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Inspiratory activation of the vocal cord adductor, part I: human study in patients with restricted abduction of the vocal cords.

OBJECTIVES/HYPOTHESIS: In patients with restricted abduction of the vocal cords, it has generally been accepted that glottis narrowing with laryngeal stridor during inspiration is attributed to static and passive obstruction of the glottis. However, active glottis narrowing can also be contributory. We tested the hypothesis that the vocal cord adductor is activated during inspiration in patients with restricted abduction of the vocal cords. STUDY DESIGN: Electromyographic evaluation of vocal cord adductor activity in patients with restricted abduction of the vocal cords. METHODS: Five patients with restricted abduction of the vocal cords who had stridor with mild to severe dyspnea during wakefulness were anesthetized with propofol. We recorded the adductor muscle electromyogram during breathing through a laryngeal mask airway while observing the vocal cord movement endoscopically. In three patients who had undergone tracheostomy, we also recorded adductor firing patterns not only while closing but also while opening the tracheostoma. RESULTS: The adductor was activated during inspiration, and the glottis was narrowed in accordance with inspiratory stridor. This adductor inspiratory activity was abolished by opening the tracheostoma in the tracheostomized patients. CONCLUSION: Not only static or passive glottis narrowing but also active narrowing may contribute to inspiratory flow limitation in patients with restricted abduction of the vocal cords. This active glottis narrowing is probably induced by an airway reflex.

Adolescent↗

Vocal cord sulcus.

Vocal cord sulcus is a congenital condition consisting of a furrow on the medial edge of the vocal cord. It is most often bilateral but may be unilateral. The symptoms are a hoarse and breathy voice due to incomplete closure of the vocal cords. The present series comprises 15 patients found among 1,400 patients with voice and speech disorders. The condition is often overlooked and regarded as part of a primary functional hyperkinetic voice disorder. By close inspection the furrow can often be seen by indirect laryngoscopy. In many cases, however, microlaryngoscopy under general anaesthesia should be performed, but the furrow is only detected if a search is made for it. The condition is often found in younger patients, probably due to the fact that the sulcus is difficult to detect in older patients who have developed severe organic changes in a effort to overcome the incomplete closure of the glottis.

Adolescent↗

Tuberculous lymphadenopathy of superior mediastinum causing vocal cord paralysis.

Vocal cord paralysis because of involvement of recurrent laryngeal nerve by benign and acute inflammatory lymphadenopathy is a rare condition. Presented here is a case of tuberculous lymphadenopathy of superior mediastinum causing left recurrent laryngeal nerve paralysis, which was successfully treated by antituberculosis treatment, with complete recovery of vocal cord function.

Adult↗

Vocal cord paralysis, synkinesis and vocal fold motion impairment.

Felix Semon's 'laws' of vocal cord paralysis were conceived over a century ago, based on the simple concept that abductor function of the recurrent laryngeal nerve was more vulnerable than adductor function. It is now clear that the neuromuscular pathology of laryngeal innervation is much more complex. Whether the nerve has been cut, crushed, stretched, cauterized or otherwise injured, it is seldom completely transected. There might be no detectable vocal cord movement at laryngoscopy, yet, electromyography usually shows at least some activity because of incomplete denervation and/or developing synkinesis. Electrical silence hardly ever persists forever. Disordered vocal fold movement following nerve injury appears to depend on laryngeal synkinesis with disorganized neuromuscular function caused by misdirected regeneration and aberrant reinnervation, sometimes by adjacent nerves. The severity of the injury, abnormal random reinnervation, scar tissue formation and nerve growth-stimulating and inhibiting factors influence the final position of the vocal fold. For a better understanding of neurolaryngological disorders it is no longer sufficient to think merely in terms of 'vocal cord paralysis'.

Electromyography↗

Unilateral vocal cord palsy: a non-psychogenic cause of vocal cord dysfunction.

We believe this to be the first case report of VCD occurring in a patient with an underlying unilateral paralysis of the vocal cord. VCD, though rare, should be considered in any patient presenting as asthma who does not respond to conventional treatment. Physicians need to remain aware of the aetiological, co-diagnosis or causative factors that can be associated with VCD.

Adult↗

Partial laryngectomy for vocal cord cancer with marked limitation or fixation of the vocal cord.

Partial laryngectomy was the procedure utilized to treat 26 patients with either marked limitation of vocal cord motion or fixation. The absolute 24-month tumor free control rate was 73% (19 of 26). Extended hemilaryngectomy with cricoid resection should be performed if subglottic extension of 5 mm or greater is present. Extended hemilaryngectomy has a greater complication rate than the classical hemilaryngectomy.

Cricoid Cartilage↗

Loss of large myelinated nerve fibres of the recurrent laryngeal nerve in patients with multiple system atrophy and vocal cord palsy.

OBJECTIVES: Vocal cord palsy seen in some patients with multiple system atrophy may result from neuronopathy of the recurrent laryngeal nerve. METHODS: Six controls and six patients with multiple system atrophy, four with and two without vocal cord palsy were studied. The number of myelinated nerve fibres were counted and fibre diameter histograms were established for the motor and sensory divisions of the laryngeal branch of the recurrent laryngeal nerve. RESULTS: Although both groups of patients with multiple system atrophy showed selective loss of the myelinated fibres in the motor branch, the change was greater in those with vocal cord palsy than in those without. The small myelinated nerve fibres (diameter < 7 microm) were decreased in number in both multiple system atrophy groups, whereas the large myelinated nerve fibres (diameter < 8 microm) were decreased only in those with vocal cord palsy, and preserved in those without the symptom. CONCLUSION: In multiple system atrophy, the small myelinated fibres innervating the vocal cord are affected first, without obvious clinical signs. The patient develops vocal cord palsy only after the loss of the large myelinated fibres, which mostly comprise the alpha motor axons that innervate the intrinsic laryngeal muscles.

Atrophy↗

Psychological and family characteristics of adolescents with vocal cord dysfunction.

Vocal cord dysfunction (VCD) is a respiratory disorder often confused with asthma. Although previous case reports have implicated family and/or individual psychopathology in the etiology of this condition, this is the first paper to present prospective, case-control empirical data on a group of pediatric patients with VCD. A case-control methodology was employed to examine patients in terms of both family and individual functioning. Results indicate that patients with VCD were not different from asthmatic controls on measures of family functioning. However, they did experience significantly higher levels of anxiety and received a higher number of anxiety-related diagnoses such as separation anxiety and generalized anxiety disorder on a structured psychiatric interview. The nature of the relation between VCD and psychological symptoms in children is discussed. Etiologic and treatment issues are examined in the context of the findings.

Adolescent↗

Irritant-associated vocal cord dysfunction.

Vocal cord dysfunction (VCD) is a poorly understood entity that is often misdiagnosed as asthma. We report eleven cases of VCD in which there was a temporal association between VCD onset and occupational or environmental exposure. We conducted a case-control study to determine if the characteristics of irritant-exposed VCD (IVCD) cases differed from non-exposed VCD controls. Chart review of VCD patients at the authors' institution produced 11 cases that met IVCD case criteria. Thirty-three control VCD subjects were selected by age matching. There were statistical differences between the groups in ethnicity and chest discomfort. There were no statistical differences between the groups for gender, tobacco, smoking habits, symptoms, or pulmonary function parameters. Varied irritant exposures were associated with IVCD. IVCD should be considered in patients presenting with respiratory symptoms occurring after irritant exposures.

Adult↗

The influence of laser arytenoidectomy on ventilation parameters in patients with bilateral vocal cord paralysis.

Bilateral vocal cord paralysis is a symptom that may lead to serious breathing problems. The treatment of patients with vocal cord paralysis presents a challenge to otolaryngologists. Many techniques have been developed in an attempt to improve the patient's airway insufficiency. The aim of the study was to evaluate the efficacy of the laser total unilateral arytenoidectomy with posterior cordectomy in patients with bilateral vocal cord paralysis. Thrity-six patients (33 females, 3 male) aged between 24 and 76 (mean 52) were treated by laser arytenoidectomy. The flow-volume loop and pletysmography were performed in all patients before and after the operation. Additionally, a group of 15 patients with unilateral vocal cord paralysis was introduced and analyzed as a special control. Based on the relative increase of the parameters after the surgery, the most useful of them were selected for the evaluation. Also, the character of the laryngeal obstruction was defined. Changes in the flow-volume loop before and after surgery were compared by planned comparison in univariate analysis ANOVA/MANOVA with an isolated control group. As the parameters AREA(EX), FEF50, FEF75, PEF and MMEF(75/25) increased most effectively, they appeared to be the most useful in the evaluation. FIV1/FEF1, FEF50/FIF50 and FEV1/FEV(0,5) allowed the definition of the obstruction as an extrathoracic dynamically variable quantity. The resistances measured during pletysmography diminished significantly after surgery. The introduction of the special control group with unilateral vocal cord paralysis showed that despite the significant improvement after surgery, the patients who had been operated on still had a laryngeal obstruction worse than that of patients from the control group. The laser arytenoidectomy is shown to be a useful and efficacious procedure for bilateral vocal cord paralysis.

Adult↗

Atypical expiratory flow volume curve in an asthmatic patient with vocal cord dysfunction.

BACKGROUND: Vocal cord dysfunction can coexist with or masquerade as asthma. Vocal cord dysfunction, when coexistent with asthma, contributes substantially to the refractory nature of the respiratory problem. OBJECTIVE: To report a case of an asthmatic patient with vocal cord dysfunction and a previously unreported unique expiratory flow volume curve. RESULTS: A 16-year-old female, known to have asthma, developed increased frequency of her asthma exacerbations. Spirometry, during symptoms, showed an extrathoracic airway obstruction with a reproducible unique abrupt drop and rise in the expiratory flow volume loop. Laryngoscopy showed adduction of the vocal cords during inspiration and expiration. CONCLUSIONS: We report a unique expiratory flow volume curve in an asthmatic with vocal cord dysfunction that resolved with panting maneuvers. Speech and psychological counseling helped prevent future attacks.

Adolescent↗

Surgical versus non-surgical interventions for vocal cord nodules.

BACKGROUND: Vocal cord nodules are bilateral swellings of the mid-portion of the membranous vocal folds. They are of variable size and are characterised histologically by thickening of the epithelium with a variable degree of inflammatory action in the underlying superficial lamina propria. They characteristically produce hoarseness. Treatment of vocal cord nodules aims to eliminate or reduce this hoarseness. OBJECTIVES: To assess the effectiveness of surgery versus non-surgical interventions for vocal cord nodules. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (CCTR) and Medline (1966-2000), Embase (1974-2000), Biological Abstracts (1970-2000), Biological Abstracts RRM (Reports, Reviews and Meetings) on CD-ROM (1989-2000) and review articles. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing any surgical intervention for vocal cord nodules with non-surgical treatment or no treatment. DATA COLLECTION AND ANALYSIS: No suitable trials were identified. MAIN RESULTS: No studies fulfilled the inclusion criteria. REVIEWER'S CONCLUSIONS: There is a need for high quality randomised controlled trials to evaluate the effectiveness of surgical and non-surgical treatment of vocal cord nodules.

Humans↗