[Function and dysfunction of the superior laryngeal nerve]. / Funktion und Dysfunktion des N. laryngeus superior.

BACKGROUND: Diseases of the superior laryngeal nerve occur more often than thought. Paresis of the superior laryngeal nerve is one of the most frequent causes of dysfunction of this nerve, mainly occurring in the context of thyroid surgery. RESULTS AND CONCLUSION: To avoid iatrogenic damage of the superior laryngeal nerve, knowledge of the exact topography of the course of this nerve is necessary. A lesion of the superior laryngeal nerve may be associated with changes in the voice as well as with swallowing disorders with aspiration. Diagnosis of this disease is clinically challenging because the clinical symptoms are frequently not pronounced. Besides laryngoscopy, stroboscopy and electromyography are required for exact diagnosis.

Endoscopic technique to mark the site of tracheal stenosis for resection.

BACKGROUND: It is difficult to precisely localise the extent of the diseased segment on the external aspect of a stenotic trachea. A technique has been developed of marking the upper margin of stenosis, in order to open the airway at the appropriate level during segmental resection. MATERIALS AND METHODS: Prior to the open reconstructive procedure, the stenosis is visualised using microlaryngoscopy. An endo-extraluminal technique is used to drive a suture from inside out through the skin; this then serves to mark the exact top margin of the stenotic segment. This suture serves as a guide for the surgeon during the open approach to tracheal resection. RESULTS: This technique was performed in 16 cases, and allowed precise localisation of the stenosis in each case. CONCLUSION: Transcutaneous localisation of laryngotracheal stenosis, using the Lichtenberger device, is an easy and reliable technique requiring a minimum of additional time.

[Chronic aspiration secondary to a Staffieri fistula: successful therapy with Provox voice prosthesis]. / Chronische Aspiration infolge einer tracheo-ösophagealen Fistel nach Staffieri: Erfolgreiche Therapie mittels einer Provox-Stimmprothese.

BACKGROUND: The Staffieri technique is a method for surgical rehabilitation of the voice after laryngectomy. A fistula between trachea and esophagus is created to achieve a so-called "Neoglottis phonatoria". The assignment of the neoglottis is to protect the airways during ingestion and to give the patient a chance to phonate during expiration. PATIENT: The case of a 71-year-old man with aspiration via his Staffieri fistula is presented. The fistula was created in 1979 after laryngectomy because of a laryngeal carcinoma. He also suffered from a metastasized gastric carcinoma which was cured by a 2/3 resection of the stomach in 1970. He is free of recurrence with regard to his oncologic diseases. Until 2003 the patient had no problems with the fistula and was able to phonate well. In 2003 the patient had progressive aspiration via the fistula and the Staffieri fistula was therefore reduced in diameter by surgery. In 2005 the patient presented himself again because of a recurrence of the aspiration. Endoscopy of the upper aerodigestive tract showed healthy mucosa, contrast imaging of the esophagus showed a significant aspiration of the contrast medium into the trachea. Due to these findings a voice prosthesis was inserted into the fistula. This therapy cured the patient from aspiration. He is able to phonate well and has no further complaints. CONCLUSION: Aspiration via a Staffieri fistula is described in about 25 % of cases and therapy is sometimes difficult. Surgical narrowing of the diameter of the fistula is inadequate in most cases and many patients would lose their restored voice if the fistula was closed permanently. Through the insertion of a voice prosthesis aspiration could be stopped and voice was immediately restored.

[Transcutaneous identification of cricotracheal and tracheal stenosis]. / Transkutane Identifikation krikotrachealer und trachealer Stenosen.

BACKGROUND: In the reconstruction of laryngotracheal stenosis, the exact localization of the level of the stenosis in relation to the cricoid arch is of paramount importance. This report describes an easy, fast and reliable technique for projecting stenotic segments of the subglottic trachea onto the tracheal front wall. MATERIAL AND METHOD: Directly before the reconstructive procedure, the stenosis is visualized using microlaryngoscopy. An endo-extralaryngeal needle-carrier is used to drive a suture from the inside through the skin. This takes the surgeon directly to the anterior tracheal wall at the exact level of the upper margin of the stenotic segment. RESULTS: This technique has been used in 15 cases, allowing the correct identification of the stenosis in every case. Subjectively, there was a gain of time as well as of the surgeon's confidence in this critical part of the procedure. The transcutaneous identification of a laryngotracheal stenosis using the Lichtenberger endo-extralaryngeal suture technique requires a minimum of additional time. We recommend this technique for routine use whenever an open approach for airway reconstruction of the subglottic larynx or proximal trachea is to be performed.

Voice quality improvement after management of unilateral vocal cord paralysis with different techniques.

The aim of this study was to objectively evaluate the voices of patients suffering from unilateral vocal cord paralysis, before and after endoscopic augmentation and thyroplasty. In the past, we used injectable Teflon to treat this condition; later techniques included collagen injection and Isshiki thyroplasty. In the last 7 years, preferred treatment methods have included Bioplastique injection and lipoaugmentation of the vocal cords as well as medialization thyroplasty using a titanium implant according to Friedrich. Pre- and postoperative data was evaluated and compared to 25 patients. Appropriate glottic closure of the vocal cords was achieved in every case, in most cases after the first intervention. We used voice range profile measurements to evaluate the results. An objective evaluation was performed using the Friedrich dysphonia index. Significant improvements were found: the dysphonia index decreased in every case, from an average of 2.47, preoperatively, to an average of 1.18 postoperatively. In agreement with earlier studies, voice pitch range was the only parameter that not significantly improved. There was no statistical difference between the lipoaugmentation and thyroplasty according to Friedrich. We concluded that both endoscopic methods and thyroplasty can be used to achieve an optimal result. Cases must be evaluated individually so that the best technique, or combination of methods can be determined.

Critical role for NALP3/CIAS1/Cryopyrin in innate and adaptive immunity through its regulation of caspase-1.

Mutations in the NALP3/CIAS1/cryopyrin gene are linked to three autoinflammatory disorders: Muckle-Wells syndrome, familial cold autoinflammatory syndrome, and chronic infantile neurologic cutaneous and articular syndrome. NALP3, with the adaptor molecule ASC, has been proposed to form a caspase-1-activating "inflammasome," a complex with pro-IL1beta-processing activity. Here, we demonstrate the effect of NALP3 deficiency on caspase-1 function. NALP3 was essential for the ATP-driven activation of caspase-1 in lipopolysaccharide-stimulated macrophages and for the efficient secretion of the caspase-1-dependent cytokines IL-1alpha, IL-1beta, and IL-18. IL-1beta has been shown to play a key role in contact hypersensitivity; we show that ASC- and NALP3-deficient mice also demonstrate an impaired contact hypersensitivity response to the hapten trinitrophenylchloride. NALP3, however, was not required for caspase-1 activation by Salmonella typhimurium, and NALP3 deficiency only partially protects mice from the lethal effects of endotoxin. These data suggest that NALP3 plays a specific role in the caspase-1 activation pathway.

Therapy of periprosthetical leakage with tissue augmentation using Bioplastique around the implanted voice prosthesis.

Having a voice prosthesis provides a good possibility for speech rehabilitation after total laryngectomy has been performed, especially if common complications such as leakage around the valve can be reduced effectively. The early applications of a voice prosthesis-which was originally invented and applied by Mozolewski in 1972, was further developed by Blom and Singer and became an internationally available implantable instrument by 1980- already made clear not only the typical benefits, but also the complications, such as possible leakage around the implanted valve. Remacle proposed the injection of collagen into the surrounding tissues in order to stop leakage. Knowing that collagen is usually resorbed as time goes by, new substances that can be tolerated by human tissues must be found. This article reports the experiences of the authors in the search for such an injectable material that cannot be resorbed and does not migrate. In order to solve the above-mentioned problem, Lichtenberger introduced the injection of Bioplastique into the perivalvular tissues. This delivered the best results ever achieved in this field at our department. During the past 2 years, Bioplastique augmentation was performed for seven laryngectomized and speech-rehabilitated patients in order to reduce periprosthetical leakage. All procedures were successful in terms of either eliminating or reducing the leakage, and also the non-resorbable property of Bioplastique has been proven.

Evaluation of the lung function test in reversible glottis-dilating operations.

Our aim was to obtain an objective evaluation of the airway before and after reversible glottis-dilating operations using the lung function test. Bilateral abductor vocal cord paralysis remains mostly a complication of thyroid surgery. After thyroid surgery, the paralysis is potentially reversible, and the patient has a chance for recovery mostly in the first 6 months. According to these considerations, a reversible vocal cord laterofixation procedure was used instead of tracheostomy. The operations were performed endoscopically using high-frequency JET ventilation and the special endo-extralaryngeal suture technique by Lichtenberger. This technique was used in 92 cases. The pre- and postoperative data of reversible glottis-dilating techniques could be compared in 23 non-selected patients. Lung function tests that were performed were forced inspiratory volume (FIV1), forced expiratory volume (FEV1), peak inspiratory flow rate (PIF), peak expiratory flow rate (PEF) and resistance of the airways (Raw). For the evaluation of the functional results, we used the body-pletysmograph. Our aim was to obtain a quantitative evaluation of the results. These values allow us to compare the results achieved by using different glottis-dilating methods. The FEV1 (forced expiratory volume) improved 25%, and the FIV1 (forced inspiratory volume) improved 39% after the operations on average. PEF (peak expiratory flow rate) and PIF (peak inspiratory flow rate) improved 37 and 45% after glottis-dilating surgery on average. The Raw (resistence of airways) was 271.5% on average before the operations, and after reversible glottis-dilating operations decreased to a level of 200.6%.

Spasmodic dysphonia combined with insufficient glottic closure by phonation.

The authors describe the case history of a patient who suffered from symptoms deriving from two different origins. The patient's voice was spasmodic dysphonia-like interrupted and pressed. At the same time, his voice was powerless, too. The reason for this was that besides the spasmodic dysphonia caused by hyperkinesis, an incomplete closure of the vocal cords during phonation in the middle third was present. It was caused by the atrophy of the vocal cords. In order to eliminate the symptoms, initially we injected 25 IU Botox into the left vocal cord transcutaneously under the direction of EMG control. It resulted in a fluent, though breathy voice. In order to manage the closing insufficiency during phonation, we performed lipoaugmentation on the left vocal cord under high-frequency jet anaesthesia. The result of the two-step procedure was a fluent and clear voice. The speech without interruption lasted for 5 months, until the drug was eliminated. Of course, to prolong the result, the Botox injection should be repeated.

Comparison of endoscopic glottis-dilating operations.

Endoscopic glottis-dilating operations were first utilized in 1948 by Thornell, who performed an endolaryngeal arytenoidectomy. The real breakthrough in these operations was reported by Kleinsasser in 1968. There have been many modifications of the endoscopic glottis dilating operations by other authors over the past 30 years or more. These methods have brought great progress in relieving airway obstruction. However, some disadvantages have reduced the effectiveness of these operations. This study will compare the advantages and disadvantages of the previous methods and compare them to the methods based on the endo-extralaryngeal suture technique by Lichtenberger in the hope that some of the previous ineffectiveness of glottis-dilating operations can be eliminated. These recent endo-extralaryngeal suture techniques consist of two operations. The first operation performed on patients whose vocal cords were paralyzed is an irreversible operation. This was performed with and without arytenoidectomy. These operations were successful in 89 out of 94 patients. The second operation was reversible endo-extralaryngeal lateralization, which was carried out in 37 patients; of these operations, 35 were successful. The operation was performed, and, if the cords remained paralyzed, the suture was not removed. If there was evidence of a return of vocal cord function, the suture was removed, 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, and this avoids the scar and granuloma formation that are characteristic of most other glottic dilating operations.

Assessment of the results of glottis-dilating operations using lung function tests.

Our aim was to obtain an objective evaluation of the airway before and after glottis-dilating operations utilizing lung function tests. The charts of 109 patients who underwent either reversible or irreversible glottis-dilating operations by Lichtenberger were reviewed. 64 nonselected cases of these patients, all with irreversible glottis-dilating operations, were studied. Lung function tests that were performed were body-pletysmography, forced inspiratory volume (FIV1), forced expiratory volume (FEV1), peak inspiratory flow rate (PIF), peak expiratory flow rate (PEF) and resistance of the airways (RAW). The FEV1, FIV1, PEF and PIF all improved following irreversible glottis-dilating operations. The RAW was remarkably decreased post-operatively as compared to pre-operatively. In conclusion, the airways of patients undergoing irreversible glottis-dilation operations improved moderately to well following such surgeries. Lung function tests are an objective means of evaluating the airway before and after surgery.

Advances and refinements in surgical voice rehabilitation after laryngectomy.

After Blom and Singer reported the construction of the so-called "duck bill" prosthesis in 1980, there have been quite a few newer voice prostheses constructed by other workers and new methods developed to predict the results, such as the insufflation and lidocaine test. Implanting the voice prosthesis with the Blom-Singer method has presented some problems and complications related to the puncture technique, therefore the following simplified esophagotracheal puncture technique is presented. The pharynx is opened with the laryngoscope which is then led up to the entrance of the esophagus. Through the laryngoscope, the distal end of the endo-extralaryngeal needle carrier, developed by the author and modified for mass production by R. Wolf Ltd., Germany, is led into the esophagus. The instrument is pushed forward as long as its distal bent, blunt end is palpable in the upper third of the tracheostoma. The needle with the thread (2/0 prolene) is pushed through from the inside, out in the upper third of the tracheostoma. A double wire forming a loop is led through the pointed metal cone (containing a built-in needle) and the catheter and tied behind a counterfixing pierced ball. The 2/0 prolene leading thread is then knotted with the wire. By pulling the thread and the wire, the pointed end of the metal cone with the needle built-in, perforates the soft parts and pulls the catheter with it (the same procedure will be used for primary puncture as well). After this procedure the voice prosthesis can easily be placed in the fistula in a conventional manner. Using this technique, 59 patients could be implanted without puncture-related complications or problems. Problems, not related to the puncture technique, such as Candida albicans infection etc., were solved using the well-known treatment modalities. To stop leakage around the prosthesis, injection of Bioplastique into the soft tissue surrounding the fistula was used with success.

Reversible immediate and definitive lateralization of paralyzed vocal cords.

The author reports on glottis dilation operations based on the endoextralaryngeal suture technique he has developed. In all, 101 patients were operated on for bilateral recurrent nerve paralysis using different variations of the above method, of which 73 have had more than 1 year of follow-up. Dilation was performed in 52 patients following tracheostomy, whereas no tracheostomy was performed in 21 patients. In 9 cases irreversible laterofixation without tracheostomy was performed with good results. In 12 patients a reversible glottis dilating operation was carried out without tracheostomy not long after the development of bilateral paramedian position of the vocal cords. Tracheostomy was necessary in 1 of 12 patients, who underwent reversible glottis dilating operations. In this case later reoperation, using a definitive endoscopic glottis dilating operation, was performed with success. Three patients required reoperation using open surgical procedures after irreversible endoscopic laterofixation methods.

Endoscopic microsurgical management of scars in the posterior commissure and interarytenoid region resulting in vocal cord pseudoparalysis.

The author reports his treatment of scars in the interarytenoid region of the larynx and the surgical management of scars in the posterior commissure based on the endoextralaryngeal suture technique and the needle carrier he developed. After the examination by electromyography, the scars are separated endoscopically. To prevent recurrent scarring and adhesions, two procedures are applied to the posterior commissure. When the size of the scars does not exceed 5 mm, both vocal cords are lateralized temporarily once the scars have been separated. In this way, the surfaces of the scars do not touch, thus preventing adhesion. When the scars are larger than 5 mm but less than 10 mm, a soft silicon stent replicating the shape of the lumen is fixed between the scars in the lumen of the larynx using the author's technique and suture device. The laterofixing sutures and silicon stent are removed in the fourth postoperative week. As a result of the operation, the lumen of the larynx has been found to be of adequate width and suitable for normal breathing and sound formation. These procedures have been applied successfully in 12 out of 13 patients.

New and Simple Endo-extra Oesophagotracheal Method of Developing the Fistula for the Implantation of a Voice Prosthesis.

The author has simplified the Blom-Singer(1) puncture. The fistula is formed with the help of his new device, the endo-extralaryngeal needle carrier and pointed metal cone fixed to a catheter. The voice prosthesis is placed in the fistula formed thus in an endo-extra oesophagotracheal way. The advantage of the method is, that when the fistula being formed from inside out, the back wall of the oesophagus will not become injured.