Endolaryngeal contact pressures

In this work, we present a new method for in vivo endolaryngeal contactpressure measurement with a miniature pressure transducer. Using this methodology, contact pressures can be measured during videoendoscopy at different locations between the artyenoids and also at various locations along the membranous vocal folds. Twenty adults with organic and functional voice disorders and two vocally healthy adults participated as subjects. Endolaryngeal contact pressure measures were made during a series of phonatory tasks varying pitch, loudness, and phonatory onset and offset. Measures were also made during nonphonatory tasks, including throat clearing, coughing, Valsalva maneuvres, and gagging. The most remarkable findings were: (1) interarytenoid contact pressures were considerably greater than intraglottal contact pressures; (2) interarytenoid contact pressures were greater for lower than higher pitches; (3) both interarytenoid and intraglottal contact pressures were remarkably large during hard glottal attack; and (4) overall, the largest endolaryngeal pressures were recorded between the arytenoids, during a thoracic fixation maneuver and during gag reflex.This work was supported in part by Deutsche Forschungsgemeinschaft (He 2869/1-1), by a grant from the “Verein zur Förderung hör-, sprach- und stimmgestörter Patienten an der FU Berlin e.V.” (nonprofit organization), Berlin, Germany, and by Grant No. K08 DC00139 from the National Institute on Deafness and Other Communication Disorders.     

Arytenoid Cartilage Dislocation: A 20-year Experience

SUMMARY: Arytenoid cartilage dislocation is an infrequently diagnosed cause of vocal fold immobility. Seventy-four cases have been reported in the literature to date. Intubation is the most common origin, followed by external laryngeal trauma. Decreased volume and breathiness are the most common presenting symptoms. We report on 63 patients with arytenoid cartilage dislocation treated by the senior author (RTS) since 1983. Significantly more posterior than anterior dislocations were represented. Although reestablishing joint mobility is difficult, endoscopic reduction should be considered to align the heights of the vocal processes. This process may result in significant voice improvement even long after the dislocation. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography (CT) imaging are helpful in the evaluation of patients with vocal fold immobility to help distinguish arytenoid cartilage dislocation from vocal fold paralysis. Familiarity with signs and symptoms of arytenoid cartilage dislocation and current treatment techniques improves the chances for optimal therapeutic results.     

Permanent medialization of the paralyzed vocal fold utilizing botulinum toxin and Gelfoam

The clinical picture of a paralyzed vocal fold often has the same appearance as a subluxated arytenoid, with anterior and medial displacement of the arytenoid and a foreshortened and lax vocal fold. Previous work by the authors has shown that a subluxated arytenoid may be permanently repositioned by reduction and selective injection of the intrinsic laryngeal musculature with botulinum toxin. The injection changes the forces within the larynx, allowing the arytenoid to be brought back to proper position on the cricoid cartilage. This concept has been extended to the paralyzed vocal fold. It has been noted that even a clinically paralyzed vocal fold has voluntary motor units that may still act on the arytenoid through residual action from the interarytenoid and synkinesis. These forces are significant enough to manipulate the arytenoid and, thus, the vocal fold, into its correct, adducted position. In this paper, the arytenoid is mobilized to free any fibrosis. The thyroarytenoid and lateral cricoarytenoid muscles are then injected to prevent any forward synkinetic pull on the arytenoid. Next, a Gelfoam injection medializes the vocal fold to create glottic closure. This rebalancing sufficiently positions the arytenoid, so that valvular function is permanently restored. In the ten patients studied for over 1 year, there was a 90% success rate as measured by videostroboscopy, phonation time, and V-RQOL analysis. There were no untoward complications. All the materials used are nonpermanent. The procedure does not limit other techniques from being performed at a later time.     

Arytenoid dislocation

Arytenoid dislocation is a common yet infrequently diagnosed complication of laryngeal trauma. It may result in various symptoms, including permanent dysphonia, although immediate voice change is not always present. Early reduction is the treatment of choice; however, late reduction is often successful in restoring voice. A high index of suspicion based on the history of the patient is necessary to recognize arytenoid dislocation. Thorough physical examination and objective tests are helpful in confirming this diagnosis.     

Unilateral recurrent laryngeal nerve paralysis: A re-examination

Re-examination of flexible fiberoptic videotaped laryngeal images of 39 patients with unilateral recurrent laryngeal nerve paralysis (URLNP) by four observer-judges revealed consistent findings of a unilaterally appearing shorter vocal fold with asymmetry of the arytenoid complex on the involved side. No previous similar experience in otolaryngological training or practice has been encountered. Multiple discrepancies between and among observer-judges regarding vocal fold positions during phonation were encountered. Possible explanations are discussed. The need for further investigation to determine the mechanics causing these differences is stressed. It is suggested that for the present, such terms as median, paramedian, and intermediate be used in teaching and in practice as generalities only.