, hypokalemic familial paralysis (Westphall disease) was diagnosed by molecular genetic testing (disease-causing mutation in CACNA1S) in the proband and in three other family members. The second case occurred in a 24-year-old male who experienced rapid onset flaccid tetraplegia due to intracellular potassium shift that was quickly reversible after administration of intravenous potassium. Biology revealed thyrotoxicosis due to Grave's disease. To the best of our knowledge, this is the first case described in a people from pacific origin. The clinical, biological, and electromyographic findings of the most frequent causes of periodic paralysis are underlined as well as the molecular genetic diagnosis in familial forms. PMID:17081960
Burtey, Stéphane; Vacher-Coponat, Henri; Berland, Yvon; Dussol, Bertrand
Microlaryngeal surgery (MLS) is difficult in patients with anaesthetic and cervical contraindications. An alternative approach is proposed here using a flexible laryngeal fiberscope and specially designed laryngeal instruments under local anaesthesia. Equipment and technique of the procedure is described. Indications and contraindications are highlighted based on our experience of 117 patients. Laryngeal fibrescopic surgery (LFS) was found to be a safer alternative. But this procedure cannot be used for all laryngeal pathologies. PMID:23120593
Anand, V; Reji, R; Santosh, S; Preeti, I A
A laryngocele is an abnormal dilatation of the laryngeal saccule. The relationship between layngoceles and laryngeal carcinoma is still debated. We present the case of a 45-year-old male patient with bilateral asymptomatic laryngocele and laryngeal squamous cell carcinoma. We discuss the possible etiopathogenetic influence of increased intralaryngeal pressure with preoperative CT and explorative findings, and the current literature is reviewed.
Yucel Akbas; Murat Ünal; Yavuz Selim Pata
Viscoelastic properties of canine laryngeal muscles were measured in a series of in vitro experiments. Laryngeal posturing that controls vocal fold length and adduction/abduction is an essential component of the voice production. The dynamics of posturing depends on the viscoelastic and physiological properties of the laryngeal muscles. The time-dependent and nonlinear behaviors of these tissues are also crucial in the voice production and pitch control theories. The lack of information on some of these muscles such as posterior cricoarytenoid muscle (PCA), lateral cricoarytenoid muscle (LCA), and intraarytenoid muscle (IA) was the major incentive for this study. Samples of PCA and LCA muscles were made from canine larynges and mounted on a dual-servo system (Ergometer) as described in our previous works. Two sets of experiments were conducted on each muscle, a 1-Hz stretch and release experiment that provides stress-strain data and a stress relaxation test. Data from these muscles were fitted to viscoelastic models and Young's modulus and viscoelastic constants are obtained for each muscle. Preliminary data indicates that elastics properties of these muscles are similar to those of thyroarytenoid and cricothyroid muscles. The relaxation response of these muscles also shows some similarity to other laryngeal muscles in terms of time constants.
Alipour, Fariborz; Hunter, Eric; Titze, Ingo
The relationship between the human papillomavirus (HPV) and cancer of the upper aerodigestive trace is controversial. There is no doubt that at least some nasal, oral, pharyngeal and laryngeal carcinomas contain HPV DNA. However, the diversity in the reported incidence of HPV in these tumours represents a major problem. In the present study we have examined 30 laryngeal dysplastic lesions for HPV by the polymerase chain reaction, using three different pairs of consensus primers (GP5+/GP6+, MY09/MY11 and CPI/CPII). The single HPV-positive specimen was from a recurrent laryngeal papilloma. The HPV type present could not be determined, but it was not type 6, 11, 16, 18, 30, 31, 33 or 45. Restriction fragment length polymorphy analysis suggested a yet unknown HPV-type in this lesion. This investigation does not support the idea of HPV as an oncogenic cofactor in most laryngeal carcinomas as HPV was present in only 1/30 precancerous laryngeal lesions. PMID:9298618
Lindeberg, H; Krogdahl, A
Objective. Examining the prevalence of laryngeal sensory neuropathy (LSN) in goiter patients versus a control group. Study Design. Cross-sectional study. Methods. 33 Goiter patients were enrolled versus 25 age-matched controls. TSH levels, size of thyroid gland, and presence or absence of thyroid nodules were reported. Subjects were asked about the presence or absence of any of the following symptoms: cough, globus pharyngeus, and/or throat clearing that persistented for more than 6 weeks. The presence of one or more of these symptoms for at least six weeks in the absence of LPRD, allergy, asthma, ACE inhibitor intake, and psychogenic disorder was defined as LSN. Results. For goitrous patients mean age (years) was (41.73 ± 9.47) versus (37.44 ± 10.89) for controls. 82% goitrous patients had known nodules and 27% carried a simultaneous diagnosis of hypothyroidism. Among those with documented size (61%), mean total thyroid volume was 26.996 ± 14.852?cm3, with a range from 9.430 to 67.022?cm3. The overall prevalence of LSN among goitrous patients was 42% versus 12% among controls (P = 0.0187). There was no correlation between LSN, size of thyroid gland, and TSH level. Conclusion. The prevalence of LSN in goitrous patients is significantly higher than that in a nongoitrous population.
Hamdan, Abdul Latif; Jabour, Jad; Azar, Sami T.
Objective To determine lifetime prevalence rates of sleep paralysis. Data Sources Keyword term searches using “sleep paralysis”, “isolated sleep paralysis”, or “parasomnia not otherwise specified” were conducted using MEDLINE (1950-present) and PsychINFO (1872-present). English and Spanish language abstracts were reviewed, as were reference lists of identified articles. Study Selection Thirty five studies that reported lifetime sleep paralysis rates and described both the assessment procedures and sample utilized were selected. Data Extraction Weighted percentages were calculated for each study and, when possible, for each reported subsample. Data Synthesis Aggregating across studies (total N = 36533), 7.6% of the general population, 28.3% of students, and 31.9% of psychiatric patients experienced at least one episode of sleep paralysis. Of the psychiatric patients with panic disorder, 34.6% reported lifetime sleep paralysis. Results also suggested that minorities experience lifetime sleep paralysis at higher rates than Caucasians. Conclusions Sleep paralysis is relatively common in the general population and more frequent in students and psychiatric patients. Given these prevalence rates, sleep paralysis should be assessed more regularly and uniformly in order to determine its impact on individual functioning and better articulate its relation to psychiatric and other medical conditions.
Barber, Jacques P.
Ticks are obligate haematophagous ectoparasites of various animals, including humans, and are abundant in temperate and tropical zones around the world. They are the most important vectors for the pathogens causing disease in livestock and second only to mosquitoes as vectors of pathogens causing human disease. Ticks are formidable arachnids, capable of not only transmitting the pathogens involved in some infectious diseases but also of inducing allergies and causing toxicoses and paralysis, with possible fatal outcomes for the host. This review focuses on tick paralysis, the role of the Australian paralysis tick Ixodes holocyclus, and the role of toxin molecules from this species in causing paralysis in the host.
Hall-Mendelin, S; Craig, S B; Hall, R A; O'Donoghue, P; Atwell, R B; Tulsiani, S M; Graham, G C
The aim of the present paper has been to explore the medieval evidence on miraculous healings of paralysis and to confront it with modern medical knowledge. Paralysis has been selected as a model for such a study and St. Bernardino of Siena (1380-1444) as a model of a saintly healer. Analyzed were the primary sources and modern literature. Paralysis was found to be among the most frequent diseases in medieval miracle reports, including the healings by St. Bernardino. According to the hypothesis offered in the paper, the majority of medieval cases of "miraculously healed paralysis" was of conversive origin. PMID:23697246
Muzur, Amir; Rinci?, Iva
Context: Facial palsy is a common problem encountered in clinical practice. These patients suffer serious functional, cosmetic & psychological problems with impaired ability to communicate. Functional problems around the eye are usually a first priority for the patient with facial palsy.The nerve to masseter as a direct nerve transfer to the zygomatic branch of facial nerve to reinnervate viable facial muscles within a year after the onset of paralysis has been scarcely reported. This study was contemplated to evaluate the feasibility of neurotisation of zygomatic branch of facial nerve with masseteric nerve branch of the trigeminal nerve Objectives: Establishing the anatomic relationship of masseteric nerve to masseteric muscle, determining feasibility of neurotisation of zygomatic branch of facial nerve using the nerve to the masseter and establishing fascicular correlation of the donor and the recipient nerves. Materials and Methods: Ninteen hemi-faces in ten fresh cadavers (6 Male and 4 Female)were dissected in a forensic morgue and access was by a standard preauricular incision and anterior skin flap is elevated in a subcutaneous plane. Facial nerve and its two main divisions are dissected in its full A*/extratemporal course. Zygomatic branch dissected upto zygomatic arch and the nerve to the masseter is identified within the masseter muscle, dissected proximodistally to isolate it. Feasibility of transfer of this masseteric nerve to the zygomatic branch without using nerve graft is determined. At the completion of dissection, the ends of both nerves are sent for HPE analysis to determine fascicular anatomy and count. Results: The dissection of massteric nerve was done taking into consideration of 3 axes, that is anteroposterior (x), vertical (y) axes and mediolateral(z) for locating the nerve and for standardization of the dissection. The nerve was cut and stored in glutaraldehyde solution and subjected to histopathologic examination after fixing and staining with Haematoxilin-eosin stain. Donor masseter neve has 7-10 fascicles. Recipient zygomatic branch has 2-3 fascicles. And the buccal branch has 5-6 fascicles. Conclusion: The use of the nerve to masseter offers a simpler ipsilateral alternative for neurotisation of the facial nerve branches in patients who have an early facial nerve paralysis.
Annamaneni, Ravi Chander Rao; Reddy, Mukunda D.; Srikanth, R.; Komuravelly, Arpitha; Sadam, Srinivasa Rao; Kanth V., Shashi; Rao V., Bhadra
\\u000a Together, the relationship between the mechanical response of neural tissues and the related mechanisms of injury provide\\u000a a foundation for defining relevant thresholds for injury. The nerves and nerve roots are biologic structures with specific\\u000a and important functions, and whose response to mechanical loading can have immediate, long-lasting and widespread consequences.\\u000a In particular, when nerves or nerve roots are mechanically
Kristen J. Nicholson; Beth A. Winkelstein
The purpose of this project was to attempt restoration of abduction of a recently denervated left dorsal cricoarytenoid muscle in the horse by anastomosing the first cervical nerve to the abductor branch of the left recurrent laryngeal nerve. Ten horses were used in the study. In six horses the left recurrent laryngeal nerve was transected and ligated while the ventral branch of the left first cervical nerve was anastomosed to the abductor branch of the left recurrent laryngeal nerve. The remaining four horses also had the left recurrent laryngeal nerve transected and ligated but had no nerve anastomosis performed. Each horse was evaluated preoperatively, and at one week, three and six months after surgery, by endoscopy and determination of upper airway resistance. The endoscopy was performed with the horses breathing room air and while breathing 10% carbon dioxide. All ten horses showed endoscopic signs of complete laryngeal hemiplegia immediately postoperatively. Starting at three months postoperatively clonic movements of the left arytenoid cartilage were observed in four of the six reinnervated horses but not in the sham operated horses. At the sixth postoperative month five reinnervated horses had clonic movements of the left arytenoid cartilage. The comparison of upper airway resistance measurements before surgery and at one week, three and six months after surgery showed no significant differences in either control or experimental horses. Following euthanasia at six months postoperatively, the left and right dorsal crioarytenoid muscles were compared for evidence of reinnervation. No significant difference in weight was noted in the reinnervated horses but the left dorsal cricoarytenoid muscle weighed less than the control horses. Images Fig. 2. Fig. 3. Fig. 4. Fig. 5. Fig. 6. Fig. 7. Fig. 8. Fig. 9.
Ducharme, N G; Viel, L; Partlow, G D; Hulland, T J; Horney, F D
Objective: To investigate the expression of extracellular matrix protein 1 (ECM1) in benign laryngeal lesions, precancerous lesions and malignant laryngeal lesions and analyze the clinical significance of ECM1 changes in the pathogenesis and metastasis of laryngeal carcinoma. Methods: A total of 46 patients with laryngeal lesions were recruited with a median age of 48.2 years (range: 33-67 years). Among these patients, 29 had laryngeal carcinoma (12 with metastasis and 17 without metastasis), 8 had benign laryngeal lesions and 9 had precancerous laryngeal lesions (laryngeal leukoplakia). Immunofluorescence staining was employed to detect the protein expression of ECM1 in benign laryngeal lesions, laryngeal leukoplakia and malignant laryngeal lesions; RT-PCR was used to measure the mRNA expression of ECM1 in laryngeal carcinoma and benign laryngeal lesions. Results: ECM1 expression was detected in 25% (2/8) of patients with benign laryngeal lesions, 78% (7/9) of patients with precancerous laryngeal lesions, and 100% (29/29) of patients with laryngeal carcinoma. Among the laryngeal carcinoma patients, high ECM1 expression (+++) was found in 64.7% (11/17) of patients without lymph node metastasis and 91.7% (11/12) of patients with lymph node metastasis. Increased ECM1 expression was found in laryngeal carcinoma when compared with other laryngeal lesions and the ECM1expression in patients with metastasis was significantly higher than that patients without metastasis (P<0.01). RT-PCR showed that the mRNA expression of ECM-1 in laryngeal carcinoma was markedly higher than that in benign laryngeal lesions. Conclusion: ECM1 expression is in an increasing order in benign laryngeal lesions, precancerous laryngeal lesions and malignant laryngeal lesions. Meanwhile, the metastatic laryngeal carcinoma has higher ECM1 expression than laryngeal carcinoma without metastasis. Our findings suggest that ECM1 plays promotive roles in the occurrence, development and metastasis of laryngeal carcinoma.
Gu, Meizhen; Guan, Jian; Zhao, Limin; Ni, Kun; Li, Xiaoyan; Han, Zhao
Laryngeal muscle dysfunction compromises voice, swallowing, and airway protection in elderly adults. Laryngeal muscles and their motor neurons and their motor neurons communicate via the neuromuscular junction (NMJ). We tested the hypothesis that aging disrupts NMJ organization and function in the laryngeal thyroarytenoid (TA) and posterior cricoarytenoid (PCA) muscles We determined NMJ density and size and acetylcholine receptor (AChR) subunit mRNAs in TA and PCA muscles from 6-, 18-, and 30- month old-rats. NMJ function was determined with tubocurarine (TC) and contractions during nerve and muscle stimulation. NMJ size, abundance, and clustering decreased in 30-month TA and PCA muscles. AChRe mTNA and protein increased with age in both muscles. AChRg mRNA increased with age in both muscles while protein content increased in TA only. Aging PCA and TA were more sensitive to TC, demonstrating functional evidence of denervation. These results demonstrate that NMJs become smaller and less abundant in aging TA and PCA muscles.
Andrade, Francisco H.
Thirty laryngeal carcinomas from patients without pre-existing laryngeal papillomatosis were examined by PCR for the presence of HPV DNA. The utmost care was taken during sectioning of the tissue blocks and DNA-extraction in order to avoid false positive results. Three pairs of consensus primers were used: MY9/MY11, GP5+/GP6+ and CPI/CPII. HPV was detected in 1/30 carcinomas. The HPV type present could not be determined, but it was not type 6, 11, 13, 16, 18, 30, 31, 33, 35 or 45. In other studies the reported frequency of HPV in laryngeal carcinomas, as estimated by PCR, varies between 3-85%. The reasons for this unacceptable variation in reported results are discussed. The present results indicate that HPV DNA does not have a major role in malignant tumours of the larynx in patients without pre-existing recurrent laryngeal papillomatosis. PMID:10656604
Lindeberg, H; Krogdahl, A
Several surgical techniques have been proposed for the reconstruction of the smile in facial paralysis. The 2-stage approach utilising a cross-facial nerve graft (CFNG) and subsequent free functional muscle transfer represents the "gold standard". A single-stage alternative is the use of the masseteric nerve as donor nerve. Here we have retrospectively analysed the outcome of 8 patients who were treated with either of these procedures (4 per treatment group). We compared the oral commisure excursion between the 2 groups. Use of the masseteric nerve led to reinnervation of the muscle graft within 3 months. The 2-stage procedure required more than 12 months from the first procedure until first muscle contractions could be observed. A spontaneous smile could not be achieved in all patients when the masseteric nerve was used. The oral commisure excursion was symmetrical when compared to the healthy side in both groups, however the excursion was significantly higher in the masseteric nerve group compared to the CFNG group of patients. Most patients with the masseteric nerve as a donor nerve underwent a secondary procedure, which involved thinning of the muscle flap. In conclusion, the use of the masseteric nerve as a donor nerve for facial reanimation surgery is a single-stage alternative to the use of a CFNG as donor nerve. It delivers reliable results with strong muscle contractions with limitations in regard to achieving a spontaneous smile. PMID:23970401
Eisenhardt, S U; Thiele, J R; Stark, G B; Bannasch, H
A 52-year-old Caucasian man presented with sudden onset of difficulty in moving his tongue to the left with preceding left-sided headache with no neck pain. Earlier, he had self-limiting chest infection without rashes or tonsillar enlargement. His medical and surgical history was unremarkable with no recent trauma. Oral examination revealed difficulty in protruding his tongue to the left with muscle bulk loss and fasciculation on the same side, suggesting left hypoglossal nerve palsy. Examination of the rest of the cranial nerves and nervous system was normal. The patient's oropharyngeal and laryngeal examination was unremarkable with no cervical lymphadenopathy. He had normal laboratory investigations and cerebrospinal fluid examination. Extensive imaging of the head, neck and chest failed to reveal any pathology. Further review by an otorhinologist and rheumatologist ruled out any other underlying pathology. He made a good recovery without treatment. English literature search revealed very few cases of idiopathic, transient, unilateral hypoglossal nerve palsy. PMID:24969070
Ahmed, Syed Viqar; Akram, Muhammad Saqub
Thirty laryngeal carcinomas from patients without pre-existing laryngeal papillomatosis were examined by PCR for the presence of HPV DNA. The utmost care was taken during sectioning of the tissue blocks and DNA-extraction in order to avoid false positive results. Three pairs of consensus primers were used: MY9\\/MY11, GP5+\\/GP6+ and CPI\\/CPII. HPV was detected in 1\\/30 carcinomas. The HPV type present
Henning Lindeberg; Annelise Krogdahl
Paediatric blunt laryngeal trauma is infrequently encountered; however, it can have fatal consequences if managed inappropriately. This paper provides an overview of the relatively limited literature available on the subject and highlights current controversies and recent advances in the management of these injuries.
Oosthuizen, J. C.
Lasers are a relatively recent addition to laryngeal surgery. Since their invention, laser use and applications have expanded rapidly. In this paper, we discuss the benefits and disadvantages of lasers for different procedures, as well as ways to overcome commonly faced clinical problems. The use of lasers in surgery has offered a time- and cost-efficient alternative to cold surgical techniques, and has been employed in the treatment of numerous laryngeal pathologies, including stenoses, recurrent respiratory papillomatosis, leukoplakia, nodules, malignant laryngeal disease, and polypoid degeneration (Reinke’s edema). However, lasers can incur adjacent tissue damage and vocal fold scarring. These problems can be minimized through understanding the mechanisms by which lasers function and correctly manipulating the parameters under a surgeon’s control. By varying fluence, power density, and pulsation, tissue damage can be decreased and lasers can be used with greater confidence. The various types of lasers and their applications to the treatment of specific pathologies are reviewed with the intention of helping surgeons select the best tool for a given procedure. Recent applications of lasers to treat benign laryngeal lesions and severe laryngomalacia demonstrate that additional research must be conducted in order to realize the full potential of this surgical tool.
Yan, Yan; Olszewski, Aleksandra E.; Hoffman, Matthew R.; Zhuang, Peiyun; Ford, Charles N.; Dailey, Seth H.; Jiang, Jack J.
Entrapment neuropathies are rarely mentioned in phoniatrics because a definite diagnosis is very difficult to make. However, several clinical examples described here strongly support this etiology, which should now be considered in the diagnosis of both partial and complete laryngeal immobility as well as in minor neuromuscular disorders. PMID:21077411
Roch, J B; Piron, A
Background Management of advanced laryngeal cancer is complex and ideal strategy is yet to be defined. This study evaluates the experience of a single head and neck oncologic centre in the management of T4 laryngeal cancer. Methods Retrospective assessment of cases primarily treated for T4a squamous cell carcinoma of the larynx, between 1980 and 2007, at a tertiary referral center. Results A total of 384 cases were studied. Five-year disease specific survival was 56.2% and local control 87.4%. Regional and distal control estimates were 90.3% and 88.3% respectively. Prognosis was significantly superior for cases treated with primary surgery compared to cases solely managed with non-surgical modalities. Positive surgical margins and regional disease worsened prognosis. Conclusion This study suggests that primary surgery remains a key element in the treatment of advanced laryngeal cancer. The need for well-designed, prospective, randomised studies in order to further evaluate the remaining role of primary surgery in the modern management of locally advanced laryngeal lesions is emphasized.
Summary A case of pleomorphic rhabdomyosarcoma of the larynx is presented, which is extremely rare in a laryngeal site. The symptomatology and macroscopic aspect of the neoplasm can simulate the presence of other neoplastic variants of the larynx, and, for this reason, histological examination must be associated with immunohistochemistry for correct diagnosis and treatment.
Pittore, B; Fancello, G; Cossu Rocca, P; Ledda, GP; Tore, G
The value of various radiographic methods (except laryngography) in laryngeal carcinoma was assessed in a material of 71 patients. Radiography proved of no value in T1 and T2 tumours if a satisfactory clinical examination could be performed but gave valuable information in recurrences as well as in T3 and T4 cases. PMID:1189963
Jorgensen, J; Jorgensen, K; Jensen, O M; Jensen, J T; Elbrond, O; Andersen, A P
nesthesiologists often select fiberoptic endotra- cheal intubation as part of the care of patients with difficult airways. An important goal in airway management is to prevent damage to laryngeal struc- tures. We report three patients who sustained airway injury during fiberoptic intubation, suggesting that this procedure may not be free of traumatic complications.
Mazen A. Maktabi; Henry Hoffman; Gery Funk
Lasers are a relatively recent addition to laryngeal surgery. Since their invention, laser use and applications have expanded rapidly. In this article, we discuss the benefits and disadvantages of lasers for different procedures, as well as ways to overcome commonly faced clinical problems. The use of lasers in surgery has offered a time- and cost-efficient alternative to cold surgical techniques, and has been used in the treatment of numerous laryngeal pathologies, including stenoses, recurrent respiratory papillomatosis, leukoplakia, nodules, malignant laryngeal disease, and polypoid degeneration (Reinke's edema). However, lasers can incur adjacent tissue damage and vocal fold scarring. These problems can be minimized through understanding the mechanisms by which lasers function and correctly manipulating the parameters under a surgeon's control. By varying fluence, power density, and pulsation, tissue damage can be decreased and lasers can be used with greater confidence. The various types of lasers and their applications to the treatment of specific pathologies are reviewed with the intention of helping surgeons select the best tool for a given procedure. Recent applications of lasers to treat benign laryngeal lesions and severe laryngomalacia demonstrate that additional research must be conducted to realize the full potential of this surgical tool. PMID:19487102
Yan, Yan; Olszewski, Aleksandra E; Hoffman, Matthew R; Zhuang, Peiyun; Ford, Charles N; Dailey, Seth H; Jiang, Jack J
Most of the literature on voice quality focuses on the vocal folds while six other gestures involving the laryngeal entry and epilaryngeal structures are largely ignored. Whole organ tracer series histograms of the larynx are examined and suggestions are made as to which muscles and\\/or forces might cause these gestures. An examination of photographs of the larynx indicates that the
Facial nerve paralysis is the most common mononeuropathy and idiopathic facial paralysis (Bell's palsy) the most common seventh nerve disease electromyographers may be asked to evaluate. The electrophysiologic method of choice to assess the facial nerve is side-to-side evoked amplitude comparison with the affected side expressed as a percentage of the nonaffected side. This examination should be performed on days 3, 5, 7, 9, 11 and 13 after onset of paralysis. If the percentage of surviving axons falls below 10% within the first 14 days, an incomplete recovery is suggested. Electromyography may assist in prognosticating a functional return, determining neural conduction across the site of injury and following reinervation in the recovery period. The persistence or early return of an absent R1 component of the blink reflex may qualitatively suggest a satisfactory functional outcome in facial paralysis. Supramaximally exciting the facial nerve at the stylomastoid foramen and comparing the clinical response on the affected and nonaffected side, maximum stimulation test, can also predict eventual seventh nerve return. Observing a minimal twitch, utilizing the nerve excitability test or measuring the facial nerve latency have yielded poor correlations with functional return and are of limited usefulness in the prognostication of acute facial palsies. Trigeminal somatosensory evoked potentials can be employed to evaluate the status of the trigeminal nerve as approximately 50% of patients with Bell's palsy also have lesions involving the fifth nerve. Side-to-side amplitude comparison and electromyography are the two most valuable electrophysiologic methods of assessing facial nerve functioning. PMID:3041998
Dumitru, D; Walsh, N E; Porter, L D
We present three cases of thyrotoxic periodic paralysis (TPP) due to painless thyroiditis presenting as acute quadriparesis. All responded to potassium supplementation and propranolol. TPP may be due to thyrotoxicosis of any etiology, commonly Grave's disease. The absence of clinical signs of thyrotoxicosis can delay diagnosis and treatment. Thyroid function tests should be a routine evaluation in all cases of hypokalemic periodic paralysis.
Sanyal, Debmalya; Raychaudhuri, Moutusi; Bhattacharjee, Shakya
Brain paralysis disease incidence rate reaches as high as 0.27% in our newborns. It has brought the serious attack to the general patient's family. It has said that dolphin human therapy is effective to cure brain paralysis. But it is too expensive to general patient family. In order to solve this problem, the ultrasonic synthetical instrument which is studied may
Chengwei Li; Jianrong Niu
Thyrotoxic hypokalemic periodic paralysis (THPP) is a complication of hyperthyroidism that is mostly diagnosed in Asian populations; consequently, it can be difficult to recognize in western populations. THPP represents an endocrine emergency that can result in respiratory insufficiency, cardiac arrhythmias, and death. Its differential diagnosis from the other more common forms of hypokalemic paralysis is important to avoid inappropriate therapy.
Arsenio Pompeo; Amleto Nepa; Maurizio Maddestra; Vincenzo Feliziani; Nicola Genovesi
Eleven patients with unilateral diaphragm paralysis of recent onset were studied to investigate the effect of the paralysis on inspiratory muscle function. Nine of the patients had noticed a decrease in exercise tolerance, which was not explained by any other pathological condition. Hemidiaphragm dysfunction was confirmed by the demonstration of a greatly reduced or absent transdiaphragmatic pressure on stimulation of
C M Laroche; A K Mier; J Moxham; M Green
ABSTRACTHypokalemic periodic paralysis is the most common form of periodic paralysis and is characterized by attacks of muscle paralysis associated with a low serum potassium (K+) level due to an acute intracellular shifting. Thyrotoxic periodic paralysis (TPP), characterized by the triad of muscle paralysis, acute hypokalemia, and hyperthyroidism, is one cause of hypokalemic periodic paralysis. The triggering of an attack of undiagnosed TPP by ?2-adrenergic bronchodilators has, to our knowledge, not been reported previously. We describe two young men who presented to the emergency department with the sudden onset of muscle paralysis after administration of inhaled ?2-adrenergic bronchodilators for asthma. In both cases, the physical examination revealed an enlarged thyroid gland and symmetrical flaccid paralysis with areflexia of lower extremities. Hypokalemia with low urine K+ excretion and normal blood acid-base status was found on laboratory testing, suggestive of an intracellular shift of K+, and the patients' muscle strength recovered at serum K+ concentrations of 3.0 and 3.3 mmol/L. One patient developed hyperkalemia after a total potassium chloride supplementation of 110 mmol. Thyroid function testing was diagnostic of primary hyperthyroidism due to Graves disease in both cases. These cases illustrate that ?2-adrenergic bronchodilators should be considered a potential precipitant of TPP. PMID:23816145
Yeh, Fu-Chiang; Chiang, Wen-Fang; Wang, Chih-Chiang; Lin, Shih-Hua
ABSTRACTHypokalemic periodic paralysis is the most common form of periodic paralysis and is characterized by attacks of muscle paralysis associated with a low serum potassium (K+) level due to an acute intracellular shifting. Thyrotoxic periodic paralysis (TPP), characterized by the triad of muscle paralysis, acute hypokalemia, and hyperthyroidism, is one cause of hypokalemic periodic paralysis. The triggering of an attack of undiagnosed TPP by ?2-adrenergic bronchodilators has, to our knowledge, not been reported previously. We describe two young men who presented to the emergency department with the sudden onset of muscle paralysis after administration of inhaled ?2-adrenergic bronchodilators for asthma. In both cases, the physical examination revealed an enlarged thyroid gland and symmetrical flaccid paralysis with areflexia of lower extremities. Hypokalemia with low urine K+ excretion and normal blood acid-base status was found on laboratory testing, suggestive of an intracellular shift of K+, and the patients' muscle strength recovered at serum K+ concentrations of 3.0 and 3.3 mmol/L. One patient developed hyperkalemia after a total potassium chloride supplementation of 110 mmol. Thyroid function testing was diagnostic of primary hyperthyroidism due to Graves disease in both cases. These cases illustrate that ?2-adrenergic bronchodilators should be considered a potential precipitant of TPP. PMID:24852589
Yeh, Fu-Chiang; Chiang, Wen-Fang; Wang, Chih-Chiang; Lin, Shih-Hua
Thyrotoxic periodic paralysis is a disease characterized by recurrent episodes of paralysis and hypokalemia during a thyrotoxic state. Thyrotoxic periodic paralysis is a common complication of hyperthyroidism in Asian populations, but can affect other ethnic groups as well. Due to population mobility, Thyrotoxic periodic paralysis is increasingly common in Western countries. Early diagnosis and prompt treatment of the thyrotoxic state and potassium supplementation prevent life-threatening complications associated with hypokalemia and muscle weakness. We present a young Turkish man who developed acute flaccid paralysis after receiving pulse prednisolone therapy for treatment of Pityriasis versicolor. His muscle strength and serum potassium fully recovered after potassium replacement and treatment of the thyrotoxic state which was a consequence of underlying Graves’ disease.
Elznerova, Tereza; Dietrich, Wenke; Schrauzer, Thomas; John, Stefan
...2009-01-01 false Disposition of thyroid glands and laryngeal muscle tissue...INSPECTION Â§ 310.15 Disposition of thyroid glands and laryngeal muscle tissue. (a) Livestock thyroid glands and laryngeal muscle tissue...
...2010-01-01 false Disposition of thyroid glands and laryngeal muscle tissue...INSPECTION Â§ 310.15 Disposition of thyroid glands and laryngeal muscle tissue. (a) Livestock thyroid glands and laryngeal muscle tissue...
A unilateral injection of botulinum toxin A (BTxA) in the calf induces paralysis and profound loss of ipsalateral trabecular bone within days. However, the cellular mechanism underlying acute muscle paralysis-induced bone loss (MPIBL) is poorly understood. We hypothesized that MPIBL arises via rapid and extensive osteoclastogenesis. We performed a series of in vivo experiments to explore this thesis. First, we observed elevated levels of the proosteoclastogenic cytokine receptor activator for nuclear factor-?B ligand (RANKL) within the proximal tibia metaphysis at 7 d after muscle paralysis (+113%, P<0.02). Accordingly, osteoclast numbers were increased 122% compared with the contralateral limb at 5 d after paralysis (P=0.04) and MPIBL was completely blocked by treatment with human recombinant osteoprotegerin (hrOPG). Further, conditional deletion of nuclear factor of activated T-cells c1 (NFATc1), the master regulator of osteoclastogenesis, completely inhibited trabecular bone loss (?2.2±11.9%, P<0.01). All experiments included negative control assessments of contralateral limbs and/or within-animal pre- and postintervention imaging. In summary, transient muscle paralysis induced acute RANKL-mediated osteoclastogenesis resulting in profound local bone resorption. Elucidation of the pathways that initiate osteoclastogenesis after paralysis may identify novel targets to inhibit bone loss and prevent fractures.—Aliprantis, A. O., Stolina, M., Kostenuik, P. J., Poliachik, S. L., Warner, S. E., Bain, S. D., Gross, T. S. Transient muscle paralysis degrades bone via rapid osteoclastogenesis.
Aliprantis, Antonios O.; Stolina, Marina; Kostenuik, Paul J.; Poliachik, Sandra L.; Warner, Sarah E.; Bain, Steven D.; Gross, Ted S.
Laryngeal papillomatosis is an uncommon respiratory disease. Often misdiagnosed, it can cause acute respiratory insufficiency, quickly fatal if not promptly faced. A case of sudden death due to laryngeal papillomatosis is described in a woman presenting to the Emergency Department (ED). Laryngeal obstruction was not diagnosed in previous medical examinations nor recognised at the time of attempted intubation in ED; only post-mortem investigation allowed discovering a large fleshy mass occluding the larynx in the region of the vocal folds. PMID:23622494
Ossoli, Andrea; Verzeletti, Andrea
Membrane potential changes and discharges from 28 laryngeal motoneurons were recorded intracellularly in the caudal nucleus\\u000a ambiguus of decerebrate, paralyzed and ventilated cats. Electrical activities were recorded from 17 expiratory laryngeal motoneurons\\u000a (ELMs) with maximal depolarizing membrane potential in early expiration, and from 11 inspiratory laryngeal motoneurons (ILMs)\\u000a with maximal depolarizing membrane potential in inspiration. Activities during breathing were compared
Christian Gestreau; Laurent Grélot; Armand Louis Bianchi
Myxomas are a rare benign neoplasm of uncertain mesenchymal cell origin, typically involving the heart. Laryngeal myxomas are uncommon, and are usually misdiagnosed as laryngeal polyp. To the best of our knowledge, there are only nine reported cases in the English literature. We report a case of a laryngeal myxoma presenting clinically as a left vocal cord polyp in a 77 year old male, and review the literature related to this rare entity. PMID:23975415
Ritchie, Angela; Youngerman, Jay; Fantasia, John E; Kahn, Leonard B; Cocker, Rubina S
Advances in the field of peripheral nerve surgery have increased our understanding of the complex cellular and molecular events involved in nerve injury and repair. Application of these important discoveries has led to important developments in the techniques of nerve repair, nerve grafting, nerve allografts, end-to-side repairs, and nerve-to-nerve transfers. As our understanding of this dynamic field increases, further improvement in functional outcomes after nerve injury and repair can be expected. PMID:12737353
Dvali, Linda; Mackinnon, Susan
The principles of management of the laryngeal cancer have evolved over the recent past with emphasis on organ preservation. These developments have paralleled technological advancements as well as refinement in the surgical technique. The surgeons are able to maintain physiological functions of larynx namely speech, respiration and swallowing without compromising the loco-regional control of cancer in comparison to the more radical treatment modalities. A large number of organ preservation surgeries are available to the surgeon; however, careful assessment of the stage of the cancer and selection of the patient is paramount to a successful outcome. A comprehensive review of various organ preservation techniques in vogue for the management of laryngeal cancer is presented.
Chawla, Sharad; Carney, Andrew Simon
Synopsis The author presents the clinical application of robotics to laryngeal surgery in terms of enhancement of surgical precision and performance of other minimally invasive procedures not feasible with current instrumentation. Presented in this article are comparisons of human arm with robotic arm in terms of degrees of freedom and discussion of surgeries and outcomes with use of the robotic arm. Robotic equipment for laryngeal surgery has the potential to overcome many of the limitations of endolaryngeal procedures by improving optics, increasing instrument degrees of freedom, and modulating tremor. Outside of laryngology, a multi-armed robotic system would have utility in microvascular procedures at the base of the skull, sinus surgery, and single port gastrointestinal and thoracic access surgery.
Hillel, Alexander T.; Kapoor, Ankur; Simaan, Nabil; Taylor, Russell H.; Flint, Paul
Some of the mechanisms involved in neoplastic transformation and progression of laryngeal squamous cell carcinoma (LSCC) are discussed. Although tumor suppressor inactivation of p53 and p16 is common in these tumors (about 50% each), oncogenic activation is less well characterized. Cyclin D1 and epidermal growth factor receptor amplification have been reported in one-third and one-quarter of LSCCs, respectively, both related
Alfons Nadal; Antonio Cardesa
The degree of impairment of ventilation and exercise performance after unilateral diaphragmatic paralysis (UDP) induced by phrenic nerve injury has been controversial due to heterogeneity in the published clinical studies. The aim of this study was to assess the effect of isolated UDP on breathing and exercise performance in conscious rats. Breathing was measured by unrestrained whole body plethysmography during quiet breathing and after moderate aerobic exercise. Additionally, incremental exercise testing was performed to evaluate the effects of intensive activity. The results demonstrated that complete UDP in rats resulted in a permanent decrease of peak inspiratory flow at rest breathing. Nevertheless, adequate ventilation could be maintained, and the breathing pattern was unaltered due to a strong compensatory mechanism and central re-coordination initiated by UDP. After being affected at an early stage, the ventilatory response to exercise was gradually regained and subsequently restored. PMID:24556382
Xu, Yali; Rui, Jing; Zhao, Xin; Xiao, Chengwei; Bao, Qiyuan; Li, Jifeng; Lao, Jie
The botulinum neurotoxins, characterized by their neuromuscular paralytic effects, are the most toxic proteins known to man. Due to their extreme potency, ease of production, and duration of activity, the BoNT proteins have been classified by the Centers for Disease Control as high threat agents for bioterrorism. In an attempt to discover effective BoNT therapeutics, we have pursued a strategy in which we leverage the blockade of K(+) channels that ultimately results in the reversal of neuromuscular paralysis. Towards this end, we utilized peptides derived from scorpion venom that are highly potent K(+) channel blockers. Herein, we report the synthesis of charybdotoxin, a 37 amino acid peptide, and detail its activity, along with iberiotoxin and margatoxin, in a mouse phrenic nerve hemidiaphragm assay in the absence and the presence of BoNT/A. PMID:24252544
Lowery, Colin A; Adler, Michael; Borrell, Andrew; Janda, Kim D
Paralysis of the facial nerve is a cause of considerable functional and aesthetic disfigurement. Damage to the upper trunk can result in eye complications with the risk of exposure keratitis. Numerous factors influence the therapeutic strategy: the cause of the injury, the time elapsed since injury, functional impairment, and the likelihood of recovery. We discuss the management of an acute injury to the facial nerve and focus on the surgical options. PMID:24090764
Colbert, Serryth; Coombes, Daryl; Godden, Daryl; Cascarini, Luke; Kerawala, Cyrus; Brennan, Peter A
This investigation details the results of a retrospective chart review of 35 patients with idiopathic vocal fold paralysis. Clinical findings at presentation, as well as patient outcomes in both the short and long-term duration are comprehensively reported. Spontaneous improvement of vocal fold function was observed in 25% of patients with long-term follow up. Of those with unilateral paralysis, 27% elected to undergo surgical intervention for improvement of symptoms. Four out of the five (80%) patients with bilateral paralysis required surgical intervention, including tracheotomy to relieve severe dyspnea and stridor. Discussions regarding possible underlying, occult etiologies of idiopathic vocal fold paralysis are presented, and suggested sequential behavioral and surgical treatment strategies are introduced. PMID:19411079
Dworkin, James Paul; Treadway, Corey
Acute flaccid paralysis can be caused by many members of the enterovirus genus, most notably the three poliviruses types 1 to 3. We report the case of acute flaccid paralysis caused by echovirus 19. The Western Pacific region has been declared polio free by the WHO since 2000. Australia is now using inactivated polio vaccine in the National Immunization Schedule. This vaccine does not carry the extremely rare risk of vaccine associated acute flaccid paralysis but it does leave our newly vaccinated population open gastrointestinal infection with polioviruses and the risk of circulation of the wild-type virus. Continued surveillance of cases of acute flaccid paralysis is to detect polioviruses is essential until poliovirus is completely eradicated. PMID:23252472
Kesson, Alison M; Choo, Chong Ming; Troedson, Christopher; Thorley, Bruce R; Roberts, Jason A
We explore the existence and underlying neural mechanism of a new norm endorsed by both black and white Americans for managing interracial interactions: “racial paralysis’, the tendency to opt out of decisions involving members of different races. We show that people are more willing to make choices—such as who is more intelligent, or who is more polite—between two white individuals (same-race decisions) than between a white and a black individual (cross-race decisions), a tendency which was evident more when judgments involved traits related to black stereotypes. We use functional magnetic resonance imaging to examine the mechanisms underlying racial paralysis, to examine the mechanisms underlying racial paralysis, revealing greater recruitment of brain regions implicated in socially appropriate behavior (ventromedial prefrontal cortex), conflict detection (anterior cingulate cortex), deliberative processing (dorsolateral prefrontal cortex), and inhibition (ventrolateral prefrontal cortex). We also discuss the impact of racial paralysis on the quality of interracial relations.
Mason, Malia F.; Vandello, Joseph A.; Biga, Andrew; Dyer, Rebecca
We explore the existence and underlying neural mechanism of a new norm endorsed by both black and white Americans for managing interracial interactions: "racial paralysis', the tendency to opt out of decisions involving members of different races. We show that people are more willing to make choices--such as who is more intelligent, or who is more polite-between two white individuals (same-race decisions) than between a white and a black individual (cross-race decisions), a tendency which was evident more when judgments involved traits related to black stereotypes. We use functional magnetic resonance imaging to examine the mechanisms underlying racial paralysis, to examine the mechanisms underlying racial paralysis, revealing greater recruitment of brain regions implicated in socially appropriate behavior (ventromedial prefrontal cortex), conflict detection (anterior cingulate cortex), deliberative processing (dorsolateral prefrontal cortex), and inhibition (ventrolateral prefrontal cortex). We also discuss the impact of racial paralysis on the quality of interracial relations. PMID:22267521
Norton, Michael I; Mason, Malia F; Vandello, Joseph A; Biga, Andrew; Dyer, Rebecca
Squamous cell laryngeal carcinoma accounts for 1% of all cancer deaths and 95% of all laryngeal malignancies. It is most frequently found in smokers over 40 years of age. This neoplasm is presently the object of cytogenetic studies in an attempt to identify a specific chromosome pattern. In a study of 29 cases of malignant primary laryngeal tumor, Nawroz (1993) found a loss of alleles in different loci mapped in the short arm of chromosome 9 (9p) in more than two-thirds of the cases. In the same chromosome region, the loss of heterozygotes (LOH) was previously described in other neoplasms (leukemia, hematic tumors, melanomas). In an attempt to verify the predominant chromosome pattern and the loss of heterozygotes in chromosome 9, a cytogenetic, genetic-molecular study was performed on ten cases of laryngeal carcinoma. Among these subjects, two showed a hyperdiploid chromosome pattern (metaphase with more than 46 chromosomes per cell), five had a hypodiploid pattern (with less than 46 chromosomes per cell) while, for the remaining three cases, it was not possible to identify any metaphase. Numerous structural and numerical karyotype defects were found in chromosomes 1, 3, 4, 5, 9, 10, 13, 14, 16, 18, and Y. In 6 of the cases abnormality was found in chromosome 9 while in 10 it was apparently a homozygote. The study was performed with the use of fluorescent in situ hybridization (FISH) using a chromosome library specific for chromosome 9. A loss of the 9p segment could be found as a result of different types of alterations: deletion (case 1, 2, 5, 7); non uniform transfer between chromosome 2 and chromosome 9 (case 2); other transfers involving the 9p segment (case 1, 4, 5, 7, 10). In six cases, analysis was further detailed at the molecular level by means of DNA amplification methods (PCR) and electrophoresis on denatured 10% polyacrylammide gels. LOH was studied using a polymorphic system specific for the short arm of chromosome 9. Four of the cases examined showed LOH for the system used while one case (case 4) gave no information. Case 9 did not show any loss of alleles. The present study suggests that the loss of a DNA sequence on chromosome 9p is primary to the neoplastic progression in laryngeal cancer. PMID:9549121
Brunelli, M; Baroli, P; Bianchi, B
We present three cases of thyrotoxic periodic paralysis (TPP) due to painless thyroiditis presenting as acute quadriparesis. All responded to potassium supplementation and propranolol. TPP may be due to thyrotoxicosis of any etiology, commonly Grave's disease. The absence of clinical signs of thyrotoxicosis can delay diagnosis and treatment. Thyroid function tests should be a routine evaluation in all cases of hypokalemic periodic paralysis. PMID:24251144
Sanyal, Debmalya; Raychaudhuri, Moutusi; Bhattacharjee, Shakya
Objective Human enteroviruses are the major cause of aseptic meningitis and also cause a wide range of other acute illnesses, including\\u000a neonatal sepsis like disease, meningitis, acute flaccid paralysis and acute hemorrhagic conjunctivitis. Infection in neonates\\u000a is particularly life threatening.Methods : Stool samples of 523 children (age < 4 years) showing symptoms of acute flaccid paralysis (AFP) were studied. National
Amit Kapoor; A. Ayyagari; T. N. Dhole
Bilateral vocal-cord paralysis usually causes dyspnoea with inspiratory stridor. Most patients have a fairly satisfactory voice. The purpose of this paper is to present the results of a series of 24 patients with bilateral vocal-cord paralysis treated by CO2 laser cordectomy during 1978–86. Breathing improved in 19 patients. In most of the patients, however, the voice worsened. If further surgery
Adriaan F. Holm; Bert Wouters; Jos J. M. Van Overbeek
Background The surgical management of obstetrical brachial plexus palsy can generally be divided into two groups; early reconstructions in which the plexus or affected nerves are addressed and late or palliative reconstructions in which the residual deformities are addressed. Tendon transfers are the mainstay of palliative surgery. Occasionally, surgeons are required to utilise already denervated and subsequently reinnervated muscles as motors. This study aimed to compare the outcomes of tendon transfers for residual shoulder dysfunction in patients who had undergone early nerve surgery to the outcomes in patients who had not. Methods A total of 91 patients with obstetric paralysis-related shoulder abduction and external rotation deficits who underwent a modified Hoffer transfer of the latissimus dorsi/teres major to the greater tubercle of the humerus tendon between 2002 and 2009 were retrospectively analysed. The patients who had undergone neural surgery during infancy were compared to those who had not in terms of their preoperative and postoperative shoulder abduction and external rotation active ranges of motion. Results In the early surgery groups, only the postoperative external rotation angles showed statistically significant differences (25 degrees and 75 degrees for total and upper type palsies, respectively). Within the palliative surgery-only groups, there were no significant differences between the preoperative and postoperative abduction and external rotation angles. The significant differences between the early surgery groups and the palliative surgery groups with total palsy during the preoperative period diminished postoperatively (p < 0.05 and p > 0.05, respectively) for abduction but not for external rotation. Within the upper type palsy groups, there were no significant differences between the preoperative and postoperative abduction and external rotation angles. Conclusions In this study, it was found that in patients with total paralysis, satisfactory shoulder abduction values can be achieved with tendon transfers regardless of a previous history of neural surgery even if the preoperative values differ.
Neurotherapeutic or neuroprotective effects of gonadal steroids on the injured nervous system have been demonstrated in our laboratory and others. We have previously demonstrated that testosterone propionate (TP) administered systemically at supraphysiological levels accelerates both recovery from facial paralysis and regeneration rates following facial nerve injury in the hamster. Initial temporal studies of steroidal enhancement of functional recovery from facial
Lisa Tanzer; Kathryn J Jones
Vagal nerve stimulation (VNS) is a recognised and effective measure in treating refractory epilepsy and depression. VNS implantation is a widely accepted surgical procedure, most commonly performed by neurosurgeons. Otolaryngologists, in particular those with an interest in head and neck surgery, are very familiar with the surgical anatomy and dissection of the vagus nerve in the carotid sheath. We present a retrospective analysis of the first 12 patients to be implanted in our department. Our series suggests that otolaryngologists can safely and effectively perform VNS implantation. Otolaryngologists can assess and treat the most common post-operative complication of dysphonia and help the neurologist set the correct level of stimulation in such a way as to minimise laryngeal complications. PMID:19083010
Pratap, R; Farboud, A; Patel, H; Montgomery, P
Speech production is one of the most complex and rapid motor behaviors and involves a precise coordination of over 100 laryngeal, orofacial and respiratory muscles. Yet, we lack a complete understanding of laryngeal motor cortical control during production of speech and other voluntary laryngeal behaviors. In recent years, a number of studies have confirmed the laryngeal motor cortical representation in humans and provided some information about its interactions with other cortical and subcortical regions that are principally involved in vocal motor control of speech production. In this review, we discuss the organization of the peripheral and central laryngeal control based on neuroimaging and electrical stimulation studies in humans and neuroanatomical tracing studies in non-human primates. We hypothesize that the location of the laryngeal motor cortex in the primary motor cortex and its direct connections with the brainstem laryngeal motoneurons in humans, as oppose to its location in the premotor cortex with only indirect connections to the laryngeal motoneurons in non-human primates, may represent one of the major evolutionary developments in humans towards the ability to speak and vocalize voluntarily.
Simonyan, Kristina; Horwitz, Barry
Klebsiella pneumoniae subsp. ozaenae was isolated from the pharynx of a woman with laryngeal scleroma. K. pneumoniae subsp. ozaenae is rarely isolated from clinical infections and has never been reported in laryngeal scleroma, which is usually caused by K. pneumoniae subsp. rhinoscleromatis.
De Champs, C.; Vellin, J. F.; Diancourt, L.; Brisse, S.; Kemeny, J. L.; Gilain, L.; Mom, T.
Despite considerable growth in the field of brain-computer or brain-machine interface (BCI/BMI) research reflected in several hundred publications each year, little progress was made to enable patients in complete locked-in state (CLIS) to reliably communicate using their brain activity. Independent of the invasiveness of the BCI systems tested, no sustained direct brain control and communication was demonstrated in a patient in CLIS so far. This suggested a more fundamental theoretical problem of learning and attention in brain communication with BCI/BMI, formulated in the extinction-of-thought hypothesis. While operant conditioning and goal-directed thinking seems impaired in complete paralysis, classical conditioning of brain responses might represent the only alternative. First experimental studies in CLIS using semantic conditioning support this assumption. Evidence that quality-of-life in locked-in-state is not as limited and poor as generally believed draise doubts that "patient wills" or "advanced directives"signed long-before the locked-in-state are useful. On the contrary, they might be used as an excuse to shorten anticipated long periods of care for these patients avoiding associated financial and social burdens. Current state and availability of BCI/BMI systems urge a broader societal discourse on the pressing ethical challenges associated with the advancements in neurotechnology and BCI/BMI research. PMID:23536247
Birbaumer, Niels; Gallegos-Ayala, Guillermo; Wildgruber, Moritz; Silvoni, Stefano; Soekadar, Surjo R
In a 19 yr old male with familial hyperkalemic periodic paralysis, paralysis was consistently induced by the administration of potassium chloride, corticotropin-gel, and a variety of glucocorticoids (dexamethasone, 6-methylprednisolone, triamcinolone) but not by mineralocorticoids (D-aldosterone, deoxycorticosterone) or by adrenocorticotropin (ACTH)-gel plus metyrapone. Induced attacks were virtually identical with spontaneous attacks, being associated, after a latent period of a few hours, with a rise in plasma K+ and HCO3- and a simultaneous fall in plasma Na+ and Cl- concentrations to an extent implying exchange of 1 K+ with 2 Na+ and 2 Cl- between extracellular and intracellular fluid. ACTH-induced paralysis was preceded by rising serum inorganic P, and associated with increased plasma glucose, blood lactate, and serum creatine phosphokinase concentrations. In normal subjects ACTH, cortisol, and triamcinolone administration failed to change plasma electrolytes or strength, while ingestion of KCl produced no weakness and smaller changes in plasma K and Na than in the patient. Since the patient and normal subjects showed the same changes in renal excretion of K after the administration of cortisol and KCl, it seems likely that paralysis in the patient resulted from abnormally slow uptake (and/or excessive loss) of K by the muscle cells, possibly caused by an abnormal “ion-exchange pump.” Normal adrenocortical function and absence of a peak in plasma 11-hydroxycorticoid (11-OHCS) concentration preceding spontaneous paralysis, indicated that spontaneous paralysis did not result from changes in cortisol secretion. Similar hyperkalemic paralysis was precipitated by ACTH-gel in a brother and first cousin of the propositus. Administration of acetazolamide and fludrocortisone reduced the rise in plasma K concentration and prevented the weakness which otherwise invariably followed KCl administration to the patient. He and two close relatives have been completely protected from severe attacks of paralysis in the past 14 months by treatment with these two medications.
Streeten, David H. P.; Dalakos, Theodore G.; Fellerman, Herbert
Introduction Spontaneous radial palsy is a not rare finding in hand clinics. The anatomy of the radial nerve renders it prone to pressure paralysis as often called “Saturday night palsy”. This problem is a transient nerve lesion and an acute one but the case presented here is very unusual in that it seems this entity can also occur as an acute on chronic situation with neuroma formation. Case Presentation A 61 year-old man presented with the chief complaint of inability to extend the wrist and the fingers of the left hand which began suddenly the night before admission, following a three-week history of pain, numbness and tingling sensation of the affected extremity. He had no history of trauma to the extremity. Electromyography revealed a severe conductive defect of the left radial nerve with significant axonal loss at the upper arm. Surgical exploration identified a neuroma of the radial nerve measuring 1.5 cm in length as the cause of the paralysis. The neuroma was removed and an end-to-end nerve coaption was performed. Conclusions Complete recovery of the hand and finger extension was achieved in nine months.
Ebrahimpour, Adel; Nazerani, Shahram; Tavakoli Darestani, Reza; Khani, Salim
Acute bee paralysis virus (ABPV), Kashmir bee virus (KBV) and Israeli acute paralysis virus (IAPV) are part of a complex of closely related viruses from the Family Dicistroviridae. These viruses have a widespread prevalence in honey bee (Apis mellifera) colonies and a predominantly sub-clinical etiology that contrasts sharply with the extremely virulent pathology encountered at elevated titres, either artificially induced or encountered naturally. These viruses are frequently implicated in honey bee colony losses, especially when the colonies are infested with the parasitic mite Varroa destructor. Here we review the historical and recent literature of this virus complex, covering history and origins; the geographic, host and tissue distribution; pathology and transmission; genetics and variation; diagnostics, and discuss these within the context of the molecular and biological similarities and differences between the viruses. We also briefly discuss three recent developments relating specifically to IAPV, concerning its association with Colony Collapse Disorder, treatment of IAPV infection with siRNA and possible honey bee resistance to IAPV. PMID:19909972
de Miranda, Joachim R; Cordoni, Guido; Budge, Giles
Background The ability of cancer to infiltrate along nerves is a common clinical observation in pancreas, head and neck, prostate, breast, and gastrointestinal carcinomas. For these tumors, nerves may provide a conduit for local cancer progression into the central nervous system. Although neural invasion is associated with poor outcome, the mechanism that triggers it is unknown. Methods We used an in vitro Matrigel dorsal root ganglion and pancreatic cancer cell coculture model to assess the dynamic interactions between nerves and cancer cell migration and the role of glial cell-derived neurotrophic factor (GDNF). An in vivo murine sciatic nerve model was used to study how nerve invasion affects sciatic nerve function. Results Nerves induced a polarized neurotrophic migration of cancer cells (PNMCs) along their axons, which was more efficient than in the absence of nerves (migration distance: mean?=?187.1 ?m, 95% confidence interval [CI]?=?148 to 226 ?m vs 14.4 ?m, 95% CI = 9.58 to 19.22 ?m, difference = 143 ?m; P < .001; n = 20). PNMC was induced by secretion of GDNF, via phosphorylation of the RET-Ras–mitogen-activated protein kinase pathway. Nerves from mice deficient in GDNF had reduced ability to attract cancer cells (nerve invasion index: wild type vs gdnf+/?, mean = 0.76, 95% CI = 0.75 to 0.77 vs 0.43, 95% CI = 0.42 to 0.44; P < .001; n = 60–66). Tumor specimens excised from patients with neuroinvasive pancreatic carcinoma had higher expression of the GDNF receptors RET and GRF?1 as compared with normal tissue. Finally, systemic therapy with pyrazolopyrimidine-1, a tyrosine kinase inhibitor targeting the RET pathway, suppressed nerve invasion toward the spinal cord and prevented paralysis in mice. Conclusion These data provide evidence for paracrine regulation of pancreatic cancer invasion by nerves, which may have important implications for potential therapy directed against nerve invasion by cancer.
Cavel, Oren; Kelly, Kaitlyn; Brader, Peter; Rein, Avigail; Gao, Sizhi P.; Carlson, Diane L.; Shah, Jatin P.; Fong, Yuman
The diagnosis and treatment of petrous bone cholesteatoma is a challenge to aural surgeons. Seven patients with extensive petrous bone cholesteatomas which invaded the labyrinth and fallopian canal are presented. These cholesteatomas originated as secondary to acquired lesions. The cases were evaluated according to the clinical features, the intraoperative findings, the radiological findings, and the surgical approaches. In this series, six patients presented with facial paralysis associated with profound or total deafness. The transtemporal lateral approach was used in all the cases. Acute facial nerve palsy or facial nerve pareses progressing to palsy in patients with chronic ear disease should be studied radiographically for petrous bone cholesteatoma, even if there is no physical evidence of cholesteatoma. PMID:8031580
INTRODUCTION This is a retrospective case series analysis to compare the incidence of cranial nerve injuries in carotid endarterectomy by the retrojugular and anteromedial approaches. PATIENTS AND METHODS Data were extracted from a prospectively collected database. Ninety-one retrojugular carotid endarterectomies were compared with 145 anteromedial carotid endarterectomies. All were performed under local anaesthesia and used the eversion technique. Data were analysed using the chi-squared test. RESULTS Nine (3.8%) cases were complicated by cranial nerve injuries. In four cases, multiple nerves were involved. In total, 13 (5.5%) cranial nerves were injured. The affected nerves were: two (0.8%) marginal mandibular, two (0.8%) laryngeal, three (1.2%) accessory and six (2.5%) hypoglossal. There was no statistically significant difference in total or specific cranial nerve injuries between the two surgical approaches. CONCLUSIONS The risk of cranial nerve injuries was similar following either the retrojugular or anteromedial approach. Accessory nerve injuries were only seen in the retrojugular approach but this did not reach statistical significance.
Beasley, William D; Gibbons, Christopher P
Esophageal involvement is an extremely rare complication of tuberculosis even in countries with high prevalence of infection. We report the case of a 57 year-old hiv-seronegative patient with simultaneous diagnoses of oral blastomycosis and laryngeal papillomatosis. Both were confirmed by anatomopathological analysis. The esophageal biopsy revealed granulomatous esophagitis with necrosis and ziehl-neelsen stain showed acid-fast alcohol resistant bacilli suggestive of tuberculosis. The patient's history included pulmonary tuberculosis twice and previous abandonment of therapy. Thus, it was necessary to use oral itraconazole combined with second-line anti-tuberculosis drugs administered through a gastrostomy tube. The clinical development was favorable. PMID:22858774
Montoya, Manuel; Chumbiraico, Robert; Ricalde, Melvin; Cazorla, Ernesto; Hernández-Córdova, Gustavo
Olfactory ensheathing cells (OECs) represent an interesting candidate for cell therapy and could be obtained from olfactory mucosa (OM-OECs) or olfactory bulbs (OB-OECs). Recent reports suggest that, depending on their origin, OECs display different functional properties. We show here the complementary and additive effects of co-transplanting OM-OECs and OB-OECs after lesion of a peripheral nerve. For this, a selective motor denervation of the laryngeal muscles was performed by a section/anastomosis of the recurrent laryngeal nerve (RLN). Two months after surgery, recovery of the laryngeal movements and synkinesis phenonema were analyzed by videolaryngoscopy. To complete these assessments, measure of latency and potential duration were determined by electrophysiological recordings and myelinated nerve fiber profiles were defined based on toluidine blue staining. To explain some of the mechanisms involved, tracking of GFP positive OECs was performed. It appears that transplantation of OM-OECs or OB-OECs displayed opposite abilities to improve functional recovery. Indeed, OM-OECs increased recuperation of laryngeal muscles activities without appropriate functional recovery. In contrast, OB-OECs induced some functional recovery by enhancing axonal regrowth. Importantly, co-transplantation of OM-OECs and OB-OECs supported a major functional recovery, with reduction of synkinesis phenomena. This study is the first which clearly demonstrates the complementary and additive properties of OECs obtained from olfactory mucosa and olfactory bulb to improve functional recovery after transplantation in a nerve lesion model.
Bon-Mardion, Nicolas; Duclos, Celia; Genty, Damien; Jean, Laetitia; Boyer, Olivier; Marie, Jean-Paul
Hypokalemic Periodic Paralysis is one form of Periodic Paralysis, a rare group of disorders that can cause of sudden onset weakness. A case of a 29 year old male is presented here. The patient presented with sudden onset paralysis of his extremities. Laboratory evaluation revealed a markedly low potassium level. The patient's paralysis resolved upon repletion of his low potassium and he was discharged with no neurologic deficits. An association with thyroid disease is well established and further workup revealed Grave's disease in this patient. Although rare, Periodic Paralysis must differentiated from other causes of weakness and paralysis so that the proper treatment can be initiated quickly.
Soule, Benjamin R; Simone, Nicole L
Voice disorders can have major impact on quality of life. Problems caused by these disorders can be experienced in different domains. The Voice Handicap Index (VHI) is a well-known voice-related quality of life instrument to measure physical, emotional and functional complaints. VHI change after treatment in seven separate benign laryngeal disorders was studied. In addition, correlation between the three domains was examined. VHI forms were completed before and 3 months after treatment. In a 5-year-period, 143 patients with seven specific diagnoses were retrospectively included. VHI improved for six diagnoses polyp (p < 0.000), cyst (p = 0.001), unilateral paralysis (p = 0.001), Reinke edema (p = 0.016), papillomatosis (p = 0.001), nodules (p = 0.002). Sulcus glottidis did not change (p = 0.897). Mean VHI after treatment was higher for females (p = 0.021). The values of the three domains correlate statistically significant. For each diagnosis, the mean VHI after treatment remained higher than in subjects with a healthy voice. Because the domains are interdependent, their absolute values could not be compared. After treatment, VHI improved in six of the seven diagnoses. The scores on the physical, emotional, and functional domain are interdependent. Scores of the different domains cannot be compared. PMID:24141520
Stuut, Marijn; Tjon Pian Gi, Robin E A; Dikkers, Frederik G
Thyrotoxic hypokalemic periodic paralysis has been described to occur quite frequently in male Asiatic patients. The syndrome is, however, very rare in patients of Caucasian origin. To our knowledge it has never been described in Austria so far. This is the reason why we present the following case: A 22-year old male patient of Kurdish origin suffered from two periods of typical flaccid paralysis of the extremities after strenuous physical exertion, that were 4 months apart. The periods of paralysis were quickly reversed by substitution with potassium. Graves' disease was retrospectively diagnosed to have existed already during the first period. The patient was treated with an ablative dose of 131-I (25 mCi) and can perform strenuous exercise without symptoms since. This case and the review of the literature clearly illustrates the advantage of screening for thyroid dysfunction in patients with flaccid paralysis: unnecessary further periods of paralysis can be avoided by the correct treatment of thyrotoxicosis in such patients. PMID:9816404
Gamper, G; Stulnig, T; Weissel, M
Gastroesophageal reflux disease (GERD) is a common medical condition affecting approximately 35-40% of the adult population in the western world. Chronic laryngeal signs and symptoms associated with GERD are often referred to as reflux laryngitis or laryngopharyngeal reflux (LPR). It is estimated that up to 15% of all visits to the otolaryngology offices are because of manifestations of LPR. Injury may occur as a result of one or chronic reflux of gastroduodenal contents directly injuring the laryngeal mucosa. Since less amount of acid is required to make the injury to the larynx as compared to injury to esophagus; it is believed that intermittent exposure to small amount of gastric content can result in laryngitis. The most common presenting symptoms of LPR include hoarseness, sore throat, throat clearing, and chronic cough. The diagnosis of LPR is usually made on the basis of presenting symptoms and associated laryngeal signs including laryngeal edema and erythema. Current recommendation for management of this group of patients is empiric therapy with twice daily proton-pump inhibitors for 2 to 4 months. In majority of those who are unresponsive to such therapy other causes of laryngeal irritation is considered. Surgical fundoplication is most effective in those who are responsive to acid suppressive therapy. PMID:17557046
Farrokhi, F; Vaezi, M F
Objective. Not fully understanding the type of axons activated during vagus nerve stimulation (VNS) is one of several factors that limit the clinical efficacy of VNS therapies. The main goal of this study was to characterize the electrical recruitment of both myelinated and unmyelinated fibers within the cervical vagus nerve. Approach. In anesthetized dogs, recording nerve cuff electrodes were implanted on the vagus nerve following surgical excision of the epineurium. Both the vagal electroneurogram (ENG) and laryngeal muscle activity were recorded in response to stimulation of the right vagus nerve. Main results. Desheathing the nerve significantly increased the signal-to-noise ratio of the ENG by 1.2 to 9.9 dB, depending on the nerve fiber type. Repeated VNS following nerve transection or neuromuscular block (1) enabled the characterization of A-fibers, two sub-types of B-fibers, and unmyelinated C-fibers, (2) confirmed the absence of stimulation-evoked reflex compound nerve action potentials in both the ipsilateral and contralateral vagus nerves, and (3) provided evidence of stimulus spillover into muscle tissue surrounding the stimulating electrode. Significance. Given the anatomical similarities between the canine and human vagus nerves, the results of this study provide a template for better understanding the nerve fiber recruitment patterns associated with VNS therapies.
Yoo, Paul B.; Lubock, Nathan B.; Hincapie, Juan G.; Ruble, Stephen B.; Hamann, Jason J.; Grill, Warren M.
In order to find out the genes involved in the tumorigenesis of laryngeal carcinoma, we analyzed 18 laryngeal carcinoma with comparative genomic hybridization. Results show that each one has different degree of variances, included gains and losses of partial and whole chromosome. Each case has 12.9 abnormal regions averagely; losses are more than gains, equal to 7.2 and 5.7 per case respectively. Main regions are gains in chromosomes 3q (78%), 5p (61%), 11q (56%), 1q (50%), 8p (44%), 8q (39%) and 15q (39%), and losses of 3p (70%), 5q (78%), 9p (67%), 13q (50%), 1p (44%) and 14q (39%). There are many specific gains and losses in several chromosomes,especially the increase of copy number karyotype in 1p13-21(8/18), 3p21-23 (14/18), 5p21-22 (14/18), 9p12-pter (10/18) and 13q21-31 (8/18), while the decrease in 1q11-21 (11/18), 3q15-21 (12/18), 8p22-24 (6/18), 11q12-13 (8/18), 15q21-23 (7/18), 18p11 (8/18) are the characteristic varieties. These results suggest that there are oncogene, tumor suppressor gene and other associated genes involved in the tumorigenesis. PMID:15490869
Shang, Chao; Fu, Wei-Neng; Xu, Zhen-Ming; Li, Fu-Cai; Huang, Dai-Fa; Sun, Kai-Lai
Diet and other risk factors for cancer of the larynx were examined in a case-control study among white males in Western New York, conducted in 1975-1985. Incident, pathologically-confirmed cases and age- and neighborhood-matched controls were interviewed to determine usual diet, and lifetime use of tobacco and alcohol. Because response rates were low for both cases and controls, this cannot be considered a population-based study. A strong association of risk with cigarette but not pipe and cigar smoking was found. Beer and hard liquor but not wine were associated with increased risk. After control for cigarettes, alcohol and education, the upper quartile odds ratio for fat was 2.40, while the odds ratio for high intake of carotenoids was 0.51. There was effect modification by smoking. Carotenoids were most negatively associated with risk among lighter smokers; dietary fat was most positively associated with risk among heavier smokers. Total calories, protein, and retinol were associated with increased risk; there was no relationship between laryngeal cancer and vitamins C and E or carbohydrate. This study again demonstrates the strong association between tobacco and alcohol and laryngeal cancer and also suggests that diets low in carotenoids and high fat may increase risk.
Freudenheim, J.L.; Graham, S.; Byers, T.E.; Marshall, J.R.; Haughey, B.P.; Swanson, M.K.; Wilkinson, G. (State Univ. of New York, Buffalo (United States))
Stroke is the most common neurological disease in adults that is associated with deglutition disorders. The presence of laryngeal sensitivity is very important in developing safe swallowing without risk of pulmonary complications. The aim of this study was to correlate laryngeal sensitivity with laryngeal penetration and tracheal aspiration after swallows of three food consistencies (puree, thickened liquid, and liquid) in poststroke individuals in the late phase. A cross-sectional clinical study was performed with 91 post-ischemic stroke individuals, with oropharyngeal dysphagia, who were in rehabilitation center treatment from 2009 to 2011. They had a mean age of 68.1 years and average time since injury was 22.6 months; 39 had injury to the right hemisphere and 52 had injury to the left hemisphere. All underwent fiberoptic endoscopic evaluation of swallowing and evaluation of laryngeal sensitivity by touching the tip of the endoscope to the arytenoids and aryepiglottic folds. The linear correlation coefficient of Spearman was applied to evaluate the correlation between laryngeal penetration and tracheal aspiration and the presence/absence of laryngeal sensitivity. There was a negative correlation between the observation of penetration and tracheal aspiration and laryngeal sensitivity, with all bolus consistencies (p < 0.001 for aspiration and p ? 0.01 for penetration). The absence of laryngeal sensitivity determines the more frequent findings of penetration and tracheal aspiration. This sensory stimulus in the mucosa of the pharynx and larynx is an essential element for safe swallowing and its deficiency associated with altered motor activity can cause laryngeal penetration and aspiration in poststroke individuals regardless of food consistency. PMID:24442645
Onofri, Suely Mayumi Motonaga; Cola, Paula Cristina; Berti, Larissa Cristina; da Silva, Roberta Gonçalves; Dantas, Roberto Oliveira
After thyroidectomy, the anesthesiologist usually performs a laryngoscopy to detect laryngeal edema and nerve palsies. The goal of this study was to compare three different methods of laryngeal examination after tracheal extubation of the patients. For that purpose, between 1990 and 1995, a prospective series of 1608 patients operated for thyroidectomy has been studied. The series was divided into 4 groups. In group I (n = 200), four anesthesiologists have evaluated the efficiency of the immediate postextubation direct laryngoscopy. In group II (n = 100), one anesthesiologist has compared the direct, indirect, and flexible laryngoscopies in every patient in a fixed and timed fashion. In group III (n = 100), the four examiners have evaluated the flexible laryngoscopy at a different timing so as to eliminate the possible temporal relationship of the ease of visualization in group II. In group IV (n = 1208), the four examiners have evaluated flexible laryngoscopy, on a large scale, at any time during the 1-h stay in the recovery room. Special attention was directed to the patients with known cardiovascular diseases. Direct and indirect laryngoscopies were only effective in 76 and 73%, respectively, of the patients, whereas flexible laryngoscopy was effective in 99.6% of them. Flexible laryngoscopy was easy to perform in 96.5% of the patients versus 65 and 55% with direct and indirect laryngoscopies. Finally, variations in monitored cardiovascular parameters were significantly lower with flexible and indirect laryngoscopies than with direct laryngoscopy. These mild variations induced by flexible laryngoscopy were well tolerated by patients with known cardiovascular diseases. Flexible laryngoscopy is the best method for an immediate laryngoscopic examination after thyroidectomy. PMID:8777379
Lacoste, L; Karayan, J; Lehuedé, M S; Thomas, D; Goudou-Sinha, M; Ingrand, P; Barbier, J; Fusciardi, J
Many articles and anatomy textbooks accurately describe the anatomy and anatomical variations of the marginal mandibular branch of the facial nerve (VII). This is not, however, true for the cervical branch, damage to which results in paralysis of the platysma and, because of its insertions at the lower lip and labial commissure, in disfigurement, especially when smiling. This may be mistaken for paralysis of the marginal mandibular branch of the facial nerve. Precise anatomical description of the cervical branch of the facial nerve allows certain technical safeguards to be determined which, if adhered to, should reduce the risk of injury, especially during surgical excision of the submandibular gland on a transcervical approach. PMID:24139074
Righini, C A; Petrossi, J; Reyt, E; Atallah, I
The phenomena involved in paradoxical upper lid retraction have been observed during recovery from paralysis of the third cranial nerve (CN). One of these phenomena is pseudo-Graefe's sign or Fuch's sign, which is characterized by elevation or retraction of the upper eyelid when the eye is looking downwards and inwards. This synkinesis is caused by an aberrant regeneration of newly formed axons of the third CN that subsequently reach muscles not originally connected with them. Pseudo-Graefe's sign may occur after congenital or acquired diseases. Acquired forms occur more frequently and result from paralysis of the third CN following various intracranial diseases: aneurysms, traumas and tumors. PMID:8444362
Martorina, M; Porté, E
Thyrotoxic hypokalemic periodic paralysis (THPP) is a complication of hyperthyroidism that is mostly diagnosed in Asian populations; consequently, it can be difficult to recognize in western populations. THPP represents an endocrine emergency that can result in respiratory insufficiency, cardiac arrhythmias, and death. Its differential diagnosis from the other more common forms of hypokalemic paralysis is important to avoid inappropriate therapy. Here, we discuss the main pathogenetic hypotheses, clinical features, and therapies of this disease. We also report an example of THPP management in our primary care unit. PMID:17693226
Pompeo, Arsenio; Nepa, Amleto; Maddestra, Maurizio; Feliziani, Vincenzo; Genovesi, Nicola
A wide variety of neurological manifestations are known in patients with diabetes mellitus. We describe a 40-year-old man who presented with hypokalemic paralysis. On evaluation, we found that the cause of the hypokalemia was osmotic diuresis induced by marked hyperglycemia due to undiagnosed diabetes mellitus. The patient had an uneventful recovery with potassium replacement, followed by glycemic control with insulin. Barring a few instances of symptomatic hypokalemia in the setting of diabetic emergencies, to our knowledge uncomplicated hyperglycemia has not been reported to result in hypokalemic paralysis. PMID:24472241
Vishnu, Venugopalan Y; Kattadimmal, Anoop; Rao, Suparna A; Kadhiravan, Tamilarasu
We report two cases of maternal obstetrical paralysis by injuries to the sacral plexus (lumbosacral trunk). This nervous lesion is rare and occurs more often in young small primigravidae, carrying a large fetus, during a prolonged labor and a delivery requiring midforceps. The symptoms appear usually a few hours after delivery: paresthesias of the leg and the foot as well as weakness and possible footdrop (the paralysis may be mild or severe). The different mechanisms involved are inspected. The prognosis of this lesion is good, the patients recover usually within a period of three months. The treatment appears to be physiotherapy. PMID:9026518
Graesslin, O; Elaerts, M; Palot, M; Bednarczyk, L; Quereux, C
There are many causes for the paralysis of the external sciatic popliteal nerve , such as the intraneural ganglion cyst. In this case, we evaluate a 52-year-old woman with no relevant personal record, who was admitted with paresis of the right foot of 4?months of evolution associated with alterations in the sensitivity that rose up to the posterolateral region of the leg. The diagnosis was based on MR and cyst decompression and disconnection of the articular branch. Given the low incidence of these lesions, their origin is still subject to controversy. The most widely accepted theory is the unifying articular theory described by Spinner in the year 2003. Intraneural ganglion cysts must be included in the differential diagnosis of progressive paralysis of the sciatic nerve, lesions of the nerve root at L5 and nerve sheath tumours that start at the lateral compartment of the knee. The treatment of a fibular intraneural ganglion cyst must be surgical and the operation must be performed as soon as possible. PMID:24891476
Rendon, Diego; Pescador, David; Cano, Carlos; Blanco, Juan
Grafts of optic nerve were placed end-toend with the proximal stumps of severed common peroneal nerves in inbred mice. It was found that fraying the proximal end of adult optic nerve grafts to disrupt the glia limitans increased their chances of being penetrated by regenerating peripheral nerve fibres. Suturing grafts to the proximal stump also enhanced their penetration by axons.
P. N. Anderson; P. Woodham; M. Turmaine
The voice disorders in a case of recurrent laryngeal granuloma with chronic gastroesophageal reflux was described. There was emphasized necessity of complex treatment pharmacological and phoniatric, as well as there were pointed out some indications of microsurgery. PMID:16821546
Wiskirska-Wo?nica, Bozena; Obrebowski, Andrzej
Introduction: Laryngeal leiomysarcoma is an extremely rare malignancy originating from smooth muscle cells. Its rarity is due to the fact that only less than 50 cases of pure laryngeal leiomyosarcoma and less than 10 cases of hypopharyngeal leiomyosarcaoma have been reported in modern medical literature. Even though the clinical presentation mimics that of a laryngeal carcinoma forming the major bulk of the laryngeal malignancies, the difference in management, warrants an accurate diagnosis. Case Report: We reported a case of this very rare malignancy presenting in the supraglottic region by highlighting the clinical features, histological and radiological diagnosis and management of this extremely rare malignant entity. Conclusion: An accurate histological diagnosis may be difficult; but supplementing by electron microscopy and immunohistochemical staining, the diagnosis can be reached certainly.
Khadivi, Ehsan; Taziky, Mohammad Hossein; Jafarian, Amir Hossein; Nasseri Sadr, Msoud
The tonus of extrinsic laryngeal muscles was studied in sleeping humans by means of electromyograms. A striking decrease in the muscle tonus was observed at the onset of each phase of electroencephalographic light sleep, rapid eye movements, and dreaming.
Ralph J. Berger
1. Silastoseal cuffs containing 25% and 45% lignocain, 25% marcain and 25% NaCl were placed onto the sciatic nerve. The effects of this on the sciatic nerve as well as the soleus and extensor digitorum longus (EDL) muscles was studied. 2. Cuffs containing local anaesthetics caused both early and late phases of paralysis, cuffs containing NaCl caused only the late phase of paralysis, showing that the late phase of paralysis was not due to the anaesthetic properties of the drugs. The paralysis produced by these procedures was irreversible. 3. Responses to indirect and direct stimulation of soleus and EDL muscles were compared to assess the degree of denervation. In case of cuffs containing 25% marcain and 45% lignocain more than half of the muscle fibres were denervated. 4. Acetylcholine sensitivity was assesses in all experiments. Soleus and EDL muscles from all animals that had cuffed nerves containing either local anaesthetics or 25% NaCl were hypersensitive to ACh. The degree of hypersensitivity could be correlated to the degree of "denervation" as assessed by comparing the directly and indirectly elicited twitch tensions. 5. It was found that the sciatic nerve undergoes degenerative changes when exposed to cuffs containing either local anaesthetics or 25% NaCl. PMID:1238984
Blunt, R J; Vrbová, G
Despite the wide spectrum of hemifacial microsomia manifestations, treatment mainly focuses on mandible and ear abnormalities, rather than on facial paralysis. In fact, the surgical treatment of facial paralysis associated with hemifacial microsomia is quite underdeveloped, be- cause the degree of paralysis is frequently incomplete or partial. Timing and type of surgery are also difficult to determine. Neurovascular free-muscle transfer
Akihiko Takushima; Kiyonori Harii; Hirotaka Asato; Atsushi Yamada
Following the great tradition established in the Szent Rókus Hospital and Institutions by author's predecessor Prof. Aurel Réthi, there have been more than 300 patients operated on for treatment of laryngotracheal stenosis. The vast majority of the cases referred to the department suffering from bilateral vocal cord paralysis were the consequences of thyroid surgery and its complications. Confronted with this challenging clinical scenario, the author became determined to focus not only on reconstruction but also on prevention. For example, all thyreoidectomies are performed with identification and preservation of the recurrent nerves. As the author's department is a center for laryngotracheal reconstruction, patients from different institutions were treated with larynx dilating operations, benefiting from the newly developed additional techniques. With the goal of refining alternatives to previous glottis dilating operations, new methods have been worked out for the management of bilateral vocal cord paralysis based on our endo-extralaryngeal suture technique. These recently popularized approaches consist of two operations, an irreversible one and a reversible one. The first operation is performed on patients whose vocal cords are paralyzed. This irreversible operation can be performed with and without arytenoidectomy. These operations were successful in 94 out of 99 patients. The second operation was the reversible endo-extralaryngeal lateralization, which was carried out in 63 patients, 61 of which were successful. In the reversible technique the suture was not removed if the cords remained paralyzed. If there was evidence of return of vocal cord function, the suture was removed, thus eliminating the need for further dilating operations. The author feels that these two operations are quite successful because the medial mucous membrane of the vocal cord is preserved, avoiding scar and granuloma formation. The operations may be performed without any kind of tracheostomy. These are significant advantages over most other glottic dilating operations. PMID:15101276
Diaphragmatic paralysis (DP) after cardiac surgery is an important complication especially in infants. We analyzed the incidence, clinical course, surgical management and follow up of the patients with DP, retrospectively. Between 1996 and 2005, 3,071 patients underwent cardiac surgery. Total number of patients with DP was 152 (4.9%). Out of 152 patients, 42 were surgically treated with transthoracic diaphragm plication (1.3%). The overall incidence of diaphragm paralysis was higher in correction of tetralogy of Fallot (31.5%), Blaloc-Taussig (B-T) shunt (11.1%) and VSD closure with pulmonary artery patch plasty (11.1). The incidence of DP which require plication was higher in B-T shunt (23.8%) arterial switch (19%) and correction of tetralogy of Fallot (11.9%). Mean and median age at the time of surgery were 17.8 +/- 3.6 and 6 months, respectively. Median time from cardiac surgery to surgical plication was 12 days. Indications for plication were repeated reintubations (n = 22), failure to wean from ventilator (n = 12), recurrent lung infections (n = 5) and persistent respiratory distress (n = 3). Mortality rate was 19.1%. Being under 1 year of age, pneumonia and plication 10 days after mechanical ventilation were associated with higher incidence mortality (P < 0.05). Phrenic nerve injury is a serious complication of cardiac surgery. It is more common after some special procedures. Spontaneous recovery is very rare. Being under 1 year of age, plication after 10 days from the surgery and pneumonia are major risk factors for mortality even in plicated patients. Transthoracic plication is helpful if performed early. PMID:16518591
Akay, Tankut Hakki; Ozkan, Süleyman; Gultekin, Bahadir; Uguz, Emrah; Varan, Birgul; Sezgin, Atilla; Tokel, Kursad; Aslamaci, Sait
The aim of the study was an assessment of the incidence of injury to cranial and peripheral nerves as complication of patency restoration of the internal carotid artery, and analysis of the effect of peripheral nerve injury on the results of carotid patency restoration. From Oct 1987 to Sept 1999 543 procedures were carried out for restoration of patency of the internal carotid artery. After the operation hypoglossus nerve injury was found in 7 cases (1.4%), vagus injury in 9 (1.8%). Signs of exclusively recurrent laryngeal nerve damage were found in 6 cases (1.2%). Glossopharyngeus nerve was damaged in 2 cases (0.4%), transient phrenic nerve palsy as a result of conduction anaesthesia was noted in 2 cases (0.4%). Damage to the transverse cervical nerve was found in 96 cases (60%). In 2 patients (1.2%) lower position of mouth angle was due to section of the mandibular ramus of the facial nerve. In another 2 cases skin sensation disturbances were a consequence of lesion of the auricularis magnus nerve and always they coexisted with signs of transverse cervical nerve damage. In conclusion: damage to the cranial nerves during operation for carotid patency restoration are frequent but mostly they are not connected with any health risks and often they regress spontaneously. PMID:11732265
Myrcha, P; Ciostek, P; Szopi?ski, P; Noszczyk, W
Radionecrosis of the larynx is a debilitating disease associated with pain, dysphagia, respiratory obstruction, and, in some cases, the need for laryngectomy. Persistent poor wound healing can lead to death. A series of eight patients with advanced (grades III and IV, Chandler classification) radionecrosis of the larynx treated with adjunctive hyperbaric oxygen therapy is presented. Signs and symptoms of radionecrosis were dramatically ameliorated in seven of eight patients, while one patient, despite subjective improvement, eventually required laryngectomy. There were no deaths. These results are compared to previous series on radionecrosis of the larynx in which hyperbaric oxygen was not used. This series indicates that hyperbaric oxygen therapy is a useful and effective adjunctive treatment modality in the management of laryngeal radionecrosis.
Ferguson, B.J.; Hudson, W.R.; Farmer, J.C. Jr.
Radiological examinations are a prerequisite for accurate assessment of laryngeal tumors, especially when contemplating partial (voice conservation) surgery. The clinical assessments and preoperative radiographs from five cases have been compared with the histologic findings in whole organ serial sections of the laryngectomy specimens. These studies demonstrated both the accuracies and the deficiencies of the present clinical and radiologic examination methods. The mucosal extension of tumor is accurately assessed by a combination of direct laryngoscopy and radiography. The latter mainly gives information concerning the vertical extent of tumor, especially contrast laryngography. Xeroradiography may give additional information. Deep invasion of tumor with cartilage destruction and spread outside the larynx is often not assessable preoperatively. Circumferential and symmetrical lesions may be missed radiologically as much of the interpretation is based on asymmetry. New methods must be developed to assess the deep invasion of tumor. The necessity of a close liaison between the laryngologist, radiologist, and clinical pathologist is stressed. PMID:1131731
Olofsson, J; Freeland, A P; Sokjer, H; Renouf, J H; van Nostrand, A W; Grontoft, O
Multiple endocrine neoplasia (MEN) type 2 syndrome is an autosomal dominant inherited disease caused by mutations of the RET proto-oncogene, and is clinically divided into three phenotypes: MEN2A, MEN2B, and familial medullary thyroid carcinoma. Although multiple mucosal neuromas are commonly observed in patients with MEN2B, there are only a few reports of laryngeal neuroma. We present here a rare case of laryngeal mucosal neuromas with MEN2B. PMID:24389350
Kudo, Naomi; Matsubara, Atsushi; Abe, Takahisa; Inoue, Taku; Takahata, Junko
Objectives: Cysts in the region of the larynx seldom caused clinical significant symptoms. The adult patients with laryngeal cysts complained primarily of hoarseness, dysphagia, and stridor. However, laryngeal cysts may result in obstructive sleep apnea syndrome.Methods: We report a case of a 47-year-old woman who arrived at our hospital with progressive snoring and daytime sleepness for more than 12 months.
Li-Ang Lee; Tuan-Jen Fang; Hsueh-Yu Li
Two cases of severe laryngeal injuries were evaluated by computed axial tomography (CT). Results of these studies correlated well with surgical findings and were helpful in planning structural repair. Axial views obtained by laryngeal CT were distinctly superior to the bidimensional picture obtained by polytomography. In addition, the method proved more advantageous than contrast laryngography, which is often impossible to perform in the presence of massive swelling. PMID:7092690
Maceri, D R; Mancuso, A A; Canalis, R F
We report on a 70-year-old patient who underwent ventral fusion of the cervical spine (C3/4 and C4/5) for spinal canal stenosis performed by the neurosurgery department. The patient suffered an exceedingly rare complication of the surgery – laryngeal dislocation. Had the deformed laryngeal structures been overlooked and the patient extubated as usual after surgery, reintubation would have been impossible due to the associated swelling, which might have had disastrous consequences. Leftward dislocation of the larynx became apparent post-operatively, but prior to extubation. Extubation was therefore postponed and a subsequent computed tomography (CT) scan revealed entrapment of laryngeal structures within the osteosynthesis. A trial of repositioning using microlaryngoscopy performed by otolaryngology (ears, nose and throat) specialists failed, making open surgical revision necessary. At surgery, the entrapped laryngeal tissue was successfully mobilised. Laryngeal oedema developed despite prompt repositioning; thus, necessitating tracheotomy and long-term ventilation. Laryngeal dislocation may be an unusual cause of post-operative neck swelling after anterior cervical spine surgery and should be considered in the differential diagnosis if surgical site haematoma and other causes have been ruled out. Imaging studies including CT of the neck may be needed before extubation to confirm the suspicion and should be promptly obtained to facilitate specific treatment.
Krauel, Jenny; Winkler, Dietrich; Munscher, Adrian; Tank, Sascha
We report on a 70-year-old patient who underwent ventral fusion of the cervical spine (C3/4 and C4/5) for spinal canal stenosis performed by the neurosurgery department. The patient suffered an exceedingly rare complication of the surgery - laryngeal dislocation. Had the deformed laryngeal structures been overlooked and the patient extubated as usual after surgery, reintubation would have been impossible due to the associated swelling, which might have had disastrous consequences. Leftward dislocation of the larynx became apparent post-operatively, but prior to extubation. Extubation was therefore postponed and a subsequent computed tomography (CT) scan revealed entrapment of laryngeal structures within the osteosynthesis. A trial of repositioning using microlaryngoscopy performed by otolaryngology (ears, nose and throat) specialists failed, making open surgical revision necessary. At surgery, the entrapped laryngeal tissue was successfully mobilised. Laryngeal oedema developed despite prompt repositioning; thus, necessitating tracheotomy and long-term ventilation. Laryngeal dislocation may be an unusual cause of post-operative neck swelling after anterior cervical spine surgery and should be considered in the differential diagnosis if surgical site haematoma and other causes have been ruled out. Imaging studies including CT of the neck may be needed before extubation to confirm the suspicion and should be promptly obtained to facilitate specific treatment. PMID:23983289
Krauel, Jenny; Winkler, Dietrich; Münscher, Adrian; Tank, Sascha
The objective of the study was to evaluate the association between changes in laryngeal sensation and initiation of swallowing reflex or swallowing function before and after (chemo)radiotherapy. A prospective study was conducted in a tertiary referral university hospital. Thirteen patients who received (chemo)radiotherapy for treatment of laryngeal or hypopharyngeal cancer were included. Laryngeal sensation was evaluated at the tip of the epiglottis before and 1, 3 months, and 1 year after (chemo)radiotherapy. Videofluoroscopy was performed at the same time. Quantitative determinations included changes in laryngeal sensation, computed analysis of pharyngeal delay time, the distance and velocity of hyoid bone movement during the phase of hyoid excursion, and pharyngeal residue rate (the proportion of the bolus that was left as residue in the pharynx at the first swallow). Laryngeal sensation significantly deteriorated 1 month after (chemo)radiotherapy, but there was a tendency to return to pretreatment levels 1 year after treatment. Neither pharyngeal delay time nor displacement of the hyoid bone changed significantly before and after (chemo)radiotherapy. In addition, there was no significant difference in the mean velocity of hyoid bone movement and the amount of stasis in the pharynx at the first swallow before and after (chemo)radiotherapy. After (chemo)radiotherapy, laryngeal sensation deteriorated. But, in this study, videofluoroscopy showed that swallowing reflex and function were maintained. PMID:24150543
Maruo, Takashi; Fujimoto, Yasushi; Ozawa, Kikuko; Hiramatsu, Mariko; Suzuki, Atsushi; Nishio, Naoki; Nakashima, Tsutomu
Mechanisms underlying the differing chemosensitivity of laryngeal afferents have not been defined. The role of airway epithelium in transducing the chemical stimuli to neural signals was investigated by using Na(+)- and Cl(-)-channel inhibitors in anesthetized spontaneously breathing cats. Single-fiber action potentials were recorded from the peripheral cut end of the superior laryngeal nerve. Luminal application of amiloride (10(-4) M), an inhibitor of epithelial Na+ channels, reduced the responsiveness of non-respiratory-modulated endings (n = 25) to distilled water (65.76 +/- 5.77 vs. 50.67 +/- 5.13 Hz; P < 0.01). Water responsiveness of these endings was unaffected by 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid and diphenylamine-2-carboxylate, two Cl(-)-channel blockers. Respiratory-modulated endings (water responsive, n = 8; water nonresponsive, n = 9) were unaffected by Na(+)- and Cl(-)-channel blockers. These results suggest that epithelial Na+ channels play a role in the modulation of non-respiratory-modulated laryngeal endings. The lack of an effect by amiloride on other subtypes may be due to differences in location or intrinsic properties of nerve endings. Cl- channels do not appear to play an important role in the modulation of laryngeal afferents targeted in this study. PMID:7665423
Ghosh, T K; Van Scott, M R; Mathew, O P
Objective: The study goal was to determine the impact of various surgical procedures for bilateral vocal cord paralysis in children by using established principles of meta-analysis. Study Design and Setting: We conducted a retrospective review of the literature in which a predetermined protocol was used to identify articles for meta-analysis. Six articles met inclusion criteria, and pertinent data were extracted.
Matthew T. Brigger; Christopher J. Hartnick
The overall survival rate and prognosis of patients with laryngeal cancer are not optimistic despite advances in therapeutic techniques. Gene expression prognostic models enable the development of more appropriate treatment strategies. The human gene PTPN11 encoding a non-receptor protein tyrosine phosphatase, Src homology phosphotyrosine phosphatase 2 (SHP2), is a well-documented proto-oncogene in various malignancies. This study investigated the role of SHP2 expression and associated clinical manifestations in laryngeal cancer using a tissue microarray of 112 pairs of laryngeal cancer samples and corresponding adjacent normal mucosae. SHP2 expression increased in laryngeal cancer, and this result was associated with the poor survival rate of laryngeal cancer patients. Moreover, increased SHP2 expression remarkably promoted the growth of laryngeal cancer cells in vitro and tumorigenicity of laryngeal cancer cells in vivo. The Ras/Raf/Mek/Erk pathway was also found to be involved in the SHP2-induced growth of laryngeal cancer cells. Overall, our findings indicated that SHP2 plays an important role in laryngeal cancer tumorigenesis and that its expression is negatively correlated with the prognosis of patients. Thus, SHP2 may be a promising combinational therapeutic target for treatment of laryngeal cancer. The interference of SHP2 expression can serve as a novel strategy for laryngeal cancer treatment. PMID:24297342
Gu, Jia; Han, Tao; Ma, Rui-Hang; Zhu, Yu-Lin; Jia, Yi-Na; Du, Jing-Jing; Chen, Yu; Jiang, Xue-Jun; Xie, Xiao-Dong; Guo, Xing
The introduction of the CO2 surgical laser into laryngeal microsurgery has made resection of the posterior vocal cord together\\u000a with the arytenoid cartilage possible. Since November 1990, 30 arytenoidectomies, 17 partial cordectomies and 18 bilateral\\u000a cordectomies as described by Kashima were performed by means of a CO2 laser in patients with bilateral paralyses of the vocal cords. In this group
Z. Szmeja; J. G. Wójtowicz
With definitive and irreparable interruption of the N. facialis a reanimation of the paralysed face can only be brought about through reinnervation of the muscles from the N. facialis of the unparalysed side.
H. Anderl; P. Wilflingseder
In the dental office, the dentist may have to examine patients with facial asymmetry and functional disorders caused by facial paralysis (FP). Following clinical examination, it is important for the dental practitioner to establish whether FP was caused by injury to the facial nerve, and to focus on the site of the lesion and potential risk factors. The risks of dental treatment in a patient with FP should also be assessed. Through dental or surgical procedures, the dentist may cause transient or permanent FP. Interdisciplinary collaboration is required for the confirmation of diagnosis and etiology, and for the complex treatment of FP. This article aims to examine the role of the dentist within the multidisciplinary medical team and to present two cases with transient FP following intraoral anesthesia in the dental office. PMID:24392498
Ilea, Aranka; Cristea, Alexandru; T?rmure, Viorica; Trombita?, Veronica E; Câmpian, Radu S; Albu, Silviu
Purpose of the Study: This study was undertaken to highlight the method, usefulness and postoperative morbidity of using a laryngeal mask airway (LMA) to ventilate patients with difficult airways undergoing laryngeal procedures. Procedures: Retrospective chart review where we identified patients deemed to have a difficult airway who underwent laryngeal and upper tracheal procedures, and were electively ventilated using an LMA.
Nazish Khalid Hashmi; Jeff E. Mandel; Natasha Mirza
Introduction The aim of the study was to determine the content of cadmium (Cd), cobalt (Co) and nickel (Ni) in the samples from laryngeal carcinoma in comparison with the level of these elements in the samples of healthy mucous membrane from the same larynx. Material and methods The study was conducted on 43 patients with laryngeal carcinoma. The levels of Cd, Co, and Ni in carcinoma and healthy control tissues was determined by inductively coupled plasma optical emission spectrometry (ICP – OES) using sequential spectrometer. Results No significant differences were found between the levels of the Cd, Co, and Ni in laryngeal carcinoma vs tissues without carcinoma. However, it was noted that the concentration of Cd in tumors of patients with metastases to cervical lymph nodes was significantly higher than in tumors without metastases. The content of Co was significantly higher in more advanced laryngeal tumors: in stage-T4 than in stage T3. It is of interest that the levels of Cd, Co and Ni were significantly higher in tumors in patients from rural than urban areas. Conclusions The imbalance in the level of nickel, cadmium and cobalt in laryngeal cancer may be due to a changed cellular metabolism in the cancer process. However, the results of our study reveal the significant differences in the concentration of these metals between patients from urban and rural areas which suggests that this fact may be related to environmental or occupational factors and therefore it requires further study.
Klatka, Janusz; Remer, Marek; Dobrowolski, Ryszard; Pietruszewska, Wioletta; Trojanowska, Agnieszka; Siwiec, Henryk; Charytanowicz, Malgorzata
The aim of this study is to assess the use of a telescope with a high definition endoscopic video system as an alternative to the operating microscope in endoscopic laryngeal surgery. The system is economic, and allows optimal vision and improved surgeon comfort and ease. In exolaryngoscopy, the optic vitom is positioned in place of the microscope. An extracorporeal optical system (exoscope) is positioned 25 cm from the surgical field. Under exoscopic control, it is possible to use the same series of instruments using a long handle through the laryngoscope. The CO2 laser may also be used by fixing it coaxially to the optical system, and it is possible to use a classic set of microinstruments for phonosurgery. Endoscopic study with auto-fluorescence (NBI; narrow band imaging) can be easily used to visualize both precancerous and cancerous lesions. We treated 12 patients with benign and malign pathologies of the vocal cords; in all cases, the predicted result was reached, and the optic vitom showed its potential advantages in ease and comfort of the surgeon. PMID:23326013
Carlucci, C; Fasanella, L; Ricci Maccarini, A
Premalignant and malignant laryngeal lesions still offer great problems in diagnosis and classification. Early diagnosis is of the utmost importance for a good functional therapeutic result. Microlaryngoscopic techniques have increased the number of premalignant lesions which have been found. Diagnostic aids may be used e.g. toluidine blue staining and exfoliative cytology. Toluidine blue staining compared to the histological findings in 272 biopsy specimens showed an overall sensitivity of 91% but a specificity of only 52%. Exfoliative cytology compared to the histological findings in 420 cases showed an overall sensitivity of 83% and a specificity of 84%. Photometry on the histologic sections allows objective evaluation of nuclear hyperchromasia and polymorphism, which may otherwise by marked microscopically, especially in well differentiated lesions. Full use must be made of our diagnostic tools in classifying invasive carcinomas to enable selection of the most appropriate treatment. Laryngography is the best method to assess vertical tumor involvement. Computed tomography gives information about deep tumor extension and spread of tumor outside the larynx. However, the strength and weaknesses of computed tomography have to be further assessed by comparison with whole organ sections in the transverse plane. PMID:7050406
Introduction. Synovial sarcomas (SS) are aggressive malignant soft tissue tumours that are thought to arise from pluripotent mesenchymal cells. Clinical Report. A 20-year-old male presented with an acute onset of respiratory stridor. Computer tomography scanning confirmed a mass arising from the left supraglottic larynx and an emergency tracheostomy was performed. A diagnosis of biphasic synovial sarcoma was formed. A total laryngectomy and left hemithyroidectomy was performed in conjunction with a left modified radical neck dissection. The patient received adjuvant chemotherapy followed by a course of radiotherapy and remains alive and disease free at 18?months after treatment. Discussion. Prognosis for patients with SS is related to primary tumour extent, grade, and size. The presence of the diagnostic translocation, t(X;18), is being targeted and hopefully will lead to the development of new therapeutics (Guadagnolo et al., 2007). Conclusion. Laryngeal SS remains a rare and poorly understood entity. A multidisciplinary approach to treatment is essential and long-term followup is imperative.
Bova, Ron; Edwards, Melanie
We report here a review of the literature intended to clarify the nomenclature and boundaries of the nodes in the "central compartment" of the neck, the frequency with which tumors from the different laryngeal sites metastasize to these nodes, and the indications for central compartment node dissection in the treatment of cancers of the larynx. From this review, we conclude that, until consensus is reached about grouping of the lymph nodes in this area, it is best to refer to these nodes by their anatomic location, ie, prelaryngeal, pretracheal, or paratracheal lymph nodes. It is also advisable to describe dissection of these nodes as selective neck dissection (SND) with an annotation about the specific lymph node groups removed. Metastases in prelaryngeal and paratracheal lymph nodes in patients with squamous cell carcinoma of the larynx are associated with increased tumor recurrence, more frequent metastases in lymph nodes of the lateral compartment of the neck, and decreased survival. If untreated, they may lead to the development of peristomal recurrence. Therefore, elective treatment of level VI nodes is recommended in patients with squamous cell carcinomas of the subglottic region, advanced glottis carcinomas with subglottic extension, and in certain advanced carcinomas of the supraglottic region. PMID:20652888
Medina, Jesus E; Ferlito, Alfio; Robbins, K Thomas; Silver, Carl E; Rodrigo, Juan P; de Bree, Remco; Rinaldo, Alessandra; Elsheikh, Mohamed N; Weber, Randal S; Werner, Jochen A
Axillary nerve injuries are some of the most common peripheral nerve injuries in athletes who participate in contact sports. Resulting deltoid muscle paralysis is secondary to nerve trauma which occurs following shoulder dislocation or a direct blow to the deltoid muscle. Compression neuropathy has been reported to occur in quadrilateral space syndrome as the axillary nerve exits this anatomic compartment. The axillary nerve is also extremely vulnerable during any operative procedure involving the inferior aspect of the shoulder, and iatrogenic injury to the axillary nerve remains a serious complication of shoulder surgery. Accurate diagnosis of axillary nerve injury is based on a careful history and physical examination as well as an understanding of the anatomy of the shoulder and the axillary nerve in particular. Inspection, palpation and neurological testing provide the bases for diagnosis. A clinically suspected axillary nerve injury should be confirmed by electrophysiological testing, including electromyography and nerve conduction studies. During the acute phase of injury, the athlete should be rested and any ligamentous or bony injury should be treated as indicated. Patients should undergo an extensive rehabilitation programme emphasising active and passive range of motion as well as strengthening of the rotator cuff, deltoid and periscapular musculature. Shoulder joint contracture should be avoided at all costs as a loss of shoulder mobility may ultimately affect functional outcome despite a return of axillary nerve function. If no axillary nerve recovery is observed by 3 to 4 months following injury, surgical exploration is indicated. Athletes who sustain injury to the axillary nerve have a variable prognosis for nerve recovery, although the return of function of the involved shoulder is typically good to excellent. We recommend that athletes who sustain axillary nerve injury may return to contact sport participation when they achieve full active range of motion of the shoulder and when shoulder strength is documented to be good to excellent by isometric or manual muscle testing. PMID:9858397
Perlmutter, G S; Apruzzese, W
Diphtheritic polyneuropathy is a vaccine-preventable illness caused by exotoxin-producing strains of Corynebacterium diphtheriae. We present a retrospective convenience case series of 15 children (6 girls)<15 years of age (mean age 5.2 years, case-fatality rate 53%, and 1 additional case-patient who was ventilator dependent at the time of last follow-up; median follow-up period 60 days) with signs and symptoms suggestive of diphtheritic polyneuropathy. All cases were identified through national acute flaccid paralysis surveillance, which was designed to detect poliomyelitis in India during 2002-2008. We also report data on detection of diphtheritic polyneuropathy compared with other causes of acute flaccid paralysis identified by this surveillance system. PMID:23965520
Mateen, Farrah J; Bahl, Sunil; Khera, Ajay; Sutter, Roland W
Baclofen is a ?-aminobutyric acid (GABA) agonist that is commonly prescribed for the treatment of spasticity in children. The clinical indications for baclofen use in the pediatric population have increased in recent years. Prescribing baclofen mandates education regarding abrupt withdrawal and overdose because of the severe clinical reactions this can precipitate. This report highlights the case of a patient who presented with acute onset of coma and a flaccid paralysis after baclofen overdose. We reviewed the presentation, clinical course, diagnostic studies, and outcome of this patient. A review of prior literature regarding baclofen overdose is included. Baclofen overdose is heralded by dose-related alteration in consciousness and weakness, progressing to coma and a flaccid paralysis. Screening for baclofen overdose is accomplished through high-power liquid chromatography. Baclofen overdose is treated with supportive care and antiepileptic medications as indicated. There is usually full spontaneous recovery with elimination of the medication. PMID:23481445
Caron, Elena; Morgan, Robin; Wheless, James W
Study design: We present our cumulative experience with patients sustaining the most dramatic type of Conversion Disorder (CD) – Conversion Motor Paralysis.Setting: Rehabilitation departments, Reuth Medical Center, Tel-Aviv and Sheba Medical Center, Tel-Hashomer, Israel.Methods: During the period 1973–2000, 34 patients with neurological symptoms without any anatomical or physiological basis were admitted to both rehabilitation departments. This number consists of less
RJ Heruti; J Reznik; A Adunski; A Levy; H Weingarden; A Ohry
Reverse transcription-PCR assays have been established for a quick, sensitive, and specific diagnosis of acute bee paralysis virus (ABPV), a common virus of the honeybee (Apis mellifera), directly from clinical samples. A 3,071-nucleotide fragment of the ABPV genome, which includes the entire capsid polyprotein gene, was amplified from Austrian, German, Polish, and Hungarian ABPV samples and sequenced, and the se-
Tamas Bakonyi; Elvira Grabensteiner; Jolanta Kolodziejek; Miklos Rusvai; G. Topolska; W. Ritter; N. Nowotny
Various lateralization procedures have been described in the past to treat bilateral vocal cord paralysis. Though endoscopie\\u000a lateralization gives good results in terms ofdecannulation rates, the postoperative voice quality is often poor. KTP-532 laser\\u000a assisted posterior cordotomy was done in 3 cases. This preliminary study showd 100% decannulation rate and good post-operative\\u000a voice quality. The latter was assessed both subjectively
Produl Hazarika; Deepak Ranjan Nayak; R. Balakrishnan; Girish Raj; Kailesh Pujary; Shahrayar Ali Mallick
Laryngeal carcinoma is the eleventh-most common form of cancer among men worldwide and is the second-most common malignancy of the head and neck. The primary functions of the larynx involve phonation, respiration, and deglutition but it also contributes to taste and smell by allowing the movement of air over the special sense organs. Thus, loss of laryngeal function affects speech and swallowing and some of the senses that allow us to enjoy the world. Moreover, total laryngectomy bypasses the critical humidification function of the upper aerodigestive tract that renders pulmonary toiletry problematic for these patients. With relatively little change in mortality since the 1970s, recent research has focused not only on improving survival but on laryngeal preservation modalities. PMID:18570953
Chu, Eugene A; Kim, Young J
The laryngeal chemoreflex (LCR) consists of apnea, laryngospasm, and cardiovascular changes in neonates after laryngeal irritation and has been implicated in sudden infant death syndrome and apnea of infancy. Antihistamines attenuate a similar vagally mediated pulmonary chemoreflex. The intravenous antihistamine effect on the LCR was studied in neonatal piglets. Laryngeal muscle activity, respiration, blood pressure, and pulse were measured during water stimulation of the LCR. After baseline LCR recordings, intravenous diphenhydramine (2.5 mg/kg) or cimetidine (20 mg/kg) was bolused (control group received saline). LCR measurements were repeated over 7 hours. Diphenhydramine significantly shorted apneas (P < .05) 3 to 7 hours after drug bolus, which is believed to be secondary to central atropinic effects. Cimetidine demonstrated no attenuation of the LCR. PMID:7630300
Downs, D H; Johnson, K; Goding, G S
Jan Gauffin was an early user of fiber optics which allowed him to discover that laryngeal structures above the glottal level are involved in speech. His research led him to postulate three independently controlled mechanisms: fundamental frequency control, glottal adduction/abduction, and laryngealization, the latter derived from the protective closure function. He argued that phonetic theory must be revised to account for the main phonation types of the world's languages. He saw them as combinations of two interacting dimensions: adduction/abduction and laryngealization. Secondly he gave the aryepiglottic sphincter an explanatory role in accounting for the production of low pitch and downward pitch inflections. During his lifetime his work received limited attention. However, later laryngoscopic research has confirmed and extended his thinking and findings. His contribution was a pioneering one. PMID:19479620
The clinical course of various forms of chronic laryngitis, including contact granulomas not only persistant and relapsing, but also inclined to oncologic pathology due to hyperplastic changes in the larynx resulting in malignization was described. Inhibition of the leukocyte interferon-synthesizing activity was observed in more than 88.1% of the subjects. Pathogenic viruses were isolated from 48.2% of the patients, EBV and mycoplasma prevailing. High direct correlation between chronic laryngitis and Herpes viruses was shown. The presence of three-component virus associations in the larynx mucosa was likely indicative of the bening process malignancy. The use of the interferon inductor cycloferon in the complex surgical and medicamentous management of chronic laryngitis was shown valid. The rate of the relapses lowered to 1.7 episodes a year. PMID:24757822
Demchenko, E V; Romantsov, M G; Grigorian, S S; Kovalenko, A L
Introduction: Although cuff leak test has been proposed as a simple method of predicting the occurrence of postextubation stridor, cut-off point of cuff-leak volume substantially differs between previous studies. In addition, laryngeal ultrasonography including measurement of air column width could predict postextubation stridor. The aim of the present study was to evaluate the value of laryngeal ultrasonography versus cuff leak test in predicting postextubation stridor. Methods: In a prospective study, all patients intubated for a minimum of 24 h for acute respiratory failure, airway protection and other causes were included. Patients were evaluated for postextubation stridor and need for reintubation after extubation. The cuff leak volume was defined as a difference between expiratory tidal volumes with the cuff inflated and deflated. Laryngeal air column width was defined as the width of air passed through the vocal cords as determined by laryngeal ultrasonography. The air-column width difference was the width difference between balloon-cuff inflation and deflation. Results: Forty one intubated patients with the mean age of 57.16±20.07 years were included. Postextubation stridor was observed in 4 patients (9.75%). Cuff leak test (cut off point: 249 mL) showed sensitivity and specificity of 75% and 59%, respectively. In addition, laryngeal ultrasonography (cut off point for air column width: 10.95 mm) resulted in sensitivity and specificity of 50% and 54%, respectively. Positive predictive value of both methods were <20%. Conclusion: Both cuff leak test and laryngeal ultrasonography have low positive predictive value and sensitivity in predicting postextubation stridor and should be used with caution in this regard. PMID:24753828
Mikaeili, Haleh; Yazdchi, Mohammad; Tarzamni, Mohammad Kazem; Ansarin, Khalil; Ghasemzadeh, Maryam
Organ preservation regimens that combine chemotherapy and radiotherapy (chemoradiotherapy) are increasingly used as the primary treatment of laryngeal and pharyngeal cancers. Meta-analytic data show a survival benefit with combined modality therapy, but the functional sequelae can be significant. Dysphagia is recognized as a common and often devastating late effect of chemoradiotherapy. This review examines functional outcomes after chemoradiotherapy for laryngeal and pharyngeal cancers, with a particular emphasis on dysphagia. Topics examined include the burden of dysphagia after chemoradiation, pathophysiology of dysphagia, baseline functioning, recommendations to improve long-term function, and voice outcomes.
Hutcheson, Katherine A.; Lewin, Jan S.
Fine movement of laryngeal components was analyzed by digital subtraction laryngography with the use of a digital fluorography system. Two kinds of image processing modes, the super pulse image subtraction mode and the time interval difference mode, were used for this purpose. By the super pulse image mode, the distance and extent of movement of laryngeal components at vocal initiation and during phonation could be observed. By the time interval difference mode, the amount and direction of motion for a certain interval and fine movement, such as vocal initiation, were determined. PMID:1449691
Okamura, H; Sasaki, Y
Aim. This study aims to investigate the possible role of H. pylori as a cause of laryngeal squamous cell carcinoma. Method. This controlled study was performed with 31 consecutive laryngeal cancer and 28 cancer-free patients who underwent direct laryngoscopy and biopsy of laryngeal lesions. To document the previous H. pylori infection, serological analysis of the antibody titers was done. Immunohistochemical analyses were applied to the tissue samples. Results. Serology was found positive at the 90.3% of the laryngeal cancer patients and 96.4% of the benign group. There were no statistically significant differences between the two groups (P > 0.05). Immunohistochemical analysis results were determined as negative at all of the specimens of laryngeal cancer patients and patients with benign lesions. Conclusion. There were no signs of colonization of H. pylori in laryngeal tissues of both groups' patients. It is thought that no relationship exists between the H. pylori infection and laryngeal squamous cell carcinoma.
Genc, Rasan; Cagl?, Sedat; Yuce, Imdat; Vural, Alperen; Okuducu, Hac?; Pat?roglu, Tahir; Guney, Ercihan
Listeners were asked to identify six tonal variations in the production of the syllables /ji/ and /si/ produced by 10 normal laryngeal (NL), 10 standard esophageal (SE), and 10 Servox-type electrolarynx (EL) Cantonese speakers. The purpose of the present study was to determine if alaryngeal Cantonese speakers could differentiate meanings associated with different tone levels. Results indicated that listeners' identification of the six tones for each syllable produced by the SE speakers was similar in pattern to those produced by the NL speakers of Cantonese. For both NL and SE speech, the high-level, low-falling, and high-rising tones were perceived more accurately than the mid-level, low-level, and low-rising tones. Identification of the six tones for each syllable as produced by the EL speakers was significantly poorer due to the limitations of the electrolarynx. PMID:9624857
Ng, M L; Lerman, J W; Gilbert, H R
Acute facial nerve injuries involving the total facial nerve (n = 202) and its segmental branches (n = 63) were repaired with a variety of neural (n = 225) and myofascial transfer (n = 40). A system for evaluating results based on facial symmetry and tone at rest, recovery of voluntary mimetic activity,\\u000a synkinesis, and recovery of selective function in
J. G. Spector
Classical phonemic accounts of Cuzco (Peru) Quechua posit three distinct types of stops: plain, aspirated, and glottalized. A later analysis argued instead for a root-level feature of laryngealization governed by a small number of formal mechanisms. This latter analysis is taken one step further, showing that even greater explanatory power may be…
Laryngeal adjustments in voiceless obstruent clusters in Tashlhiyt Berber were examined by means of simultaneous transillumination, fibre-optic films and acoustic recordings. This lan- guage allows a rich variety of voiceless clusters naturally. Several combinations of \\/s\\/ and \\/k\\/ clusters including singleton and geminate consonants were examined. We focused on the number of glottal-opening gestures, the influence of manner of articulation
RACHID RIDOUANE; SUSANNE FUCHS; PHIL HOOLE
Temporary paralysis is a rare manifestation of envenoming following the yellow Iranian scorpion, Odontobuthus doriae (O. doriae). Thus, to elucidate the underlying mechanism, we investigated the neurotoxic effect of venom in the sciatic nerve, the possible mechanism in a mice model. The neurotoxicity and temperature effects in the venom-induced neurotoxicity were examined using the mouse sciatic nerve and mouse phrenic nerve-hemidiaphragm (MHD) preparations. O .doriae venom (1 ?g/mL) caused changes in the perineural waveform associated with nerve terminal action potentials. Venom affected on both negative and positive components of the waveform which is known as a compound action potential. The timeresponse relationship of venom-induced depression of resting membrane potential (RMP) was significant (p < 0.05). No significant difference in augmentation was seen in room temperature in comparison with 37°C. In conclusion, although there was no evidence that the venom had any specific curarizing action at the neuromuscular junction, the results suggest that the venom exerts its neuromuscular transmission on the sciatic nerve through potassium and sodium ionic-currents. Furthermore, the influence of temperature on neurotoxicity was ineffective on blockade of the neuromuscular transmission in-vitro. PMID:24250682
Vatanpour, Hossein; Jalali, Amir; G Rowan, Edward; Rahim, Fakher
Temporary paralysis is a rare manifestation of envenoming following the yellow Iranian scorpion, Odontobuthus doriae (O. doriae). Thus, to elucidate the underlying mechanism, we investigated the neurotoxic effect of venom in the sciatic nerve, the possible mechanism in a mice model. The neurotoxicity and temperature effects in the venom-induced neurotoxicity were examined using the mouse sciatic nerve and mouse phrenic nerve-hemidiaphragm (MHD) preparations. O .doriae venom (1 ?g/mL) caused changes in the perineural waveform associated with nerve terminal action potentials. Venom affected on both negative and positive components of the waveform which is known as a compound action potential. The timeresponse relationship of venom-induced depression of resting membrane potential (RMP) was significant (p < 0.05). No significant difference in augmentation was seen in room temperature in comparison with 37°C. In conclusion, although there was no evidence that the venom had any specific curarizing action at the neuromuscular junction, the results suggest that the venom exerts its neuromuscular transmission on the sciatic nerve through potassium and sodium ionic-currents. Furthermore, the influence of temperature on neurotoxicity was ineffective on blockade of the neuromuscular transmission in-vitro.
Vatanpour, Hossein; Jalali, Amir; G. Rowan, Edward; Rahim, Fakher
We report a 55-year-old female who presented to the emergency department with acute onset quadriparesis. She was diagnosed to have acquired immunodeficiency syndrome 7 years ago and was on tenofovir based anti-retroviral therapy for past 10 months. As the patient also had hypophosphatemia, glucosuria and proteinuria Fanconi syndrome (FS) was suspected. She improved dramatically over next 12 h to regain normal power and also her renal functions improved over next few days. Tenofovir induced FS presenting as hypokalemic paralysis is very rare complication and is the first case reported from India. PMID:24701043
Venkatesan, E P; Pranesh, M B; Gnanashanmugam, G; Balasubramaniam, J
Objectives/Hypothesis 1. To determine the phonation threshold pressure (PTP) and phonation threshold flow (PTF) in excised human larynges. 2. To determine the effects of posterior glottal width, glottal area, and gender on PTP and PTF. 3. To test the hypothesis that hysteresis is present in excised human laryngeal phonation. 4. To compare these results to those from canine experiments and human subject measurements. Study Design Induced phonation of excised human larynges in the laboratory. Methods Nine human larynges were harvested within 24 hours post-mortem. PTP and PTF at phonation onset and offset were measured on a bench apparatus. The effects of posterior glottal width, glottal area, and gender were examined. Results Large inter-subject variability was observed in PTP and PTF. PTP was comparable to those measured in vivo, whereas PTF was substantially higher. One-way ANOVA showed no significant dependence of PTP and PTF on posterior glottal width. Hysteresis was observed, with offset PTP and PTF lower than onset values. Offset measurements had significantly less variability than onset measurements (P = 0.012 for PTP, P = 0.0001 for PTF). Conclusions This study is one of the first to report onset and offset PTP and PTF in fresh excised human larynges. The high PTF observed likely reflects a large DC flow component due to vocal fold bowing. Offset PTP and PTF values may be intrinsically more reliably measured than onset values. The large inter-subject variability in PTP and PTF may have implication for the clinical application of these aerodynamic parameters of phonation. Level of Evidence N/A (Laboratory study).
Mau, Ted; Muhlestein, Joseph; Callahan, Sean; Weinheimer, Kent T.; Chan, Roger W.
The purpose of our investigation was to evaluate the laryngeal findings and acoustic changes in hubble-bubble smokers. A total of 42 subjects with history of hubble-bubble smoking were recruited for this study. A corresponding group with a history of cigarette smoking and controls were matched. All subjects underwent laryngeal video-endostroboscopic evaluation and acoustic analysis. In the hubble-bubble smoking group, 61.9% were males. The average age was 30.02 +/- 9.48 years and the average number of years of smoking was 8.09 +/- 6.45 years. Three subjects had dysphonia at the time of examination. The incidence of benign lesions of the vocal folds in the hubble-bubble group was 21.5%, with edema being the most common at 16.7% followed by cyst at 4.8%. The incidence of laryngeal findings was significantly higher in the hubble-bubble group compared to controls. In the cigarette-smoking group, the most common finding was vocal fold cyst in 14.8% followed by polyps in 7.4%, and edema, sulcus vocalis and granuloma. These findings were not significantly different from the hubble-bubble group except for the thick mucus, which was significantly higher in the latter. There were no significant changes in any of the acoustic parameters between hubble-bubble smokers and controls except for the VTI and MPT, which were significantly lower in the hubble-bubble group. In comparison with the cigarette-smoking group, hubble-bubble smokers had significantly higher Fundamental frequency and habitual pitch (p value 0.042 and 0.008, respectively). The laryngeal findings in hubble-bubble smokers are comparable to cigarette smokers. These laryngeal findings are not translated acoustically, as all the acoustic parameters are within normal range compared to controls. PMID:20480370
Hamdan, Abdul-latif; Sibai, Abla; Oubari, Dima; Ashkar, Jihad; Fuleihan, Nabil
Acromegalic patients can develop obstructive sleep apnea syndrome or upper airflow obstruction. The development of dyspnea is unusual and the fixation of both vocal cords is exceptional. We report the case of a patient with bilateral vocal cord paralysis. Fiberoptic laryngoscopy and computed tomography (CT) of the neck showed a supra-glottic stenosis due to a swelling of the soft tissue.
S. Saussez; V. Mahillon; G. Chantrain; M. P. Thill; T. Lequeux
Over a two-year period this study evaluated the condition of 65 athletes with nerve injuries. These injuries represent the spectrum of nerve injuries likely to be encountered in sports medicine clinics. (Author/MT)
Collins, Kathryn; And Others
Nerve stimulator applies and/or measures precisely controlled force and/or displacement to nerve so response of nerve measured. Consists of three major components connected in tandem: miniature probe with spherical tip; transducer; and actuator. Probe applies force to nerve, transducer measures force and sends feedback signal to control circuitry, and actuator positions force transducer and probe. Separate box houses control circuits and panel. Operator uses panel to select operating mode and parameters. Stimulator used in research to characterize behavior of nerve under various conditions of temperature, anesthesia, ventilation, and prior damage to nerve. Also used clinically to assess damage to nerve from disease or accident and to monitor response of nerve during surgery.
Tcheng, Ping; Supplee, Frank H., Jr.; Prass, Richard L.
A personal field chemical warfare nerve agent detector has therein a transducer having two microchemical cantilever oscillators. One of the cantilever oscillators has deposited, as an end-mass, a chemically selective substance on the cantilever. The nerve...
E. S. Kolesar
Background Obturator nerve block plays an additive role on the quality of analgesia for knee surgery. Since the use of dual guidance increases the success rate of nerve blocks, we investigated the feasibility of performing anterior cruciate ligament reconstruction under dual-guided blockade of obturator with femoral and sciatic nerves. Furthermore, we propose a novel method for the assessment of obturator nerve block. Methods Fifty-seven patients undergoing anterior cruciate ligament repair were studied. Neurostimulating needles were guided out-of-plane by ultrasound. To induce the obturator nerve block, 10 ml of ropivacaine 0.5% were injected after eliciting contractions of adductor longus, brevis and magnus followed by block assessment for 30 minutes by examining the patient lift and left down the leg. Results The sonographic recognition of obturator nerve was easy and quick in all cases. Time for applying the block was 119.9 ± 79.2 sec. Assessing this block with lifting-leaving down the leg gave satisfactory results in 24.0 ± 5.07 min. After performing femoral-sciatic blocks, the inflation of tourniquet resulted in VAS score of > 0 in 2/57 patients and operation in 12/57. Total dose of fentanyl was 120.1 ± 64.6 µg and of midazolam 1.86 ± 0.8 mg. In 6 patients propofol was administered for sedation and 1 of them required ventilation with laryngeal mask airway, converting the anesthesia technique to general anesthesia. Conclusions Our data suggest that anterior cruciate ligament reconstruction can be performed under obturator-femoral-sciatic blocks. Identification of obturator nerve with ultrasound is easy and the block can be assessed by observing how the patient lifts and leaves down the leg.
Simeoforidou, Marina; Basdekis, George; Tsiaka, Katerina; Chantzi, Eleni; Vretzakis, George
Hypokalemic paralysis is a medical emergency due to the risks of cardiac arrhythmia, respiratory failure, and rhabdomyolysis. Besides supplementing patients with KCl to hasten recovery, the astute physician must search for the underlying cause to avoid missing a treatable and curable disorder. We report on an elderly Korean man who presented with marked limb paralysis, myalgias, and mild hypertension. He
Chih-Jen Cheng; Yeong-Hwang Chen; Tom Chau; Shih-Hua Lin
Bilateral vocal cord paralysis is a symptom that may lead to serious breathing problems. The treatment of patients with vocal cord paralysis presents a challenge to otolaryngologists. Many techniques have been developed in an attempt to improve the patient's airway insufficiency. The aim of the study was to evaluate the efficacy of the laser total unilateral arytenoidectomy with posterior cordectomy
Maciej Misiolek; Grzegorz Namyslowski; Krzysztof Warmuzinski; Jacek Karpe; Roman Rauer; Hanna Misiolek
Pediatric vocal cord paralysis represents a relatively common cause of airway obstruction presenting to the pediatric otolaryngologist. Depending on whether the paralysis is unilateral or bilateral, the child may present with symptoms of stridor, vocal dysphonia or aphonia, and\\/or aspiration. A thorough search for a possible underlying disorder is critical. Exact timing of intervention and the method of intervention vary
Christopher J. Hartnick; Dana M. Thompson; J. Scott McMurray; Roger C. Nuss; Benjamin E. Hartley; Allen D. Hillel
To determine the causes and site(s) of nerve injury and to identify potential predictors of vocal fold paralysis (VFP) after carotid endarterectomy (CEA) by application of intraoperative neuromonitoring (IONM). A total of 68 CEA patients were enrolled in this study. A 3-step IONM procedure was designed to obtain vocal fold EMG data at V1 (just after identification of the vagus nerve [VN]), V2 (just before arteriotomy), and V3 (just before wound closure). We also performed IONM before/after hemostasis near the VN using bipolar forceps and before/after dissection of the VN. All patients underwent laryngoscopy to assess postoperative VFP. One patient showed loss of EMG signals between V2 and V3 and developed VFP that persisted for 11 months. The other 62 patients had no loss of EMG signals, but 2 patients had confirmed VFP for 1 month after CEA. There were no changes of EMG signal before and after VN dissection or hemostasis with bipolar forceps near the VN. PMID:23341190
Tomonori, Tamaki; Minoru, Kubota; Norihiro, Saitou; Katsuya, Umeoka; Takayuki, Mizunari; Yoji, Node
Mutations of the skeletal muscle voltage-gated sodium channel (NaV1.4) are an established cause of several clinically distinct forms of periodic paralysis and myotonia. Focal paresis has sometimes already been described. We report a case with atypical clinical manifestation comprising paramyotonia and cold-induced persistent and focal paralysis. A 27-year-old woman presented with paramyotonia congenita since her childhood. She experienced during her childhood one brief episode of generalised weakness. At the age of 27, she experienced a focal paresis lasting for several months. The known mutation p.Val1293Ile was found in the muscle sodium channel gene (SCN4A). Channel inactivation is involved in most Na(+) channelopathies. Fast inactivation is known to be responsible for the myotonia phenotype. We hypothesise that the V1293I mutation may also alter the slow inactivation in specific conditions, for example, prolonged cold exposure or prolonged and intensive exercise. This observation broadens the spectrum of clinical manifestations of this sodium channel mutation. PMID:24939454
Magot, Armelle; David, Albert; Sternberg, Damien; Péréon, Yann
The goal of this study was to investigate the acute and chronic effects of paralysis induced by spinal cord section or sciatic neurotomy on bone blood flow in the rat. Regional bone blood flow was measured in the early stage with the hydrogen washout technique and the change of whole bone blood flow was measured in the early and the late stages with the radioactive microsphere technique. Four to 6 h after cordotomy at the level of the 13th thoracic vertebra, the regional bone blood flow in the denervated tibia increased significantly (p less than 0.01). After hemicordotomy with rhizotomy at the same level, the regional bone blood flow in the denervated tibia increased significantly (p less than 0.05) 6 h postoperatively. The whole bone blood flow in the denervated tibia had also increased significantly (p less than 0.05) at 6 h and at 4 and 12 weeks postoperatively. After sciatic neurotomy, the regional and the whole bone blood flow in the paralytic tibia did not change significantly. The present study demonstrated that monoplegic paralysis caused an increase in bone blood flow in the denervated hind limb from a very early stage. It was suggested that the spinal nervous system contributed to the control of bone blood flow.
Takahashi, H.; Yamamuro, T.; Okumura, H.; Kasai, R.; Tada, K. (Kyoto Univ. (Japan))
Aims. To report outcomes of the simultaneous surgical correction of vertical rectus paralysis combined with moderate-to-large angle horizontal strabismus. Methods. If a preoperative forced duction test was positive, antagonist muscle weakening surgery was performed, and then augmented partial rectus muscle transposition (APRMT) + partial horizontal rectus recession-resection was performed 2 months later. If a preoperative forced duction test was negative, APRMT + partial horizontal rectus recession-resection was performed. Antagonistic muscle weakening surgery and/or conventional recession-resection of the horizontal and/or vertical muscles of the contralateral eye was performed 2 months later, as needed. Results. Ten patients with a mean age of 22.3 ± 13.0 years were included and mean follow-up was 7.1 months. The mean vertical deviation that APRMT corrected was 21.4 ± 3.7 PD (prism diopter). The absolute deviation in horizontal significantly decreased from a preoperative value of 48.5 ± 27.4 PD to a value of 3.0 ± 2.3 PD 6 months postoperatively. The movement score decreased from a value of ?5 ± 0 preoperatively to a value of ?2.7 ± 0.8 at 6 months postoperatively. Conclusion. For patients with complete vertical rectus paralysis combined with a moderate- to-large angle of horizontal strabismus, combined APRMT and partial horizontal rectus recession-resection is safe and effective for correcting vertical and horizontal strabismus.
Zou, Leilei; Liu, Rui; Liu, Yan; Lin, Jing; Liu, Hong
There is overwhelming evidence that prone sleeping entails more risk of sudden infant death than supine sleeping does. However, no generally accepted biological explanation of this phenomenon has been found. In a viewpoint article in Acta Paediatrica in 1994 the author has re-emphasized that the fear paralysis reflex (tonic immobility) could be a cause of sudden infant death. The response consists of immobility, apnea, profound bradycardia and vasoconstriction. The bradycardia may proceed to irreversible asystole and silent death within a few minutes. In infant monkeys, this innate, atavistic reflex, which is prompted by aversive environmental fear-producing events, has the same age distribution as sudden infant death syndrome between the 2nd and 5th month of life. Main triggering stimuli are: restraint of movement (preventing flight) and sudden exposure to unfamiliar environments and persons, events for which the organism appears to be unprepared. Movements of the extremities are more restrained in the prone than in the supine position with greater chance of eliciting fear paralysis responses and death in prone sleepers. This biological mechanism presumably also applies to the winter peak (restraint due to overwrapping), sleeping outdoors (overwrapping) and co-sleeping in the same bed as another (parent). PMID:7701496
Current approaches for treating peripheral nerve injury have resulted in promising, yet insufficient functional recovery compared to the clinical standard of care, autologous nerve grafts. In order to design a construct that can match the regenerative potential of the autograft, all facets of nerve tissue must be incorporated in a combinatorial therapy. Engineered biomaterial scaffolds in the future will have to promote enhanced regeneration and appropriate reinnervation by targeting the highly sensitive response of regenerating nerves to their surrounding microenvironment. PMID:23790730
Marquardt, Laura M; Sakiyama-Elbert, Shelly E
Lesson is designed to introduce students to cranial nerves through the use of an introductory lecture. Students will then create a three-dimensional model of the cranial nerves. An information sheet will accompany the model in order to help students learn crucial aspects of the cranial nerves.
Juliann Garza (University of Texas-Pan American Physician Assistant Studies)
Paralysis periodica paramyotonica is an overlapping disease that shares the features of paramyotonia characteristic of paramyotonia congenita (PC) and periodic paralysis characteristic of hyperkalemic periodic paralysis. We report the case of a 23-year-old man with paralysis periodica paramyotonica. His father and a younger brother also exhibited a similar phenotype. A SCN4A Arg1448Cys mutation was detected in this family. The affected family members exhibited marked shifts in compound muscle action potential amplitudes on exercise test, and muscle weakness could be induced by potassium loading and cold exposure. This case demonstrates that SCN4A Arg1448Cys can produce paralysis periodica paramyotonica. Other genetic or environmental factors may modulate the manifestation of SCN4A Arg1448Cys mutation. PMID:16801039
Hsu, Wei-Chih; Huang, Yung-Chuan; Wang, Chung-Wei; Hsueh, Chia-Hsiang; Lai, Ling-Ping; Yeh, Jiann-Horng
Background: Several missense mutations of CACNA1S and SCN4A genes occur in hypokalemic periodic paralysis. These mutations affect arginine residues in the S4 voltage sensors of the channel. Approximately 20% of cases remain genetically undefined. Methods: We undertook direct automated DNA sequencing of the S4 regions of CACNA1S and SCN4A in 83 cases of hypokalemic periodic paralysis. Results: We identified reported CACNA1S mutations in 64 cases. In the remaining 19 cases, mutations in SCN4A or other CACNA1S S4 segments were found in 10, including three novel changes and the first mutations in channel domains I (SCN4A) and III (CACNA1S). Conclusions: All mutations affected arginine residues, consistent with the gating pore cation leak hypothesis of hypokalemic periodic paralysis. Arginine mutations in S4 segments underlie 90% of hypokalemic periodic paralysis cases. GLOSSARY HypoPP = hypokalemic periodic paralysis.
Matthews, E; Labrum, R; Sweeney, M G.; Sud, R; Haworth, A; Chinnery, P F.; Meola, G; Schorge, S; Kullmann, D M.; Davis, M B.; Hanna, M G.
Modifications of phonation occurring after total thyroidectomy (TT) are usually attributed to surgical malpractice, but other causes of voice impairment even in nonoperated subjects should also be taken into account. This study analyzes 208 patients who underwent TT from January 1, 1999 through December 31, 2001. Follow-up ended on December 31, 2003. Only cases in which the surgeon ruled out
Lodovico Rosato; Maria Teresa Carlevato; Giorgio De Toma; Nicola Avenia
Objectives Reduced range of hyoid and laryngeal movement is thought to contribute to aspiration risk and pharyngeal residues in dysphagia. Our aim was to determine the extent to which movements of the hyoid and larynx are correlated in the superior and anterior directions in swallowing, and whether movement range is predictive of penetration-aspiration or pharyngeal residue. Design Prospective, single-blind study of penetration-aspiration and pharyngeal residue with objective frame-by-frame measures of hyoid and laryngeal excursion from videofluoroscopy. Setting Tertiary hospital and rehabilitation teaching hospital. Participants 28 participants referred for videofluoroscopy: 13 females, aged 57-77; 15 males aged 54-70. Individuals with known neurodegenerative diseases or prior surgery to the neck were excluded. Each swallowed three boluses of 40% w/v thin liquid barium suspension. Outcomes Two speech-language pathologists independently rated penetration-aspiration, vallecular and pyriform sinus residue. Cervical spine length, hyoid and laryngeal displacement were traced frame-by-frame. Predictive power was calculated. Results Cervical spine length was significantly greater in males. Hyoid displacement ranged from 34-63% of the C2-4 distance. Arytenoid displacement ranged from 18-66%, with significantly smaller anterior displacement in males. Positive hyoid-laryngeal movement correlations in both axes were the most common pattern observed. Participants with reduced displacement ranges (? first quartile) and with abnormal correlation patterns were more likely to display penetration-aspiration. Those with reduced anterior hyoid displacement and abnormal correlation patterns had a greater risk of post-swallow pharyngeal residues. Conclusions It is difficult for clinicians to make on-line appraisals of the extent to which hyoid and laryngeal movement may be contributing to functional swallowing consequences during videofluoroscopy. This study suggests that it is most important for clinicians to discern whether reduced anterior displacement of these structures is contributing to a patient's swallowing impairment. Measures of structural displacement in thin liquid swallowing should be corrected for variations in participant height. Reductions in anterior hyoid and laryngeal movement below the first quartile boundaries are statistically associated with increased risk for penetration-aspiration and post-swallow residues.
Steele, Catriona M.; Bailey, Gemma L.; Chau, Tom; Molfenter, Sonja M.; Oshalla, Mohamed; Waito, Ashley A.; Zoratto, Dana C. B. H.
Peripheral neuropathy is a broad category of disorders with a diverse etiology, grouped together by their common pathogenic effect on the peripheral nervous system (PNS). Because of the heterogeneity observed to be responsible for these disorders, a forward genetics method of gene discovery was employed to identify additional affected pathways. In this report we describe the mutant mouse line 20884, generated by N-ethyl-N-nitrosourea (ENU) mutagenesis, which is characterized by adult-onset transitory hind limb paralysis. Linkage mapping revealed that two point mutations are responsible for the phenotype: a partial loss-of-function mutation in the gene for phosphatidate phosphatase Lpin1 and a truncation mutation in the gene that encodes the neuronal cell adhesion molecule NrCAM. To investigate how the 20884 Lpin1 and Nrcam mutations interact to produce the paralysis phenotype, the double mutant and both single mutants were analyzed by quantitative behavioral, histological, and electrophysiological means. The Lpin120884 mutant and the double mutant are characterized by similar levels of demyelination and aberrant myelin structures. Nevertheless, the double mutant exhibits more severe electrophysiological abnormalities than the Lpin120884 mutant. The Nrcam20884 mutant is characterized by normal sciatic nerve morphology and a mild electrophysiological defect. Comparison of the double mutant phenotype with the two single mutants does not point to an additive relationship between the two defects; rather, the Lpin120884 and Nrcam20884 defects appear to act synergistically to produce the 20884 phenotype. It is proposed that the absence of NrCAM in a demyelinating environment has a deleterious effect, possibly by impairing the process of remyelination.
Douglas, Darlene S.; Moran, Jennifer L.; Bermingham, John R.; Chen, Xiang-Jun; Brindley, David N.; Soliven, Betty; Beier, David R.; Popko, Brian
Infections of the laryngeal cartilages occur clinically as local pain, dysphonia, dysphagia or dyspnoea and may lead to destruction\\u000a of the laryngeal skeleton. We present positron emission tomography\\/computed tomography (PET–CT) as a new method for detection\\u000a and monitoring of laryngotracheal chondritis. We prospectively analyzed all patients undergoing PET–CT examination, of whom\\u000a we were clinically suspicious of laryngeal cartilage chondritis. When
Markus Gugatschka; Thomas Schwarz; Gerhard Friedrich
Purpose: To describe negative pressure pulmonary edema due to biting of the laryngeal mask tube at emergence from general anesthesia.\\u000a \\u000a \\u000a Clinical features: A healthy patient underwent general anesthesia using a laryngeal mask airway and mechanical ventilation. During recovery,\\u000a the patient strongly bit the laryngeal mask and made very forceful inspiratory efforts until the mask was removed. Five minutes\\u000a later, the
Jean-Michel Devys; Christine Balleau; Christian Jayr; Jean-Louis Bourgain
The larynx is the major organ of vocalization. The intrinsic laryngeal muscles modify the internal shape of the larynx while the extrinsic laryngeal muscles move the entire larynx vertically in the airway. Previous neuroimaging research has established the somatotopic location of the intrinsic musculature of the larynx in the human motor cortex and showed it to be in an evolutionarily novel location compared to the homologous region in monkey cortex. In the current study, we attempted for the first time to determine the somatotopic localization of the extrinsic laryngeal musculature in humans. In a functional magnetic resonance imaging experiment, we had participants voluntarily move their larynx upward and/or downward in the airway in the absence of vocalization to engage the extrinsic laryngeal muscles or vocalize in the absence of vertical laryngeal movement to engage the intrinsic laryngeal muscles. Vertical movement of the larynx activated ventral pericentral sensorimotor cortex extending dorsally to overlap with the representation of the intrinsic laryngeal muscles. This pattern is a reversal from the somatotopy of the monkey, where the extrinsic laryngeal muscles are represented dorsally to the intrinsic laryngeal muscles. PMID:24886776
Belyk, Michel; Brown, Steven
Reflux laryngitis in infants may be involved not only in laryngeal disorders, but also in disorders of cardiorespiratory control through its impact on laryngeal function. Our objective was to study the effect of reflux laryngitis on non-nutritive swallowing (NNS) and NNS-breathing coordination. Two groups of six newborn lambs, randomized into laryngitis and control groups, were surgically instrumented for recording states of alertness, swallowing and cardiorespiratory variables without sedation. A mild to moderate reflux laryngitis was induced in lambs from the experimental group. A significant decrease in the number of NNS bursts and apneas was observed in the laryngitis group in active sleep (p=0.03). In addition, lower heart and respiratory rates, as well as prolonged apnea duration (p<0.0001) were observed. No physiologically significant alterations in NNS-breathing coordination were observed in the laryngitis group. We conclude that a mild to moderate reflux laryngitis alters NNS burst frequency and autonomous control of cardiac activity and respiration in lambs. PMID:24893350
Brisebois, Simon; Samson, Nathalie; Fortier, Pierre-Hugues; Doueik, Alexandre A; Carreau, Anne-Marie; Praud, Jean-Paul
ObjectivesConcurrent chemoradiotherapy (CCR) was given for the previously untreated T4 hypopharyngeal and laryngeal squamous cell carcinoma patients and the response and survival rates were evaluated.
Goshi Nishimura; Mamoru Tsukuda; Choichi Horiuchi; Kenichi Satake; Takafumi Yoshida; Junichi Nagao; Mariko Kawakami; Norio Kondo; Yasuhiro Arai; Takahide Taguchi; Hideki Matsuda; Yasukazu Mikami
Background Laryngeal fracture is a rare condition that can lead to significant problems with airway patency, voice production, and swallowing. Conflict in the literature exists regarding the most suitable way to manage this injury. Case Report We present the case of a 29-year-old Caucasian man who sustained a displaced fracture of the thyroid cartilage due to blunt trauma. He reported no swallowing, breathing, or voice problems after 1 year, and his recovery can be attributed to the early recognition and proper management of his condition. Conclusion This case illustrates the importance of ensuring a high level of suspicion for laryngeal fracture in the acute trauma patient. Early identification of this injury allows early intervention that not only protects the airway but also improves long-term voice and airway outcomes.
Schaefer, Nathan; Griffin, Aaron; Gerhardy, Benjamin; Gochee, Peter
Laryngeal papillomatosis has a high rate of recurrence after surgery. Narrow band imaging (NBI) is a novel optical enhancement technology used for the diagnosis. This is the first report to date to indicate the availability of the combination of laryngomicro surgery and videoendoscopic surgery for laryngeal papillomatosis using NBI technology. The patients were a 34-year-old man and a 30-year-old man. Both patients underwent surgery in another hospital. However, due to recurrence, they were subsequently referred to the authors' department for further evaluation. The presence of papillomas was confirmed by NBI, and the papillomas were removed using an XPS Micro Debrider and a CO2 laser. Using the NBI system, the border between the normal mucosa and the papillomas could be clearly identified, allowing precise resection. Further treatment on the lesions has been carried out several times to date using NBI. The lesions have now been eradicated without further recurrence. PMID:22597574
Imaizumi, Mitsuyoshi; Okano, Wataru; Tada, Yasuhiro; Omori, Koichi
Pityriasis rubra pilaris (PRP) is a rare group of hyperkeratotic, papulosquamous diseases that can be acquired or inherited. Cases of PRP associated with malignancy have been rarely reported. We report a case of 46-year-old man who presented with rapidly progressing PRP as a possible initial cutaneous symptom of a previously undiagnosed laryngeal carcinoma. Microlaryngoscopy was performed because of the patient's hoarseness, and this revealed leucoplakia on the left vocal cord. Histopathological examination led to the diagnosis of squamous cell carcinoma in situ. After surgical treatment, the clinical signs of PRP began to resolve, and the patient was free of skin lesions at follow-up. This case represents a rare coexistence of PRP with malignancy, and indicates that PRP can occur as paraneoplastic dermatosis associated with laryngeal cancer. PMID:20055867
Batinac, T; Kujundzi?, M; Peternel, S; Cabrijan, L; Troselj-Vuki?, B; Petranovi?, D
A comparison is made of the radiologic and clinical findings in 51 patients with laryngeal carcinoma. The radiologic methods comprised conventional films, tomography and laryngography; the clinical examination technique included microlaryngoscopy and the use of a 90 degrees optical instrument. Laryngography was found to be superior to the other two radiologic methods, for the delineation of the tumors. Radiology should be performed before laryngoscopy and biopsy. PMID:920236
Olofsson, J; Sökjer, H
Paragangliomas are neuroendocrine tumours commonly seen in the adrenal gland. The commonest paraganglioma that arises from extra-adrenal sites is carotid body. Paragangliomas are rarely seen in the larynx. It is, however, important to consider paragangliomas of the larynx in the differential diagnosis of the laryngeal masses. This study introduces a 63-year-old man who has been suffering from hoarseness for 18
Harun Üçüncü; Bülent Aktan; Yavuz Sütbeyaz; Erzurum Suat Eren
There are significant differences in how laryngeal cancer affects the two genders, with cases occuring predominantly in males.\\u000a This has been speculated to result from the different susceptibilities of the tumor cells to steroid sex hormones. Since the\\u000a sex hormone action is mediated by specific cellular receptors, several previous studies have analyzed the presence of these\\u000a sex-hormone receptors. However, the
Hjalmar G. Hagedorn; Andreas G. Nerlich
Ours is a developing country. We have still not controlled the common infectious diseases which are extinct in the West; therefore, our limited resources are spent on study of epidemiology of infectious diseases. My conclusions on epidemiology of cancer of the larynx are drawn from observations made of the clinical material over a period of 25 years. I have come to the conclusion that the smoked tobacco and the slaked lime in the Indian "Pan" are the two important carcinogenic agents. Poor nutrition appears to be carcinogenic. It requires study and confirmation at a cellular level. Misuse of voice does seem to be the cause of laryngeal cancer. Racial, genetic and other environmental factors, including pollution have not contributed to the increased incidence of laryngeal cancers. The common histological types of laryngeal cancer are known. My observations on certain biological behavior of the tumor have been helpful. 1. An exophytic growth is less infiltrative; its metastatic mass reflects the same characteristics. 2. Certain anaplastic tumors can flout all laws of cancer spread and metastasize in distal organs. 3. Presence of reticular hyperplasia in peripheral lymph nodes is of good prognostic value. PMID:1171341
Hiranandni, L H
OBJECTIVE To evaluate the consequences of lifetime, severe and un