Professor FU Wenbin's experience of "acupuncture-moxibustion-consolidation" holistic idea in treatment of laryngeal herpes zoster with vocal cord paralysis. / 符文彬教授整合思维"一针二灸三巩固"模式治疗喉带状疱疹伴声带麻痹的临床经验.

This paper introduces professor FU Wenbin's clinical experience in the treatment of laryngeal herpes zoster with vocal cord paralysis, using the holistic mode of treatment, in which, acupuncture, moxibustion and consolidation regimens are integrated. Regarding the core pathogenesis of the disease, the invaded exogenous toxic heat is transformed into fire that flows to the throat. Soothing liver and releasing heat is the general principle of treatment, guiding the entire process of treatment. For acupuncture regimen, the filiform needling is used and the acupoint prescription is composed of Baihui (GV 20), Yintang (GV 24+), Lianquan (CV 23), the four-gate points (bilateral Hegu [LI 4] and Taichong [LR 3]), the group points for conducting qi back to the primary (Zhongwan [CV 12], Xiawan [CV 10], Qihai [CV 6] and Guanyuan [CV 4]), as well as bilateral Fengchi (GB 20), Wangu (GB 12) and Yifeng (TE 17). Besides, the pricking technique is delivered to the posterior wall of the pharynx for soothing the liver, regulating the spirit, reducing the heat and benefiting the throat. For the moxibustion regimen, moxibustion is applied to Fengchi (GB 20), Feishu (BL 13), the four-flower points (bilateral Geshu [BL 17] and Danshu [BL 19]), Shenshu (BL 23) and Mingmen (GV 4), which nourishes the spleen and stomach and reduces the heat pathogen through the heating action of moxibustion specially. In the stage of consolidation, the bloodletting and cupping technique is used at Xinshu (BL 15), Ganshu (BL 18) and Jianjing (GB 21) to eliminate the liver stagnation and the intradermal needling is delivered to sustain the needling stimulation and consolidate the therapeutic effect.

Bilateral Functional Electrical Stimulation for the Treatment of Presbyphonia in a Sheep Model.

OBJECTIVES: The aim of the study was to increase muscle volume and improve phonation characteristics of the aged ovine larynx by functional electrical stimulation (FES) using a minimally invasive surgical procedure. METHODS: Stimulation electrodes were placed bilaterally near the terminal adduction branch of the recurrent laryngeal nerves (RLN). The electrodes were connected to battery powered pulse generators implanted subcutaneously at the neck region. Training patterns were programmed by an external programmer using a bidirectional radio frequency link. Training sessions were repeated automatically by the implant every other day for 1 week followed by every day for 8 weeks in the awake animal. Another group of animals were used as sham, with electrodes positioned but not connected to an implant. Outcome parameters included gene expression analysis, histological assessment of muscle fiber size, functional analysis, and volumetric measurements based on three-dimensional reconstructions of the entire thyroarytenoid muscle (TAM). RESULTS: Increase in minimal muscle fiber diameter and an improvement in vocal efficiency were observed following FES, compared with sham animals. CONCLUSION: This is the first study to demonstrate beneficial effects in the TAM of FES at molecular, histological, and functional levels. FES of the terminal branches of the RLN reversed the effects of age-related changes and improved vocal efficiency. LEVEL OF EVIDENCE: NA Laryngoscope, 134:848-854, 2024.

Effect of intracordal injection under local anesthesia on vital signs in high-risk patients.

OBJECTIVE: Intracordal injection under local anesthesia is widely performed; however, few studies show hemodynamic changes in the heart rate, blood oxygen saturation, and blood pressure during intracordal injection under local anesthesia. This study examined changes in vital signs (heart rate, blood oxygen saturation, systolic blood pressure, diastolic blood pressure) during intracordal injection under local anesthesia among high-risk patients and investigated whether intracordal injection under local anesthesia could be safely conducted. METHODS: A retrospective chart review was adopted as the research design. We investigated the changes in vital signs (heart rate, blood oxygen saturation, blood pressure) before and after intracordal injection with basic fibroblast growth factor (bFGF) preparations under local anesthesia in 46 patients who visited our institution and developed unilateral vocal cord paralysis after a thoracic aortic aneurysm, thoracic aortic dissection surgery, thyroid disease, esophageal disease, idiopathic disease, etc. RESULTS: The average operation time for the high-risk group was 3.67 minutes, with the shortest operating time being 2 minutes and the maximum operating time being 13 minutes. The average operation time for the control group was 3.73 minutes, with the shortest operating time being 1 minute and the maximum operating time being 9 minutes. Results before and after intracordal injection with bFGF preparations under local anesthesia for heart rate, blood oxygen saturation, systolic blood pressure, and diastolic blood pressure had P-values of 0.324, 0.394, 0.215, and 0.508, respectively, in the high-risk group, and no significant differences were found. Conversely, heart rate, blood oxygen saturation, systolic blood pressure, and diastolic blood pressure had P-values of 0.057, 0.232, 0.265, and 0.091, respectively, in the control group, and no significant differences were found. CONCLUSION: Intracordal injection under local anesthesia may be safe, even for patients who require blood pressure management after thoracic aortic disease surgery.

Functional Evaluation of Larynx Nerve Stimulator With EMG Acquisition Capability and Wireless Connectivity.

Recently, an electrical stimulation of the paralyzed muscle, as a potential therapy for restoring function of a denervated muscle system, has been debated as an innovative treatment in the management of patients with laryngeal paralysis. Numerous studies in acute and chronic animal models have demonstrated that electrical stimulation of the paralyzed posterior cricoarytenoideus muscle (PCA) offers an approach to induce vocal fold abduction and restore ventilation through the glottis. The study aims to test applicability of the controlled opening of the rima glottides via direct electrical stimulation of the posterior cricoarytenoideus muscle. We developed for this purpose a novel instrument system for the controlled larynx nerve stimulation. An acute experiment on the 4 years old pig showed effectiveness of the engineered stimulator. The controlled opening of rima glottidis of both posterior cricoarytenoid muscles and afterwards of both PCA muscle contraction were observed as a result of the electrical stimulation with the applied current in the range of 0.1-3 mA and pulse width of 1 ms and 10 ms. Performed research indicates a large potential of the novel nerve stimulator for the human larynx stimulation.

[Neurolaryngology]. / Neurolaryngologie.

Neurological and neurophysiological knowledge of neuromuscular diseases is combined in neurolaryngology with experience from laryngology. Laryngeal electromyography (LEMG) is the most important diagnostic and prognostic tool in neurolaryngology. It can be combined with diagnostic electrostimulation. Interest in LEMG today extends beyond the thyroarytenoid muscle to all accessible laryngeal muscles. LEMG should be performed and interpreted according to a standardized protocol. Main applications of LEMG are confirmation, topodiagnostic and prognostic assessment of vocal fold paralysis. It is possible to differentiate fresh from old recurrent laryngeal nerve lesions as well as mechanical vocal fold fixations from paralysis. Needle guidance for botulinum toxin injections in spasmodic dysphonia and for augmentation laryngoplasty can be supported by LEMG, but also by laryngeal ultrasound. The timing of therapy for temporary and permanent augmentations, thyroplasty and reinnervation surgery may be better defined with experience from neurolaryngology. The use of diagnostic neurostimulation can reveal any remaining active movement potential of a vocal fold and thus help identify candidates for future laryngeal pacemaker treatments. Other topics in neurolaryngology include spasmodic dysphonia and underlying neurological diseases such as stroke, central vocal fold paralysis, essential tremor and Parkinson's disease. Laryngoscopic, clinical and LEMG characteristics of these diseases are presented.

Anesthetic Management for Awake Tubeless Suspension Microlaryngoscopy.

OBJECTIVES/HYPOTHESIS: Patients' eligibility for bilateral selective laryngeal reinnervation surgery is evaluated by suspension microlaryngoscopy (SML) examination with laryngeal electromyography (LEMG). Maintaining spontaneous ventilation, with remifentanil sedation/analgesia without endotracheal tube, to allow the patient to phonate with the surgeon during awake, LEMG is a major challenge for the anesthesiologist and the otorhinololaryngologist. The objective of this study was to evaluate the safety and efficacy of a novel anesthesia protocol to manage airway access during awake tubeless SML. STUDY DESIGN: Retrospective study. METHODS: Anesthesia records of patients undergoing awake SML with LEMG were retrospectively analyzed. Procedures were performed with remifentanil sedation/analgesia with targeted controlled infusion (TCI) in combination with local anesthesia. The main outcome was the failure rate of the anesthesia protocol during the procedure. Secondary outcomes were as follows: rate of apnea requiring ventilation, airway bleeding, regurgitation, hemodynamic data as well as vasopressor use, complications, and surgeon satisfaction with the procedure. RESULTS: Data were obtained for 39 patients between November 2017 and September 2019, the mean age was 52 years and 29 (74%) were female. All procedures were completed without complications (0% [0-9]). Three patients (8% [1.6-20.8]) had an intraoperative episode of hypoxemia requiring mask reventilation. There was no airway bleeding, no regurgitation, and no hypotensive episode. Three patients (8% [1.6-20.8]) had noninvasive ventilation for respiratory distress after the end of the procedure. CONCLUSIONS: Our results show that awake tubeless SML allowing phonation during LEMG can be realized under sedation and local anesthesia. However, further data are needed concerning the intraoperative and postoperative safety of the procedure. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2669-E2675, 2021.

Applicability of Selective Electrical Surface Stimulation in Unilateral Vocal Fold Paralysis.

OBJECTIVE: Selective electrical surface stimulation (SES) of the larynx is not yet routinely considered therapy option in treatment of unilateral vocal fold paralysis (UVFP). Goal of this monocentric feasibility study was to provide systematic data on applicability of SES of intrinsic laryngeal muscles in UVFP under consideration of sensitivity and discomfort thresholds and nonselective side effects. METHODS: Thirty-two UVFP patients were included in the study. Symmetric triangular-shape, charge-balanced pulse widths (PWs) of 1, 10, 25, 50, 100, 250, and 500 milliseconds (ms) were tested with increasing amplitudes (AMPs). The stimulation was delivered as a train of five pulses using square surface electrodes. Selective laryngeal responses were examined by flexible laryngoscopy. Nonselective side effects (swallowing reflex, coughing, different severity degrees of unspecific strap muscle/platysma response) were judged by observation. RESULTS: Selective laryngeal response could be triggered in 28/32 (87.5%) patients during respiration/rest and in 26/32 (81.3%) patients during phonation. The most effective PWs for the selective eliciting of selective bilateral vocal fold adduction are comprised between 50 and 100 ms in combination with an average AMP comprised between 7.1 and 7.2 mA. CONCLUSION: Our results indicate that, in UVFP patients, PWs comprised between 50 and 100 ms in combination with a median AMP between 7.1 and 7.2 mA are expected to deliver in >75% of the cases a specific, effective, and safe bilateral adduction of the VF. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2566-E2572, 2021.

Rehabilitation Protocol for Unilateral Laryngeal and Lingual Paralysis (Tapia Syndrome): Comment About "A Challenging Case of Tapia Syndrome After Total Thyroidectomy" By Ildem Deveci, Mehmet Surmeli, and Reyhan Surmeli.

Tapia syndrome is a rare complication after surgery, with ipsilateral paralysis of vocal cord and tongue due to extracranial involvement of recurrent laryngeal and hypoglossal nerves. Tapia's case report is extremely interesting for both the rarity of the reported cases and for the importance of an early rehabilitation. In a previous work, we reported a case of Tapia syndrome after cardiac surgery for aortic aneurysm, and the protocol of logopedic rehabilitation adopted. In the postoperative period, he developed severe dyspnea and dysphagia that required a tracheostomy and a logopedic rehabilitation therapy that led to a fast and efficient swallowing without aspiration after 47 sessions (less than 4 months). The progressive recovery of the function suggests aprassic nerve damage. However, the logopedic therapy is recommended to limit the possibility of permanent functional deficits and quickly recover swallowing and phonation.

Subcutaneous Ports for Chronic Nerve Cuff and Intramuscular Electrode Stimulation in Animal Models.

OBJECTIVE: Tracking recovery after nerve injury may require many intermittent assessments over long periods, preferably with non- or minimally invasive methods. We developed subcutaneous electrical connection ports (ECPs) for repeated connection to nerve cuff or intramuscular electrodes via transdermal needles and evaluated them during studies of laryngeal reinnervation. STUDY DESIGN: Animal experiment. SETTING: Laboratory. METHODS: ECPs were designed and 3-dimensionally printed for connection to bipolar electrodes with biocompatible polymers. Dual compartments filled with conductive silicone capped with nonconductive silicone were used to make the connections between electrode leads and transdermally inserted needles. Ten dogs (19-29 kg) were implanted with 22 ECPs. In 7 dogs, 11 electrodes were placed on recurrent laryngeal nerves proximal to transection and suture repair to track laryngeal reinnervation. In 6 dogs, 8 spinal accessory nerve cuff electrodes were used to stimulate neck muscle contraction. In 2 dogs, 3 electrodes were implanted in the thyroarytenoid muscle. Stimulation thresholds, electromyography, and videolaryngoscopic imaging were obtained in 156 tests over survival periods up to 32 months. Stimulation data provided information about ECP performance. RESULTS: ECPs added negligible resistance to electrodes (mean ± SD, 2.14 ± 0.9 Ω). Despite some electrode leads breaking distally, ECPs were reliable and well tolerated at implant sites and enabled periodic assessment of nerve and muscle function over the time course of laryngeal reinnervation. Histology showed ECP encapsulation as thin layers of connective tissue and minimal acute inflammation. CONCLUSION: Custom ECPs are easily fabricated and cause little tissue reaction over months to years of subcutaneous implantation, facilitating long-term physiologic studies.

Comparison of voice therapy and selective electrical stimulation of the larynx in early unilateral vocal fold paralysis after thyroid surgery: A retrospective data analysis.

OBJECTIVES: The goal of the retrospective study was to investigate the 3-month-outcome after treatment of patients with early unilateral vocal fold paralysis (UVFP) with either standard voice therapy (VT) or selective electrical stimulation of the larynx (SES). DESIGN: Non-randomised retrospective study. SETTING: 1519 patients who underwent thyroid surgery between 2015 and 2018 were analysed according vocal fold mobility; UVFP patients were treated either by VT or SES. PARTICIPANTS: 51 UVFP patients. MAIN OUTCOME MEASURES: 51 UVFP patients have been advised regarding treatment options like either VT (group 1) or SES (group 2). The patients of group 1 (n = 26) and 2 (n = 25) were re-assessed up to 3 months post-operatively regarding UVFP persistence/recovery and perceptive voice sound quality. At follow-ups, perceptual analysis of voice sound (using roughness=R/breathiness=B/hoarseness=H scale) and endoscopic laryngoscopy have been performed. Position of immobile vocal fold, shape of glottal closure and RBH parameters have been considered for statistical analyses. RESULTS: Restitution of UVFP with regular respiratory vocal fold mobility of both vocal folds occurred in 53.8% of group 1 (VT), and in 40.0% of group 2 (SES) after 3 months of therapy between both groups. No difference could be seen for RBH, type of glottal closure and position of ailing vocal folds in patients with persisting UVFP within both groups and between the groups. CONCLUSIONS: The study reveals that SES can achieve similar functional outcome in early UVFP. Thus, it should be considered as an equivalent therapy alternative to VT for treatment of early UVFP patients since no significant difference in vocal outcome and glottal configuration between the two groups could be demonstrated.

Rehabilitation Therapy for Vocal Fold Paralysis Caused by Lung Cancer: A Case Report.

OBJECTIVE: Unilateral vocal fold paralysis (UVFP) can be caused by iatrogenic injury or tumor-induced damage to the recurrent laryngeal nerve. Studies of comprehensive rehabilitation therapies for patients suffering from severe UVFP are limited. The purpose of this case report is to describe an improvement in complete aphonia after comprehensive rehabilitation therapies in a patient with severe UVFP due to a lung tumor. METHODS: An 81-year-old woman with a history of bronchial adenoma had complete aphonia due to compression of the left recurrent laryngeal nerve by the tumor. Dynamic fibrolaryngoscope revealed paralysis of the left vocal fold. The patient was treated with interferential current therapy, vocal training, and kinesiology taping. Indicators of voice recovery were scored according to the grade, roughness, breathiness, asthenia, strain scale, and the voice handicap index. RESULTS: After 10 days of comprehensive rehabilitation treatment, the patient recovered from complete aphonia to normal communication. The hoarseness and breathiness of patient were significantly improved. In addition, the grade, roughness, breathiness, asthenia, strain, and the voice handicap index scores changed from severe to mild or absent. CONCLUSION: This case provided a novel comprehensive treatment for a patient with UVFP, which was safe, cost-effective, and easy to implement in clinic.

Laryngeal Synkinesis: A Viable Condition for Laryngeal Pacing.

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. A differentiation is required between favorable synkinesis (type I according to Crumley), which does not always require further therapy in the case of unilateral paralysis, and unfavorable forms of synkinesis (type II-IV) according to Crumley, which are associated with a functionally relevant malposition of the vocal fold(s) or with vocal fold jerks. Particularly when bilateral vocal fold motion does not return, type I synkinesis can be a good prerequisite for new dynamic therapy approaches, such as laryngeal pacing. The rarely occurring type II-IV synkinesis should, whenever possible, be transformed into a more favorable type I synkinesis by selective or non-selective reinnervation at an early stage of the disease. The latter applies to expected muscle atrophy with insufficient regrowth of nerve fibers.

Laryngeal Electromyography.

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. Also, the value of LEMG for other diseases than VFP is presented. First consensus recommendations for standard performance of LEMG have been published. This will facilitate the comparison of results from different researchers in the future. For many years, LEMG focused on the thyroarytenoid muscle. Data are presented showing that now more and more studies are performed including other laryngeal muscles, most importantly the posterior cricoarytenoid muscle and cricothyroid muscle. Diagnostics and estimating the prognosis for patients with VFP remains the most important issue for LEMG. First meta-analyses are now available analyzing which LEMG parameters are the best prognosticators for recovery or persistent palsy. Due to the advances in multichannel LEMG, laryngeal nerve monitoring can now control the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve during thyroid surgery. Finally, also the advances of LEMG for laryngeal pacing, guided laryngeal injections, laryngeal electrostimulation, and other indications beyond otolaryngology are discussed.

Preoperative Potassium Iodide Treatment in Patients Undergoing Thyroidectomy for Graves' Disease-Perspective of a European High-Volume Center.

BACKGROUND: Potassium iodide (KI) treatment affects the vascularity of the thyroid gland and therefore may improve intraoperative visualization of essential structures. However, clear evidence for its usage is lacking, and its implementation in patients suffering from Graves' disease is becoming rare. The objective of this retrospective study was to assess the impact of KI treatment on the intraoperative course and the outcome of patients undergoing thyroidectomy for Graves' diseases. METHODS: The study included 442 patients: 125 patients (28.3%) who received a preoperative treatment with KI ("Group KI") and 317 patients (71.7%) without a KI therapy ("Group No-KI"). Indication for KI treatment was a thyroid bruit (82.5%), as well as hyperthyroidism refractive to medical treatment with antithyroid drugs (17.4%). RESULTS: All patients underwent total thyroidectomy. Permanent vocal cord paresis and permanent hypoparathyroidism were similar in both groups. KI treatment was associated with a significantly longer operative time (142 vs. 128 min, p < 0.001) and a significant higher weight of the thyroid gland. KI treatment did not impact duration of hospital stay or occurrence of secondary hemorrhage. CONCLUSIONS: The complication rate of this study population with clinically severe GD was very low-which may be caused by pre-treatment of patients. The complementary option of a potassium iodide treatment before surgery remains a possibility and should be implemented individually.

Effect of voice therapy with or without transcutaneous electrical stimulation on recovery of injured macroscopically intact recurrent laryngeal nerve after thyroid surgery.

PURPOSE: Electrical stimulation-supported therapy is an often used modality. However, it still belongs to experimental methods in the human larynx. Data are lacking with which to evaluate the real effect in recurrent laryngeal nerve injury. The aim of this study was to investigate whether transcutaneous electrical stimulation added to voice therapy has a beneficial effect compared to voice therapy alone on vocal fold movement recovery in the case of an injured macroscopically intact recurrent laryngeal nerve. METHODS: Adults with unilateral vocal fold paralysis after thyroidectomy, in which the recurrent laryngeal nerve was left macroscopically intact, were included in this case-control study performed in tertiary referral hospital between September 2006 and June 2018. Among 175 eligible participants, 158 were included. Compliance with 6 months follow-up was 94.3%. INTERVENTIONS: medicament therapy and voice therapy (group 1) vs. medicament therapy and voice therapy and transcutaneous electrical stimulation (group 2). MAIN OUTCOME: vocal fold movement. RESULTS: A total of 149 patients were included in the analysis (group 1, 89 patients; group 2, 60 patients). The groups were homogenous. In groups 1 and 2, 64% and 60% of vocal folds, respectively, were improved after 6 months (P = 0.617). No difference was found between patients who improved and patients who did not improve. CONCLUSIONS: Adding transcutaneous electrical stimulation to voice therapy provided no beneficial effect on the recovery of vocal fold movement. Therefore, its indications should be re-evaluated; it is questionable whether stimulation should be routinely recommended.

Recurrent Laryngeal Nerve Stimulator.

Electrical stimulation of the recurrent laryngeal nerve is a safe and promising therapeutic approach with the potentiality to overcome the shortcomings of conventional surgical glottal enlargement. Although aberrant or synkinetic reinnervation is commonly considered an unfavorable condition, particularly for recovery of vocal fold movement, its presence is essential to ensure the effective clinical performance of laryngeal pacemakers. Thus, the effective selection of patients who can profit from laryngeal pacemakers implantation demands the implementation of new diagnostic tools based on tests capable of reliably detecting the presence of viable reinnervation on at least one vocal fold.

Development of a Closed-Loop Stimulator for Laryngeal Reanimation: Part 2. Device Testing in the Canine Model of Laryngeal Paralysis.

OBJECTIVE:: Laryngeal paralysis of central or peripheral origin can potentially be treated using functional electrical stimulation (FES) of laryngeal muscles. Experiments in canines (dogs) were performed using implant prototypes capable of closed-loop FES to refine engineering designs and specifications, test surgical approaches for implantation, and better understand the in vivo effects of laryngeal muscle stimulation on short- and long-term glottic function. STUDY DESIGN:: Prospective, laboratory. METHODS:: We designed and tested a series of microprocessor-based implantable devices that can stimulate glottic opening or closing based on input from physiological control signals (real-time processing of electromyographic [EMG] signals). After acute device testing experiments, 2 dogs were implanted for 8 and 24 months, with periodic testing of closed-loop laryngeal muscle stimulation triggered from EMG signals. In total, 5 dogs were tested for the effects of laryngeal muscle stimulation on vocal fold (VF) posturing in larynges with nerve supplies that were intact (7 VFs), synkinetically reinnervated (2 VFs), or chronically denervated (1 VF). In 3 cases, the stimulation was combined with airflow-driven phonation to study the consequent modulation of phonatory parameters. RESULTS:: Initial device prototypes used inductive coupling for power and communication, while later iterations used battery power and infrared light communication (detailed descriptions are provided in the Part 1 companion paper). Two animals were successfully implanted with the inductively powered units, which operated until removed at 8 months in 1 animal or for more than 16 months in the second animal. Surgically, the encapsulated implants were well tolerated, and procedures for placing, attaching, and connecting the devices were developed. To simulate EMG control signals in anesthetized animals, we created 2 types of nerve/muscle signal sources. In one approach, a neck muscle had a cuff electrode placed on its motor nerve that was connected to transdermal electrical connection ports for periodic testing. In the second approach, the recurrent laryngeal nerve on one side of the larynx was stimulated to generate a VF EMG signal, which was then used to trigger FES of the paralyzed contralateral side (eg, restoring VF movement symmetry). Implant testing identified effective stimulation parameters and closed-loop stimulation artifact rejection techniques for FES of both healthy and paralyzed VFs. Stimulation levels effective for VF adduction did not cause signs of discomfort during awake testing. CONCLUSION:: Our inductive and battery-powered prototypes performed effectively during in vivo testing, and the 2 units that were implanted for long-term evaluation held up well. As a proof of concept, we demonstrated that elicited neck strap muscle or laryngeal EMG potentials could be used as a control signal for closed-loop stimulation of laryngeal adduction and vocal pitch modulation, depending on electrode positioning, and that VFs were stimulable in the presence of synkinetic reinnervation or chronic denervation.

Mandibular resorption and vocal cord paralysis: a catastrophic form of systemic sclerosis.

Sudden respiratory distress in association with severe weight loss are unusual features of systemic sclerosis (SSc). We report the case of a 56-year-old Caucasian woman with a 9-year history of a diffuse form of SSc who presented with acute stridor due to vocal cord paralysis and required an emergency tracheostomy. She had sought medical attention only after 4 years of disease onset, presenting with a mask-like face, diffuse skin thickening, acro-osteolysis and severe interstitial lung disease. Even though skin tightness improved after immunosuppressive treatment, several spontaneous facial fractures and episodes of dysphagia and choking occurred in the years that followed. At the time of stridor, she was severely malnourished and a percutaneous endoscopic gastrostomy was required for feeding. Permanent vocal cord damage in combination with severe loco-regional bone resorption resulted in severe disability and impaired nutrition. We hereby highlight the features of SSc for which therapy remains challenging.

Liuzijue Qigong: A Voice Training Method For Unilateral Vocal Fold Paralysis Patients.

OBJECTIVES: Liuzijue Qigong (LQG), a kind of traditional Chinese health exercise (TCHE), is not only widely used to strengthen physical fitness and maintain psychological well-being in the elderly but has also been utilized to help improve respiratory function. As respiratory support is an important driving force for speech production, it is logical to postulate that the LQG training method with 6 monosyllabic speech sounds, xu, he, hu, si, chui, and xi, can help individuals (1) experience a relaxing and natural state of speech production, (2) eliminate voice symptoms, and (3) improve their overall body function and mood. In the current study, we hypothesized that the LQG method with these 6 sounds can be effective in improving vocal function in subjects with unilateral vocal fold paralysis (UVFP) in comparison with a conventional voice therapy method. METHODS: A total of 48 patients with UVFP who met the inclusion criteria were randomly divided into 2 groups. Twenty-four subjects in the experimental group were trained with LQG, and those in the control group received conventional voice training (abdominal breathing and yawn-sign exercises) for a total of 4 sessions, twice a week. Patients in both groups were assessed with acoustic tests, the GRBAS scale, the Voice Handicap Index (VHI-10), and the Hospital Anxiety and Depression Scale (HADS) pre- and posttreatment. Statistical analysis was conducted using nonparametric tests and t tests. RESULTS: There existed significant changes in maximum phonation time (MPT), jitter, shimmer, normalized noise energy (NNE), GRBAS scores, VHI-10 scores, and grade of A in HADS scores pre- and posttreatment in both the experimental group and the control group ( P < .004). However, no significant changes were seen posttreatment between the 2 groups ( P > .05). CONCLUSIONS: LQG could help improve vocal function in UVFP patients as our preliminary data showed no significant differences between LQG and conventional voice therapy methods.