Prevention of anastomotic leak using an advanced pectoral flap in total pharyngolaryngectomy and free jejunal reconstruction for hypopharyngeal or laryngeal carcinoma.

BACKGROUND: We devised an advanced pectoral flap (APF) to prevent anastomotic leak after total pharyngolaryngectomy (TPL) and free jejunal reconstruction (FJR) in patients with hypopharyngeal or laryngeal carcinoma. The APF alleviates tension on the skin in the neck, reduces the subcutaneous dead space, and promotes adhesion between the neck skin and the anastomosis. OBJECTIVE: To investigate whether an APF is effective for prevention of anastomotic leak associated with TPL/FJR. PATIENTS AND METHODS: Anastomotic leak was compared between APF (n = 65) and non-APF groups (n = 25). Patients who had received preoperative radiotherapy or undergone tracheostomy or skin infiltration requiring neck reconstruction using a pedicle flap were excluded. RESULTS: There were significantly fewer cases of anastomotic leak in the APF group than in the non-APF group (1.5% [1/65] vs. 16.0% [4/25]; p = .02). An APF could be created bilaterally within approximately 15 minutes. Unlike a deltopectoral flap, an APF does not require a skin graft. CONCLUSIONS: The postoperative anastomotic leak rate was 1.5% in patients who underwent TPL and FJR for hypopharyngeal or laryngeal carcinoma with an APF. SIGNIFICANCE: An APF is easily created and can reduce the incidence of anastomotic leak after TPL and FJR.

Features of Vocal Fold Adductor Paralysis and the Management of Posterior Muscle in Thyroplasty.

OBJECTIVE: To present the pathologic characteristics of unilateral recurrent nerve adductor branch paralysis (AdBP), and to investigate the management of posterior cricoarytenoid (PCA) muscle on the basis of our experience of surgical treatment for AdBP. STUDY DESIGN: This is a retrospective review of clinical records METHODS: Four cases of AdBP, in which surgical treatment was performed, are presented. AdBP shows disorders of vocal fold adduction because of paralysis of the thyroarytenoid and lateral cricoarytenoid muscles. The PCA muscle, dominated by the recurrent nerve PCA muscle branch, does not show paralysis. Thus, this type of partial recurrent nerve paresis retains the abductive function and is difficult to distinguish from arytenoid cartilage dislocation because of their similar endoscopic findings. The features include acute onset, and all cases were idiopathic etiology. Thyroarytenoid muscle paralysis was determined by electromyography and stroboscopic findings. The adduction and abduction of paralytic arytenoids were evaluated from 3 dimensional computed tomography (3DCT). RESULTS: In all cases, surgical treatments were arytenoid adduction combined with thyroplasty. When we adducted the arytenoid cartilage during inspiration, strong resistance was observed. In the two cases where we could cut the PCA muscle sufficiently, the maximum phonation time was improved to ≥30 seconds after surgery, from 2 to 3 seconds preoperatively, providing good postoperative voices. In contrast, in the two cases of insufficient resection, the surgical outcomes were poorer. CONCLUSIONS: Because the preoperative voice in AdBP patients is typically very coarse, surgical treatment is needed, as well as ordinary recurrent nerve paralysis. In our experience, adequate PCA muscle resection might be helpful in surgical treatment of AdBP.

The Comparison of Thyroarytenoid Muscle Myectomy and Type II Thyroplasty for Spasmodic Dysphonia.

OBJECTIVE: Surgical treatments for adductor spasmodic dysphonia include bilateral thyroarytenoid muscle myectomy (TAM) and type II thyroplasty (TPII), both of which are commonly performed. The present study aimed to compare the effects of TAM and TPII. STUDY DESIGN: Retrospective study. METHODS: Subjects were 30 and 35 patients who underwent TAM and TPII, between March 2008 and November 2012. Voice quality was evaluated based on "voice handicap index 10 (VHI10)" and auditory impressions before and 6 months after surgery using five parameters: "strangulation," "interruption," "tremor," "grade," and "breathiness." RESULTS: Comparison of the two procedures revealed significant improvements in VHI10, strangulation, interruption, and tremor, and a significant decline in breathiness after surgery. In particular, VHI10 was improved by more than six points in 90% of patients with TAM, and 96% with TPII. No significant difference was observed between the severities of two procedures preoperatively. Comparison of each postoperative score between the two procedures revealed that TAM significantly improved strangulation, interruption, and tremor, and significantly worsened breathiness, with no significant difference in VHI10. Scatter plots (x: preoperative scores; y: postoperative scores) and regression lines of evaluation items demonstrated that TAM is more effective than TPII in severe cases. CONCLUSIONS: Compared with TPII, TAM tends to improve strangulation, interruption, and tremor; however, it tends to worsen breathiness postoperatively. Postoperative VHI10 scores did not differ significantly between the two procedures. Given favorable improvement rates, both surgical procedures were considered effective.

Day surgery for vocal fold lesions using a double-bent 60-mm Cathelin needle.

Day surgery for vocal cord lesions overcomes the disadvantages of laryngomicrosurgery under general anesthesia. We present our experience with treatment of vocal fold lesions using a long double-bend Cathelin needle that can access all parts of the vocal cords. A 23G, 60-mm-long Cathelin needle was bent twice by 45(o) at a distance of 1 and 2 cm from the tip, and was attached to a syringe. Under topical anesthesia and nasal endoscopy of the laryngopharynx, the needle was inserted percutaneously perpendicular to the skin, the direction of insertion being altered when the bends in the needle reached the skin surface. This allows the tip of the needle to access all parts of the glottis, allowing the performance of procedures such as biopsies, excision of lesions, and injection into the vocal folds. Between January 2011 and December 2013, we used this technique to perform vocal fold procedures in 566 patients presenting for treatment of spasmodic dysphonia (412 cases, 73 %) and other vocal fold lesions. Only minor complications, such as hematoma (3 patients, 0.5 %) and slight bleeding from the puncture site in the epiglottic vallecula (all patients, 100 %), which ceased spontaneously within 10 min, were seen. Erroneous puncture occurred in three patients (0.5 %) and the puncture had to be repeated in 38 patients (6.7 %). The procedure was completed successfully in all cases (100 %). Surgery for vocal fold lesions under topical anesthesia using our double-bend Cathelin needle technique is simple, safe, and useful.

Analysis of high-pitched phonation using three-dimensional computed tomography.

OBJECTIVES/HYPOTHESIS: Our aim was to use three-dimensional computed tomography (3DCT) to examine arytenoid cartilage movement during a high-pitched tone task. STUDY DESIGN: This was a prospective study. METHODS: This study included 14 patients with male-to-female gender identity disorder who had undergone 3DCT imaging for surgical simulation between January 2007 and May 2008. First, to prove that the phonation condition was indeed one of the high-pitched phonation, we confirmed the rotational movement of the thyroid cartilage, horizontal gliding movement of the inferior horn, and vocal fold elongation on a high-pitched tone task. Next, we detected the arytenoid cartilage positions of the joint during a comparison of comfortable and high-pitched phonations. We measured the movement direction and movement distance of the arytenoid cartilage. RESULTS: In all cases, the cricothyroid space became narrower (rotation movement), and we observed anterior gliding movement of the inferior horn. In all cases, elongation of the vocal folds by the high-pitched phonation was confirmed and the arytenoid cartilages were displaced both anteriorly and caudally from the position during comfortable phonation by the high-pitched tone task. CONCLUSIONS: The arytenoid cartilages did not move posteriorly to elongate the vocal folds during high-pitched phonation. The arytenoid cartilages were pulled anteriorly and moved caudally because of tension associated with vocal fold elongation because of the task of high-pitched phonation. These results suggest that there are no movements at the cricoarytenoid joint that directly control the length of the vocal folds in accordance with pitch.