Advances in Oto-rhino-laryngology

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Neurolaryngology as a subspecialty of laryngology has developed considerably in the last four decades with more laryngologists, neurologists, speech and swallow therapists, and neurophysiologists taking interest in the field. The North American and Japanese laryngology societies have increasingly focused on conditions which are mainly concerned with aberrations of the nervous system affecting the larynx directly or indirectly. In the last few years, societies in Europe and the Asia-Pacific have also recognized the need to collaborate both within their organizations and with other societies globally...

We here summarize the structures of the laryngeal vocal fold as well as its insertion structures at the anterior commissure and at the area of the vocal process and place these findings within the context of biomechanical, functional, and clinical implications.

Injury to the recurrent laryngeal nerve (RLN) can result in impairment of all three laryngeal functions. The RLN is capable of regeneration, but laryngeal functions in cases of severe injury remain impaired. This permanent impairment is caused by either incomplete regeneration and/or occurrence of laryngeal synkinesis. Laryngeal reinnervation can be approached either nonselectively, focusing on nerve reconstruction, or selectively, focusing on separate target muscle reinnervation. Nonselective reinnervation comprises anastomosis to the mainstem of the RLN leading to reinnervation of both abductor and adductor muscle groups (nerve-based reconstruction)...

Neuromuscular diseases (NMDs) are diseases involving the motor nuclei of the cranial nerves and anterior horn cells of the spinal cord, the peripheral nerves, the neuromuscular junction, and/or muscle itself. The following groups of disorders from the WHO International Classification of Diseases are usually included in the classification of NMDs: (1) Motor neuron diseases or related disorders; (2) Disorders of nerve root, plexus or peripheral nerves; (3) Diseases of neuromuscular junction or muscle. These diseases include myasthenia gravis or certain specified neuromuscular junction disorders, primary disorders of muscle, and secondary myopathies...

Videostroboscopy and high-speed imaging is now an accepted way to evaluate laryngeal function in patients with voice disorders. In patients with neurolaryngological diseases such as tremor, laryngeal spasm, and paralysis, having an objective way to evaluate vocal function is desirable. Using digital imaging and analysis, both the videostroboscopy and the high-speed video can be analyzed to obtain relevant measures of vocal function. From the videostroboscopy, the montage of the glottal cycle derived from steady of vocal vibration can be analyzed by using edge tracking software to obtain the glottal area waveform...

Laryngeal electromyography (LEMG) is an important diagnostic and prognostic tool in neurolaryngology. This chapter presents the advances in LEMG in the last 5 years based on clinical trials. LEMG is in most cases an office-based procedure for decision making in neurolaryngology. When performed in a standardized way, LEMG helps to differentiate abnormal function of the vocal folds from nonorganic disorders. It is mainly used to confirm the diagnosis of vocal fold paralysis (VFP) and is less frequently used for the diagnosis of myopathies and motor neuron disorders...

Visual diagnosis of laryngeal neurologic impairments is not only possible but is perhaps the most accurate method for evaluating the neurologic status of the upper airway. Precise assessments may lead to appropriate treatment without an EMG study. Principles of the neurolaryngology examination include: (1) each muscle has a single action; (2) that action can be elicited and to some degree isolated and visualized; (3) each muscle has an appropriate time to contract; (4) that timing can be compared to the opposite side; (5) inappropriate timing represents reinnervation; (6) inappropriate degree of motion represents reinnervation; (7) patients naturally compensate for any loss; (8) removing compensation during an exam reveals pathology...

In the setting of a voice clinic, the voice may be assessed in a number of different ways. As a bare minimum, assessment should include stroboscopic examination, patient self-reported questionnaires, and clinician-reported perceptual evaluation. In addition, recordings of the voice may be analyzed using computer software: several different measures exist, but the most widely used are jitter, shimmer, and noise-to-harmonic ratio. There are, however, significant limitations of these measures, including access to the equipment, inter-test reliability of the measurements, and a lack of correlation with clinical improvement...

The role of imaging in assessment of neurolaryngology will predominantly involve the assessment of pathology along that of laryngeal nerve pathways. The anatomical pathways of the vagus and laryngeal nerves are well described in standard anatomical textbooks and will not be detailed here. Whilst there are 3 principle laryngeal nerves/branches, the recurrent laryngeal nerve will clearly constitute the mainstay of imaging input. This chapter will elaborate on the pathology encountered at the various levels and the imaging characteristics of these disorders...

The history of research on the voice of opera soloists shows that there are certain functional features of the cranial nerves and cortical nerve centers. In this chapter, we review the most important findings in the field of canto voice neuroanatomy, which we corroborate with the results of our team research and experience. Our study focuses on the nerve structures involved in phonation at each level of the vocal formants: infraglottic, glottic, and oropharyngeal. We consider this research to have direct applicability in the fields of neurolaryngology, neuroscience, phoniatry, but also in the academic teaching...

Adduction arytenopexy is a surgical procedure that allows the surgeon to position the arytenoid cartilage in a vocally favorable position with a suture. It is not needed in most cases of vocal paralysis when there is favorable synkinesis and good positioning of the arytenoid body. When there is a large posterior gap (intercartilaginous region), height discrepancy, or an anteriorly displaced arytenoid, adduction arytenopexy is used to suture the arytenoid cartilage into the posterior and medial aspect of the cricoarytenoid joint facet, bringing the medial bodies of the arytenoid cartilages together allowing increased closure resulting in higher dynamic range in postoperative voices...

Laryngeal synkinesis as a form of defective healing is the rule rather than the exception in persistent vocal fold paralysis. It typically occurs 4-6 months after the onset of the recurrent laryngeal nerve paralysis. The incidence is up to 85%. Not all laryngeal muscles need to be equally affected. Reliable evidence can only be provided by a laryngeal electromyography. Physiological co-activation of the laryngeal muscles during antagonistic maneuvers must be considered. Although synkinesis undeniably worsens the prognosis for a motion recovery, it protects the muscle fibers from degeneration...

The objectives of this chapter are to discuss the factors involved in the decision-making algorithm of an appropriate intervention for glottal insufficiency. Management strategies not only depend on the etiology, history, symptoms, size of glottal gap on visualization, but also on patient goals and expectations. The goal of this chapter is to organize the management of glottal incompetence for patients and providers, supported by an evidence-based approach.

Spasmodic dysphonia (SD) is a rare focal laryngeal dystonia. It is characterized by task-specific voice dysfluency resulting from selective intrinsic laryngeal musculature hyperfunction. Symptoms may be attenuated by a sensory trick. Although SD can be seen at times in generalized dystonia syndromes, it is typically a sporadic phenomenon. Involvement of the laryngeal adductor muscles is more common than abductor muscles. The standard treatment of this disorder is with botulinum toxin injection, usually electromyography-guided, which must be repeated periodically as the toxin wears off...

Laryngeal transplantation offers the hope of replacing voice and laryngeal function in patients with debilitating laryngeal injuries or loss of the larynx from trauma or oncologic reasons. Our group at UC Davis performed a laryngotracheal transplantation, and our experience is reviewed in this chapter. The indications, challenges, and limitations of this procedure are highlighted, and the world's other published cases are reviewed.

Injection laryngoplasty as used in this chapter is synonymous with the term "injection augmentation." Injection augmentation is a technique designed to enhance glottic closure in patients with glottic insufficiency, or failure of glottic closure, by injecting material into the lateral aspect of the vocal fold to move the vibrating surface to the midline. This type of injection augments the vocal fold and improves glottic closure. Injection augmentation originated over 100 years ago. However, the current indications, techniques, and materials have changed significantly...

Vocal fold immobility can be either unilateral or bilateral and partial or complete. The aim of this chapter is to discuss the management of unilateral paresis using medialization thyroplasty with or without arytenoid adduction as a means of treating neurogenic causes as opposed to mechanical fixation. Medialization thyroplasty is an open surgical procedure that is performed under local or general anesthesia. Essentially, it aims to close the glottic gap, approximating both vocal folds together and thereby allowing for restoration of the efficiency of the larynx...

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Treating malignant tumors of the anterior skull base (ASB) is a challenging task, given their late presentation, diverse histology, and involvement of an intricate anatomical space requiring complex surgery. Advances in imaging, gradual refinement of surgical and reconstruction techniques, and improvement of perioperative care during recent decades have resulted in improved clinical outcomes for patients. In addition, assessing functional outcomes and quality-of-life issues have become a fundamental part in the holistic care of patients with ASB tumors...