Pathophysiology and Surgical Treatment of Unilateral Vocal Fold Paralysis

Transcription

1

2 Pathophysiology and Surgical Treatment of Unilateral Vocal Fold Paralysis Denervation and Reinnervation Eiji Yumoto 123

3 Pathophysiology and Surgical Treatment of Unilateral Vocal Fold Paralysis

4

5 Eiji Yumoto Pathophysiology and Surgical Treatment of Unilateral Vocal Fold Paralysis Denervation and Reinnervation

6 Eiji Yumoto Department of Otlaryngology Head and Neck Surgery Graduate School of Medical Sciences Kumamoto University Kumamoto, Japan Additional material to this book can be downloaded from ISBN DOI / ISBN (ebook) Library of Congress Control Number: Springer Tokyo Heidelberg New York Dordrecht London Springer Japan 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer Japan KK is part of Springer Science+Business Media (

7 Foreword Many individuals have contributed to the art and science of phonosurgery over the last several decades. With pioneering achievements including those of Dr. Oskar Kleinsasser, Dr. Geza Jako, Dr. Harvey Tucker, Dr. John Conley, and then, of course, the great Dr. Minoru Hirano, and perhaps most notably Dr. Nobuhiko Isshiki. But it is on the shoulders of these greats that Dr. Eiji Yumoto takes the next step in creating a book that redefines and modernizes our thinking surrounding diagnostic and surgical laryngology. This book provides a unique insight as to the value and the clinical potential for surgical techniques to address vocal fold paralysis focusing on laryngeal reinnervation and thyroplasty. These methods have evolved over time. Dr. Yumoto applies sound science to the techniques and provides a balanced and detailed description of the state of the art. This book stands apart due to its scientific rigor, clinically applicable information, and problem-focused approach. It is bound to contribute in an extremely meaningful way to the advancement of laryngology worldwide. Chapter 1 provides a solid background to the anatomy and pathophysiology of vocal fold immobility. Included is a well-supported narrative describing the effects of recurrent laryngeal nerve injury and regeneration, the probable cause of vocal fold atrophy; synkinesis; glottis insufficiency; and vibratory deficits. The chapter is concluded with a rationale for appropriate therapeutic intervention. Chapter 2 is dedicated to the evaluation and surgical treatment of vocal fold paralysis with a detailed analysis of prior published work and emphasizes the merits of reinnervation and highlights Dr. Yumoto s 15-year experience clinically managing this patient group. Chapter 3 provides a basic science framework for the clinical finding identified with vocal fold denervation and reinnervation and includes data on the cellular effects of nerve muscle pedicle flap implantation. Chapter 4 discusses the diagnosis of paralytic dysphonia. The chapter includes the use and value of clinical voice measures, direct visual imaging, and the unique v

8 vi Foreword use of three-dimensional computer tomography and a new glottal configuration classification system. The chapter also contains valuable information on laryngeal electromyography. Chapter 5 provides the details of the surgical technique of thyroarytenoid nerve muscle pedicle flap reinnervation, which includes an analysis of patient outcomes, addressing phonatory and respiratory function as well as expected events and complications. Chapter 6 summarizes the work and provides a framework for future directions for research and enhanced clinical care of the paralyzed vocal fold. Certainly, I am very pleased to have the opportunity to preview the text and express my gratitude to the author for this contribution to our literature. Madison, WI, USA Timothy M. McCulloch

9 Preface Vocal fold paralysis is a unique disease entity because clinical symptoms, degree of breathy dysphonia, and stroboscopic findings of vocal fold vibration differ from patient to patient. For example, some patients show over-adduction of the unaffected vocal fold over the midline during phonation while others do not even when a glottal gap exists. Prof. Nobuhiko Isshiki introduced laryngeal framework surgeries to surgically treat paralytic dysphonia. His idea was great in that the surgical methods were developed to modify position, mass, and tension of the vocal fold by changing the locational relation among thyroid, cricoid, and arytenoid cartilages without any intervention on vocal fold mucosa. Framework surgeries now have been popularized worldwide. I started to work on these surgeries in the 1980s. Some patients recovered a very good voice, just like their own pre-paralysis voice, but unfortunately not all of them obtained a good voice although the postoperative voice definitely had improved compared with the preoperative voice. Based on the studies regarding vocal fold vibration with which I was involved for nearly 10 years from the latter half of the 1980s, I was convinced that, in addition to median location of the affected vocal fold, symmetrical mass, tension, and stiffness, thyroarytenoid (TA) muscle tonus is indispensable to recover the occurrence of the normal dynamic mucosal wave of the vocal fold. Therefore, since I moved to Kumamoto University in 1998, my colleagues and I have been working to clarify denervation effects on the TA muscle and effects of the nerve-muscle pedicle (NMP) method on reinnervation of the TA muscle including muscle fibers, nerve fibers within the muscle, and neuromuscular junctions. The NMP method has been proven to reinnervate the denervated TA muscle and to be useful in recovering the pre-paralysis normal voice of each patient when combined with arytenoid adduction. This book describes the pathophysiology and surgical treatment of unilateral vocal fold paralysis from the point of view of denervation and reinnervation. vii

10 viii Preface I believe that we have arrived at a new horizon, having come from static adjustment by framework surgery alone to dynamic reconstruction by reinnervation combined with arytenoid adduction. Needless to say, as described in Chap. 6, much remains to be studied further. Kumamoto, Japan Eiji Yumoto, M.D.

11 Acknowledgments It is my privilege to express my sincere gratitude to my mentors, Emeritus Prof. Naoaki Yanagihara and the late Associate Prof. Hiroshi Okamura, Ehime University, Japan, for their guidance and encouragement in laryngology. I also would like to express my sincere gratitude to Emeritus Prof. Nobuhiko Isshiki, Kyoto University, Japan, for his valuable advice. I would like to acknowledge my great appreciation to the following colleagues who have spent a challenging time together carrying out basic animal experiments and clinical data analysis: Ryosei Minoda, Yasuhiro Samejima, Tetsuji Sanuki, Yoshihiko Kumai, Satoru Miyamaru, Takashi Aoyama, Yutaka Toya, Kohei Nishimoto, and Narihiro Kodama, Kumamoto University, Japan. All of them devoted themselves to the creation and refinement of this book. Any inaccuracies in the text remain entirely my responsibility, but they have certainly been reduced by the very helpful and constructive comments on the manuscript by Edgardo S. Aberaldo, M.D., to whom special thanks are due. Finally and most importantly, I wish to thank my wife, Kyoko, for her patience and forbearance during the work on this book. ix

12

13 Contents 1 Basic Knowledge of Vocal Fold Paralysis What Is Vocal Fold Paralysis? Anastomotic Patterns of the RLN and Its Regeneration After Damage Symptoms Vocal Fold Vibration Glottal Insufficiency Atrophy of the Thyroarytenoid Muscle Lowered Stiffness and Tension of the Vocal Fold What Should Be Done to Obtain a Normal Voice? Factors to Be Considered During Diagnosis Glottal Insufficiency Decrease in the Thickness of the Affected Vocal Fold Lowered Tension and Stiffness of the Vocal Fold Synkinetic Movement of the Affected Vocal Fold Over-adduction of the Normal Fold During Phonation References Etiologies of Vocal Fold Paralysis and Conventional Surgical Procedures Used to Treat Paralytic Dysphonia Etiologies of Vocal Fold Paralysis Diagnostic Procedures The Author s Experience Phonosurgical Procedures to Improve Paralytic Dysphonia Historical Review Intracordal Injection and Fascia Insertion Type I Thyroplasty (Medialization Thyroplasty) xi

14 xii Contents Arytenoid Adduction Combination of AA with the Type I Method or Intracordal Injection Remobilization of an Affected Vocal Fold Reinnervation of the Laryngeal Muscles Vocal Function After Application of the Abovementioned Methods The Author s Experience During the 15 Years Between 1986 and References Denervation and Reinnervation of the Thyroarytenoid Muscle Historical Review Histological Changes in the Laryngeal Muscles After Denervation Role of Basic Fibroblast Growth Factor in the Nucleus Ambiguus Atrophic Changes in Laryngeal Muscle Fibers After Denervation Changes in the Human Laryngeal Muscles and the Cricoarytenoid Joint After Denervation Reinnervation of Denervated Muscle Changes in the TA Muscle After Denervation Short-Term Changes in Muscles Long-Term Changes in the TA Muscle Nerve Muscle Pedicle (NMP) Flap Implantation into the TA Muscle Immediate Implantation Delayed Implantation NMP Flap Implantation into the TA Muscle of the Aged Rat NMP Flap Implantation into the TA Muscle in the Presence of Partial Innervation References Diagnosis of Paralytic Dysphonia and Its Clinical Characteristics Introduction The Vocal Function Test Battery Image Analysis of Unilateral Vocal Fold Paralysis Three-Dimensional Computed Tomography (3D CT) Glottal Configuration During Phonation and Vocal Function Over-adduction of the Unaffected Vocal Fold During Phonation

15 Contents xiii 4.4 Electromyographic Recruitment, 3D Morphology of the Vocal Folds, and Vocal Function Subjects and the LEMG Procedure LEMG Recruitment and Aerodynamic Analysis LEMG Recruitment and 3D Morphology of the Vocal Folds References Surgical Treatment of Unilateral Vocal Fold Paralysis; Reinnervation of the Thyroarytenoid Muscle Introduction The Basic Policy Primary Reconstruction of the RLN Operative Procedures Subjects Assessment of Vocal Function Comments Delayed Reinnervation of the TA Muscle After Onset of UVFP Indication Operative Procedures for TA Muscle Reinnervation Combined with AA Subjects Assessment of Vocal Function Comments Complications After Surgery Retrospective Review of Our Experience Prospective Evaluation of Laryngeal Edema After AA Respiratory Function After Surgery References Summary and Future Perspectives Duration from UVFP Onset to Implementation of NMP Procedure Enhancement of the Effects of the NMP Method Synkinesis Due to Misdirected Reinnervation Unavailability of NMP Flap Formation References