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PubMed1978

Clinical observations on 600 cases of recurrent laryngeal nerve paralysis.

A statistical review was made on 600 cases of recurrent laryngeal nerve paralysis who visited the author's clinic during the last 16 years. The yearly incidence, the age and sex distributions and the classifications of the causes of paralysis were presented and discussed. A special attention was given to the topics of associated laryngeal paralysis, bilateral recurrent laryngeal nerve paralysis and the so-called epidemic paralysis. A brief comment was also made on diagnosis and treatment of recurrent laryngeal nerve paralysis in general.

Adolescent↗
PubMed1999

Vocal cord paralysis after subtotal oesophagectomy.

BACKGROUND: Although vocal cord paralysis is a well known complication of subtotal oesophagectomy, precise data concerning origin, incidence and associated morbidity are lacking. METHODS: A retrospective study was performed of 241 patients who underwent transhiatal oesophagectomy for carcinoma of the mid/distal oesophagus between 1994 and 1998. Preoperative and postoperative laryngoscopy results were available for 140 patients. RESULTS: There were 109 men and 31 women, of mean age 63 years. Thirty-one patients (22 per cent) with recurrent laryngeal nerve paralysis were identified, three with bilateral and 28 with unilateral dysfunction. Paralysis occurred ipsilateral to the side of the cervical incision in 22 of 28 patients. It was permanent in six patients. The associated morbidity was substantial: pulmonary complications were more common in patients with vocal cord paralysis (12 of 31 versus 26 (24 per cent) of 109), leading to significantly more reintubations, and a significantly prolonged ventilation time and stay in the intensive care unit. CONCLUSION: Although mostly transient, vocal cord paralysis is a frequent complication with significant associated morbidity. In an extended transthoracic resection (including a lymphadenectomy in the aortopulmonary window where the left recurrent laryngeal nerve is at risk) the cervical anastomosis should be made on the left side, to minimize the risk of bilateral vocal cord paralysis.

Esophageal Neoplasms↗
PubMed2005

[Prevention of recurrent laryngeal nerve paralysis by demonstration of the nerve during thyroid surgery].

INTRODUCTION: Recurrent laryngeal nerve paralysis is one of the major complications of thyroid surgery. The importance of dissection and exploration of the recurrent laryngeal nerve during thyroid surgery remains controversial. METHODS: 74 thyroid gland operations with obligatory dissection and exploration of the recurrent laryngeal nerve were analysed. RESULTS: 118 recurrent laryngeal nerves were explorated in these operations. Transitory postoperative vocal cord paralysis was observed in 4 patients. In one patient vocal cord paralysis was permanent. This results in a transitory vocal cord paralysis rate of 3.4 % and a permanent vocal cord paralysis rate of 0.85 %. DISCUSSION: Our results and the literature review indicate that dissection and visualization of the recurrent laryngeal nerve can reduce the risk of permanent paralysis to a minimum. Obviously mechanical trauma like compression and crushing due to dissection do not increase incidence of permanent nerval disorders. Certain dissection and identification of the recurrent laryngeal nerve during thyroid surgery is recommended in principle.

Adult↗
PubMed1996

[Periodic paralysis as the first manifestation of hyperthyroidism].

HISTORY AND CLINICAL FINDINGS: A 19-year-old man had mild diarrhoea at the time that suddenly one night he was unable to turn in his bed and the following morning could not move his arms and legs for 4 hours. Neither he nor any family members had previously had any paralysis. Physical examination was unremarkable except for mild tachycardia and first-degree goitre. INVESTIGATIONS: A provocation test with glucose (3 g/kg) and insulin (0.1 IU/kg) caused renewed paralysis for several hours, serum potassium falling from 4.3 to 3.4 mmol/l. The paralysis was reversed on oral potassium (40 mmol) Thyroid function tests revealed hyperthyroidism with an increased concentration of free thyroxine (25.5 pg/ml) and free triiodothyronine (9.7 pg/ml), while thyroid-stimulating hormone was decreased (0.07 mU/I), supporting the diagnosis of autoimmune thyroiditis. TREATMENT AND COURSE: Thyrostatic treatment was started with thiamazole (10 mg every other day). There was no further periodic paralysis and another provocation test was negative. CONCLUSION: Fleeting paralysis is often misdiagnosed as being psychogenic. Potassium abnormalities are the most common cause but are only rarely associated with hyperthyroidism. This case of thyrotoxic hypokalaemic paralysis was probably based on a genetic defect of muscle fibre membrane manifesting itself only in the presence of hyperthyroidism.

Adult↗
PubMed2001

Management of bilateral vocal fold paralysis: experience at the University of Athens.

The treatment of patients with vocal fold paralysis presents a challenge to the otolaryngologist-head and neck surgeon. Many techniques have been proposed to manage individuals with unilateral or bilateral vocal fold paralysis. We herein describe the experience of our department in dealing with bilateral vocal fold paralysis. At the University of Athens, patients presenting with symptomatic bilateral paralysis are treated with a posterior cordectomy by using the CO2 or KTP-532 laser. During the last 5 years, we have treated 20 patients (8 men and 12 women) presenting with symptomatic bilateral vocal fold paralysis. For augmentation of the glottic airway, a modification of Kashima's cordotomy was used, completing a partial posterior cordectomy of one or both true and false vocal folds with the CO2 laser (15 patients) and the KTP-532 laser (5 patients). An elective tracheotomy was done before the cordotomy. Complications, such as infection, stridor, or dyspnea, were minimal. Although no objective voice analysis was performed, all patients were able to communicate without any phonation device and were satisfied with the result of the surgery. When compared with other techniques, the advantages offered by the posterior cordectomy included rapidity and simplicity in concept, reliability of outcome, short hospitalization, low risk of complications, and the possibility for revision when necessary (posterior cordectomy). From the successful postsurgical results of this study, it can be concluded that the posterior cordectomy is a reliable treatment option for the management of patients with bilateral vocal fold paralysis.

Academic Medical Centers↗
PubMed2006

Transient vocal cord paralysis after fine-needle aspiration biopsy of thyroid tumor.

OBJECTIVE: Complications of thyroid fine-needle aspiration biopsy (FNAB) are exceedingly rare. Hematoma formation is the most commonly encountered complication. Infection and seeding of carcinoma cells in the needle track has also been reported in a rare case. Here we describe patients diagnosed as having transient vocal cord paralysis after FNAB of benign thyroid tumor. DESIGN: Retrospective review of patients with concurrent diagnosis of vocal cord paralysis after FNAB. MAIN OUTCOME: Among 10,974 patients who underwent FNAB, 4 patients showed vocal cord paralysis on laryngoscopy. These patients had solid and/or cystic lesion in the thyroid. Routine FNAB of the nodule was performed using a 23-gauge needle. Cytologic findings were benign tumor. Change of voice in the patients occurred 1 or 2 days after FNAB and vocal cord paralysis ipsilateral to FNAB was determined by flexible laryngoscopy. Vocal cord paralysis of all patients resolved spontaneously within 6 months (average, 4 months). CONCLUSION: Although the incidence of vocal cord paralysis in patients with thyroid tumor after FNAB is reported to be 0.036%, the true incidence is unknown because asymptomatic subjects are not screened. This report should alert the examiner to the possibility of vocal cord palsy after FNAB.

Aged↗
PubMed1989

Thyrotoxic periodic paralysis in a Latin-American taking acetazolamide.

A Latin-American teenager was begun on a regimen of acetazolamide for a presumptive diagnosis of familial periodic paralysis. He presented 2 weeks later with near total body paralysis and was found to have florid manifestations of Graves' disease. Although thyrotoxic periodic paralysis occurs most frequently in Oriental males, it occasionally is found in Caucasians. Unlike familial, euthyroid, and periodic paralysis, thyrotoxic periodic paralysis may be worsened by administration of acetazolamide. Physical signs and laboratory evidence of hyperthyroidism must be sought in cases of periodic paralysis to differentiate the two diseases.

Acetazolamide↗
PubMed1997

Facial nerve paralysis after intratemporal and extratemporal blunt trauma.

Definitive facial nerve paralysis by intratemporal and extratemporal blunt injury is uncommon. Facial palsy as a result of closed temporal trauma is assumed to result if a petrous or temporal fracture is produced. Injury of the extratemporal trunk is extremely rare, but peripheral branches can be more easily injured. An exhaustive examination is necessary for an assessment if facial nerve damage is inside its bony canal or if it is severed distal to the stylomastoid foramen. Evaluation of facial muscle tone and motion, tear production, taste distribution, and stapedius muscle function must be evaluated. Electroneurography is mandatory because it is an important prognosis factor. Many prognosis factors must also be considered. Computed tomographic scan is also mandatory for providing localization of temporal fractures. Of 30 patients with facial paralysis registered by us between 1991 to 1996, 5 (17%) blunt trauma was the cause. In 2 of these patients with facial paralysis by extratemporal injury, showing selective facial branch injuries (one in the buccal branch and another in the marginal mandibular branch), recovery was complete and spontaneous. Another patient presented with a definitive selective buccal branch palsy after a complete facial paralysis produced by blunt preauricular injury. Of another 2 patients with facial paralysis by intratemporal injury without fracture, 1 recovered and the other did not. In 4 of the just-mentioned 5 patients, prednisolone was prescribed 1 week after trauma; no patients underwent surgical treatment. In conclusion, an extratemporal blunt trauma can produce a temporary facial palsy or paresis by injury of the main trunk or peripheral facial branch; however, recovery is usually complete. Intratemporal closed trauma with or without temporal fractures can produce a definitive facial nerve paralysis; recovery is uncertain.

Adult↗
PubMedDate not supplied

Chemical paralysis reduces energy expenditure in patients with burns and severe respiratory failure treated with mechanical ventilation.

Predictive formulas often overestimate energy requirements, particularly in patients being treated with mechanical ventilation, resulting in significant overfeeding. The purpose of this study was to quantify the effect of chemical paralysis on energy expenditure in patients with burn injuries receiving ventilation treatment, and compare measured energy expenditure with estimates of energy expenditure based on predictive formulas. The study was a retrospective review of 14 patients with burn injuries treated with mechanical ventilation that required chemical paralysis to reduce inspiratory pressures or improve oxygenation. Indirect calorimetry was performed before, during, and after paralysis. Measured energy expenditure (MEE) was compared with the energy predictions of the Harris-Benedict (HBEE) and Curreri (CEE) estimates. During paralysis, mean MEE was significantly lower than pre- or postparalysis (19.65 +/- 1.65 versus 26.00 +/- 2.42 and 29.49 +/- 2.83 kcal/kg/24 hr, respectively). Mean HBEE (2031 +/- 145 kcal/24 hr) approximated MEE pre-(1989 +/- 350 kcal/24 hr) and postparalysis (2237 +/- 269 kcal/24 hr), but overestimated MEE during paralysis (1532 +/- 208 kcal/24 hr; p < 0.05). Mean CEE (2957 +/- 229 kcal/ 24 hr) estimates significantly overestimated MEE before, during, and after paralysis (1989 +/- 350, 1532 +/- 208, and 2237 +/- 269, respectively p < 0.05). Predictive formulas significantly overestimate measured energy requirements in these patients. Indirect calorimetry should guide nutrition support in patients requiring prolonged mechanical ventilation.

Adult↗
PubMed2002

Neurovascular free-muscle transfer to treat facial paralysis associated with hemifacial microsomia.

Despite the wide spectrum of hemifacial microsomia manifestations, treatment mainly focuses on mandible and ear abnormalities, rather than on facial paralysis. In fact, the surgical treatment of facial paralysis associated with hemifacial microsomia is quite underdeveloped, because the degree of paralysis is frequently incomplete or partial. Timing and type of surgery are also difficult to determine. Neurovascular free-muscle transfer is now a standard procedure for the dynamic smile reconstruction of longstanding facial paralysis. This type of strategy has considerable potential in the treatment of facial paralysis in patients with hemifacial microsomia. We present here our experience with neurovascular free-muscle transfer for smile reconstruction in eight patients with facial paralysis associated with hemifacial microsomia. The age of the patients at the time of surgery ranged from 7 to 28 years old, (average, 13.9 years). Six were male patients and two were female patients. The two-stage method combining gracilis muscle transfer with cross-face nerve grafting was performed in three patients, whereas the one-stage transfer of the latissimus dorsi muscle was performed in five. To construct a natural or near-natural smile, the muscles were transferred into the paralyzed cheek in all except one patient, in whom the latissimus dorsi muscle was transferred into the sublabial area to reconstruct a paralyzed lower lip. A dermal flap segment vascularized with perforating vessels from the latissimus dorsi muscle was simultaneously inserted into the underdeveloped cheek for soft-tissue augmentation in this patient. Muscle contraction was evident in all patients between 4 and 8 months after muscle transfer. Our present series revealed that neurovascular free-muscle transfer is a good option not only for smile reconstruction but also for restoration of the facial contours of patients with hemifacial microsomia. Compared with the two-stage method combining gracilis muscle transfer with cross-face nerve grafting, the one-stage method using the latissimus dorsi muscle has some advantages, including a one-stage operation, a shorter recovery period, and the absence of sequelae that occur after harvesting a sural nerve.

Adolescent↗
PubMed2005

Long-term effects of micronized Alloderm injection for unilateral vocal fold paralysis.

OBJECTIVES: Micronized Alloderm (Cymetra) is a relatively new product used for vocal fold augmentation. Previous studies evaluating possible long-term effectiveness of this product have shown mixed results. The objective of this present study is to reassess possible long-term results of Cymetra injection laryngoplasty in patients with unilateral true vocal fold paralysis. STUDY DESIGN: Retrospective review of patients with unilateral true vocal fold paralysis who received Cymetra injection laryngoplasty between March 2001 and March 2004. METHODS: Preoperative voice samples and videostroboscopic findings were compared with the most recently available postoperative data to assess efficacy of the procedure. A panel of voice experts analyzed both vocal and vibratory function in these samples. In addition, pre- and postoperative voice-related quality of life measures and patients' self-ratings of voice outcomes were compared. RESULTS: Twenty patients (7 male, 13 female; 14 with left-sided paralysis, 6 with right-sided paralysis) were identified in the study population. Cymetra injection was performed an average of 45.1 months after onset of vocal fold paralysis (range -216 months), and average follow-up postinjection was 11.2 (range -35) months. Comparing pre- and postoperative measures, voice quality (P < .0001), glottal closure (P < .0001), and degree of vocal fold bowing (P < .0001) were all improved by injection. Quality of life measures and patients' self-perceptions of vocal quality were also improved (P < .01). Fifteen (75%) patients showed long-lasting results. Eight patients showed improvement for more than 12 months after injection. CONCLUSION: Cymetra injection laryngoplasty offers improved vocal and vibratory function to patients with unilateral true vocal fold paralysis. The benefits of such medialization may be longer lasting than previously reported, and further long-term study is warranted.

Adult↗
PubMed2004

The role of glottal gap in predicting aspiration in patients with unilateral vocal paralysis.

Aspiration has been frequently noted among patients suffering from vocal-fold paralysis. The association between a defect of glottal closure and aspiration in patients with unilateral vocal paralysis appears to have been rarely reported. The current study reviews collected data consisting of videotaped flexible nasoendoscopy and stroboscopy for patients with a unilateral vocal-fold paralysis. Mean normalized glottal gap areas for patients suffering vocal paralysis with associated aspiration are significant greater than that for the non-aspiration group. Subsequent to the surgical correction of the glottal gap, all patients recovered well from their earlier aspiration. The investigation of objectively derived data revealed that poor airway protection due to incomplete closure of the vocal fold was the major cause of aspiration for patients suffering unilateral vocal-fold paralysis. Intracordal autologous fat injection can successfully improve the breath control and eliminate aspiration in patients with vocal-fold paralysis.

Adult↗
PubMed2001

Prospective survey of tick paralysis in dogs.

OBJECTIVE: To obtain information on tick paralysis in dogs, including the nature of disease, host signalment, tick-host relationship, treatment, disease progression and recovery, and preventive measures. DESIGN: A prospective survey of 577 dogs affected by tick paralysis was conducted during 1998. Forty-two veterinary clinics along the eastern coast of Australia were instructed to complete survey forms for the first 15 dogs that presented with tick paralysis during September to November. RESULTS: Five percent of dogs died from tick paralysis. Younger dogs were more likely to survive. Long coat length was associated with a greater tick burden but not greater tick size, whereas coat thickness had no bearing on either. Dogs with mild disease recovered more quickly from tick paralysis. Respiratory and gait scores reflected disease severity and were good prognostic indicators. The size of the tick did not reflect the severity of the clinical condition it induced in the host. No method of tick removal or in situ treatment improved recovery time or reduced mortality. However, the time spent in hospital was significantly less for dogs from which the live tick was manually removed. Inspiratory stridor, evident in some dogs with tick paralysis, was not related to tick attachment on the neck. The use of acepromazine maleate or dexamethasone did not reduce recovery time or mortality. Increasing the dose of tick antitoxin serum (TAS) above 0.1 mL/kg had no effect on mortality or recovery time. Dogs with severe disease that received an additional dose of TAS were significantly less likely to survive. Subcutaneous use of TAS at the site of tick attachment was of no benefit in reducing mortality or time to initial clinical improvement. A registered preventative product had not been used on the majority of dogs. Clipping the coat to search for ticks did not reduce mortality. CONCLUSIONS: Therapy needs to address cardiopulmonary dysfunction that may be due directly to the effect of tick toxin and not just respiratory compromise caused by progressive respiratory muscle failure.

Acepromazine↗
PubMed2006

Tick paralysis with atypical presentation: isolated, reversible involvement of the upper trunk of brachial plexus.

Tick paralysis is a disease that occurs worldwide. It is a relatively rare but potentially fatal condition. The only way to establish the diagnosis is to carefully search for the tick paralysis. It is caused by a neurotoxin secreted by engorged female ticks. Tick paralysis generally begins in the lower extremities and ascends symmetrically to involve the trunk, upper extremities and head within a few hours. Although early-onset prominent bulbar palsy and isolated facial weakness without generalised paralysis are rare, there is no report in the English literature concerning isolated, reversible involvement of the upper trunk of brachial plexus caused by tick bite. We report a case of isolated, reversible involvement of the upper trunk of brachial plexus as a variant of tick paralysis. Diagnosis was confirmed with needle electromyography and nerve conduction examination. Within 2 weeks, the patient was fully recovered. The purpose of presenting this case is to remind clinicians that tick paralysis should be considered even in cases with atypical neurological findings admitted to the emergency department.

Aged↗
PubMed1998

Motor evoked potentials in unilateral lingual paralysis after monohemispheric ischaemia.

OBJECTIVES: The occurrence of a lingual paralysis after unilateral upper motor neuron lesions is an infrequent clinical phenomenon, and the underlying pathophysiological mechanisms are poorly understood. We studied the cortical motor representations of ipsilateral and contralateral lingual muscles in healthy controls and in a selected group of stroke patients, to clarify the variable occurrence of a lingual paralysis after recent monohemispheric ischaemia. METHODS: A special bipolar surface electrode was used to record the ipsilateral and contralateral compound muscle action potentials (CMAPs) from the lingual muscles after transcranial magnetic stimulation (TMS) of the human motor cortex and peripheral electrical stimulation (PES) of the hypoglossal nerve medial to the angle of the jaw. Four patients with a lingual paralysis (group 1) and four patients with symmetric lingual movements (group 2) after monohemispheric first ever stroke were studied and compared with 40 healthy controls. RESULTS: In controls, TMS of either hemisphere invariably produces CAMPs in the ipsilateral and contralateral lingual muscles, elicited through crossed and uncrossed central motor pathways, respectively. In the 40 healthy controls, TMS of either hemisphere elicited CMAPs of significantly greater amplitudes and shorter onset latencies from the contralateral muscles compared with the ipsilateral responses (p<0.0001). In the patient groups, TMS of the affected hemisphere failed to evoke any CMAP from either lingual side; TMS of the unsevered hemisphere always produced normal ipsilateral and contralateral responses, irrespective of whether the ipsilateral muscles were paralysed or not. CONCLUSIONS: Bilateral crossed and uncrossed corticonuclear projections are invariably existent in humans. After unilateral interruption of these pathways, some people do exhibit a lingual paralysis whereas others do not. The development of a central lingual paralysis is most likely dependent on the ability of the unsevered hemisphere to utilise the pre-existent uncrossed motor projections. The variable availability of these pathways among individual subjects is in good agreement with the inconstant occurrence of a lingual paralysis after restricted monohemispheric lesions.

Adult↗
PubMed1999

Hypokalaemic paralysis.

Hypokalaemic paralysis is a relatively uncommon but potentially life-threatening clinical syndrome. If recognised and treated appropriately, patients recover without any clinical sequellae. The syndrome of hypokalaemic paralysis represents a heterogeneous group of disorders characterised clinically by hypokalaemia and acute systemic weakness. Most cases are due to familial or primary hypokalaemic periodic paralysis; sporadic cases are associated with numerous other conditions including barium poisoning, hyperthyroidism, renal disorders, certain endocrinopathies and gastrointestinal potassium losses. The age of onset, race, family history, medications, and underlying disease states can help in identifying the cause of hypokalaemic paralysis. Initial therapy of the patient with hypokalaemic paralysis includes potassium replacement and search for underlying aetiology. Further management depends on the aetiology of hypokalaemia, severity of symptoms, and duration of disease. This review presents the differential diagnosis for hypokalaemic paralysis and discusses management of the syndrome.

Acidosis, Renal Tubular↗
PubMed1994

Respiratory muscle compensation for unilateral or bilateral hemidiaphragm paralysis in awake canines.

In humans and some animals, the surviving respiratory muscles are able to compensate fully for unilateral, and partially for bilateral, hemidiaphragm paralysis. To examine differential activity of individual respiratory muscles after unilateral or bilateral diaphragm paralysis, length and electromyogram (EMG) of left costal and crural diaphragm segments, parasternal intercostal, and transversus abdominis were measured directly in five awake canines after implantation with sonomicrometry transducers and bipolar EMG electrodes under three conditions: during normal breathing (NOFRZ), after infusion of local anesthetic (bupivacaine) through a cervical phrenic nerve cuff to induce reversible contralateral hemidiaphragm (CNFRZ), and after bilateral diaphragm (BIFRZ) paralysis. From NOFRZ to CNFRZ, costal, crural, parasternal, and transversus abdominis increased shortening and EMG activity to compensate for contralateral diaphragm paralysis, but the increase in activity was not equivalent for each muscle. With BIFRZ, parasternal and transversus abdominis showed further increases in activity, coordinated between both inspiration and expiration. Normalized intrabreath profiles revealed dynamic differences in development of muscle activity within each breath as paralysis worsened. Review of simultaneous muscle activities showed coordinated interactions among the compensating muscles: passive shortening of transversus, and lengthening of costal and crural, coincided with increased active inspiratory shortening of parasternal. We conclude that an integrated strategy of respiratory muscle compensation for unilateral or bilateral diaphragm paralysis occurs among chest wall, abdominal, and diaphragm segmental muscles, with relative contributions of individual muscles adjusted according to the degree of diaphragm dysfunction.

Animals↗
PubMed1993

Use of corticotropin-induced potassium changes in the diagnosis of both hypo- and hyperkalemic periodic paralysis.

Both hypo- and hyperkalemic periodic paralysis may be difficult to diagnose conclusively when patients are not seen during attacks. Since paralysis of both types can be induced with ACTH, we have determined the frequency of this response in small groups of patients. Weakness or paralysis with appropriate changes in serum K concentration resulted from ACTH gel administration, in 4 of 5 patients with known hypokalemic periodic paralysis and in 3 of 3 patients with hyperkalemic paralysis. No adverse effects of the test were observed, but hospitalization and careful monitoring were necessary. The response to ACTH appears to be a sensitive, useful aid to the diagnosis of both hypo- and hyperkalemic periodic paralysis.

Adolescent↗