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Superior laryngeal nerve injury from thyroid surgery.

BACKGROUND: Injury to the recurrent laryngeal nerve is a well-recognized complication of thyroid surgery. Injury to the superior laryngeal nerve is less documented, perhaps due to the difficulty in recognizing its manifestations. This study was designed to document the incidence of injury to the superior laryngeal nerve in a series of patients who underwent thyroidectomy. METHODS: Twenty consecutive patients with thyroidectomy during a 9-month period underwent evaluation for superior laryngeal nerve injury 3 months postoperatively. Methods for evaluation included laryngeal videostroboscopy, laryngeal electromyography, and a subjective interview. RESULTS: One patient (5%) was diagnosed with unilateral superior laryngeal nerve injury. CONCLUSIONS: The risk of injury to the superior laryngeal nerve during thyroidectomy is significant, and the result may be devastating to those patients who rely on their voices professionally. Laryngeal videostroboscopy and electromyography may be necessary to diagnose superior laryngeal nerve injury.

Adolescent↗

Misdirected regeneration of injured recurrent laryngeal nerve in the cat.

INTRODUCTION: Misdirected regeneration (MR) frequently occurs following injury to the recurrent laryngeal nerve (RLN) resulting in neurotmesis or axonotmesis. Physiological and anatomic parameters involved in the functional recovery of the larynx following freezing injury or neurorrhaphy of the RLN were studied. A multi-facilitated approach is undertaken to clarify the functional abnormalities caused by the MR after recurrent laryngeal nerve injury. MATERIALS AND METHODS: Three groups of adult cats were studied. These included controls, cats with recurrent laryngeal neurorrhaphy, and cats with recurrent laryngeal nerve freeze injuries. From 2 weeks to 9 months after the nerve injury, the animals were studied endoscopically and with electromyography (EMG). Using the same animal, the number and location of motoneurons supplying the ipsilateral posterior cricoarytenoid (PCA) muscle were examined with horseradish peroxidase (HRP). Animals were subsequently sacrificed to study the pattern of reinnervation. RESULTS: Following neurorrhaphy all cats had vocal cord paralysis. After neurorrhaphy, effective motion function did not return in the affected vocal cord and it remained fixed in the paramedian position. Although EMG of the laryngeal muscles of the affected side showed interference voltage, the pattern of activities was markedly different from that of the unaffected side, and reciprocity among the laryngeal muscles was not restored. The number of PCA motoneurons recovered to the normal range, but a considerable number of neuronal bodies were dispersed outside the normal PCA area. This indicates misdirected reinnervation to the PCA muscle by motoneurons that originally served other laryngeal muscles. In the freezing injury, effective vocal cord movement finally recovered after 6 months. At this time, EMG showed a normal pattern, although a relatively small amount of misdirected neurons was observed. DISCUSSION: Functional recovery of vocal cord motion does not occur following neurorrhaphy. Prominently disorganized arrangement of laryngeal motor neurons was observed in the horseradish peroxidase study. This suggests that inappropriate reinnervation develops in spite of reapproximation and suturing. Altered central organization of the motor nucleus is a significant pathogenic factor in the loss of laryngeal muscular coordination following recurrent laryngeal nerve lesions. The degree of recovery is related to the mechanism of injury.

Animals↗

Equine laryngeal hemiplegia. Part IV. Muscle pathology.

This study confirmed that neurogenic muscle pathology exists in intrinsic laryngeal muscles supplied by the recurrent laryngeal nerves in horses subclinically and clinically affected with laryngeal hemiplegia. An important additional observation was the occurrence in three out of four laryngeal hemiplegic horses of neurogenic muscle changes in a hindlimb muscle, the extensor digitorum longus, a muscle supplied by another long peripheral nerve. This finding suggests that a polynenropathy exists in laryngeal hemiplegic horses, and supports the classification of this disease as a distal axonopathy. Comparison of the degree of pathology in the intrinsic laryngeal muscles and that of the recurrent laryngeal nerves innervating them, demonstrated a strong correlation between the extent of damage in the distal left recurrent laryngeal nerve and the overall degree of muscle pathology. The muscle damage in clinically affected horses is a reflection of the nerve damage present in the most distal portion of the recurrent laryngeal nerve. The more variable pathological changes found in proximal levels of the left and right recurrent laryngeal nerves probably reflects the ongoing nature of the pathological process affecting nerve fibres. The existence of a subclinically affected group of horses, the earliest involvement of an adductor, the left cricoarytenoideus lateralis muscle, and the presence of changes in the right intrinsic laryngeal muscles all confirmed the findings of previous workers.

Journal Article↗

Dysphonia and laryngeal sequelae in paracoccidioidomycosis patients: a morphological and phoniatric study.

The larynx is the third most commonly involved organ in paracoccidioidomycosis (PCM). While a few studies have evaluated laryngeal sequelae, there have not been any investigations of voice abnormalities in PCM patients. To evaluate persistent dysphonia and laryngeal lesions, we studied 15 normal subjects and 30 post-treatment PCM patients, i.e., 15 with only pulmonary and 15 with both laryngeal and pulmonary involvement. Perceptual and acoustic voice analysis were performed with all patients, while endoscopic studies were also conducted with the 15 laryngeal patients. Voice analysis showed instability by perceptual analysis (P<0.01) in both groups, but more severe dysphonia was noted in the laryngeal group (P<0.01). The dysponia, seen in 66.7% of these patients (dysphonia index < 7.0), was characterized by roughness and breathness. The Dr. Speech (Tiger Electronics) analysis program did not accept five voices from the laryngeal group due to the severe dysphonia. Jitter was elevated in five laryngeal lesion patients. Endoscopy showed that 80% of patients with laryngeal lesion had two or more laryngeal structures involved. Vocal fold alterations were seen in all laryngeal lesion patients, which included involvement of the arythenoids, epiglottis, and vestibular folds. This first functional study of laryngeal sequelae in PCM revealed frequent and severe dysphonia that may have important social consequences for patients.

Adult↗

Prevalence of laryngeal paresis in dogs undergoing general anaesthesia.

OBJECTIVE: To estimate the prevalence of laryngeal paresis within a selected population of dogs and identify some of the distinguishing characteristics of affected dogs. DESIGN: A prospective study involving laryngoscopic examination of 250 dogs. PROCEDURE: The laryngeal movements of 250 dogs undergoing general anaesthesia were observed. The severity of laryngeal paresis in these dogs was graded (0 = normal laryngeal movements, 4 = bilateral laryngeal paralysis). The following information was also recorded for each dog: age, sex, weight, breed, condition score, anaesthetic protocol, clinical suspicion of disease and observer. RESULTS: Twenty five percent of the dogs examined had some degree of laryngeal paresis. Affected dogs were significantly older than unaffected dogs (P < 0.001). There was a trend for the severity of laryngeal paresis to increase with age. There was no difference between the sexes. Dogs with laryngeal paresis were significantly heavier than normal animals (P < 0.02). Overweight animals had a significantly higher laryngeal grade than those with a normal condition score (P < 0.05). Labrador Retrievers and Rottweilers had a significantly higher risk of having laryngeal paresis (P < 0.05). Clinical suspicion was found to have high diagnostic value. An intra-class correlation coefficient for inter-rater reliability between the two observers was 0.95. CONCLUSIONS: Laryngeal paresis had a high prevalence in the animals surveyed and was strongly associated with age and breed. The results of this study are consistent with the concept of a progressive degenerative disease with a breed susceptibility. Clinical suspicion for the presence of the disease was a reliable indicator. The grading system used had a high degree of inter-observer agreement.

Anesthesia, General↗

Androgen directs sexual differentiation of laryngeal innervation in developing Xenopus laevis.

In adult Xenopus laevis, innervation of the vocal organ is more robust in males than in females. This sex difference originates during tadpole development; at stage 56, when the gonads first differentiate, the number of axons entering the larynx is the same in the sexes, but by stage 62, innervation is greater in males. To determine if androgen secretion establishes sex differences in axon number, we treated tadpoles with antiandrogen or androgen beginning at stage 48 or 54 and counted laryngeal nerve axons at stage 62 using electron microscopy. When male tadpoles were treated with the antiandrogen hydroxyflutamide, axon numbers were reduced to female-typical values; axon numbers in females were unaffected by antiandrogen treatment. When female tadpoles were treated with the androgen DHT (dihydrotestosterone), axon numbers were increased to male-like values. These findings suggest that endogenous androgen secretion during late tadpole stages in males is required for the sexual differentiation of laryngeal innervation observed from stage 62 on. Because androgen treatment and laryngeal innervation affect myogenesis in postmetamorphic frogs, numbers of laryngeal dilator muscle fibers were determined for hormonally manipulated tadpoles. At stage 62, vehicle-treated males had more laryngeal axons than females; laryngeal muscle fiber numbers did not, however, differ in the sexes. Both male and female tadpoles, treated from stage 54 with DHT, had more muscle fibers at stage 62 than vehicle-treated controls. Thus, while endogenous androgen secretion during late tadpole stages is subthreshold for the establishment of masculinized muscle fiber numbers, laryngeal myogenesis is androgen sensitive at this time and can be increased by suprathreshold provision of exogenous DHT. A subgroup of tadpoles, DHT treated from stage 54 to 62, was allowed to survive, untreated, until postmetamorphic stage 2 (PM2: 5 months after metamorphosis is complete). Androgen treatment between tadpole stages 54 and 62 does not prevent the ontogenetic decrease in axon numbers characteristic of laryngeal development. In addition, the elevation in stage 62 axon numbers produced by DHT-treatment at late tadpole stages was not associated with elevated numbers of laryngeal muscle fibers at PM2. Juvenile males normally maintain elevated axon numbers (relative to final adult values) through PM2 and the presence of these additional axons may result from--rather than contribute directly to--laryngeal muscle fiber addition.

Animals↗

Developmental changes in histochemical properties of intrinsic laryngeal muscles in rats.

OBJECTIVE: Using neonatal rats, the developmental changes in muscle fiber type of the intrinsic laryngeal muscles were analyzed. The potential influence of two factors were also studied, that were predicted would influence developmental changes in muscle fiber type, denervation and hypothyroidism. METHODS: Using the histochemical technique of myosin ATPase staining, postnatal changes in the ratio of muscle fiber types of each intrinsic laryngeal muscle were determined. In addition, to clarify factors influencing the development of the intrinsic laryngeal muscles, the same technique was employed to study recurrent laryngeal nerve-denervated rats and rats with experimentally-induced hypothyroidism. RESULTS: In normal pups, type 2C fibers had almost disappeared by postnatal day (PND) 14. In denervated pups, differentiation to type 1 and 2A muscle fibers was not observed. In contrast, differentiation to type 2B muscle fibers was impaired in the hypothyroid pups. CONCLUSION: The differentiation of intrinsic laryngeal muscles occur earlier than that of hindlimb muscles. Each intrinsic laryngeal muscle exhibits a particular pattern of developmental changes in normal pups. The developmental changes in the intrinsic laryngeal muscles are affected by recurrent laryngeal nerve innervation and thyroid hormonal control. The findings suggest that both recurrent laryngeal nerve innervation and thyroid hormone play important roles in the differentiation of the intrinsic laryngeal muscles.

Animals↗

[Gastro-oesophageal reflux disease presenting as laryngeal pathology--epidemiology, symptoms, diagnosis. Preliminary report].

UNLABELLED: Symptoms from the ears, throat, nose and larynx--the laryngeal mask's manifestations of gastroesophageal reflux disease (GERD) are important clinical problem of significant occurrence. AIM: (1) Determination of GERD's frequency of occurrence, especially within the group of patients with the pathology of the posterior laryngeal commissure. (2) Evaluation of the effective algorithms for detecting and management of patients demonstrating symptoms of laryngeal mask, which develop on the ground of gastroesophageal reflux disease. The investigation included 9 patients who were hospitalized in the Department of Otolaryngology of Karol Marcinkowski University of Medical Sciences in Poznań. Every patient was carefully interviewed by means of 3 questionnaires: the first one being Karlsson's general questionnaire, the second one--author's questionnaire designed in the Department of Otolaryngology of Medical Academy in Poznań which emphasises laryngeal symptoms; and the third one being the inquiry including serious past diseases, regularly taken medications, and stimulants. The objective condition of the hypopharynx and larynx was estimated on the basis of indirect laryngoscopy, followed by manometric examination of the oesophagus and 24-hour pH-metry carried out in Motility Laboratory of Surgical Department. 8 patients (88.9%) out of 9 were diagnosed as having GERD on the ground of the questionnaires as well as on the base of the results from the 24-hour pH-metry, and among 7 patients (87.5%) out of the 8 motility disfunction of the oesophagus was detected. Within the group of 8 patients with diagnosed GERD on the ground of additional tests 3 patients (37.5%) were diagnosed as having posterior laryngitis, 2 patients (25%) were diagnosed as having chronic laryngitis and the last 1 (12.5%) suffering from dysphagia. Among 3 patients (37.5%) with tumors of the larynx of rare location within the posterior laryngeal commissure coexistence of gastroesophageal reflux disease (GERD) was proved. The remaining 1 patient (11.1%) with the larynx cancer had no confirmation of GERD. The connection between chronic laryngitis and gastroesophageal reflux disease and/or motility disfunction of the oesophagus described in the literature was confirmed within the group of examined patients. Awareness of GERD and diagnostics carried out in that direction is needed in the group of patients with typical symptoms of the laryngeal mask. Significant frequency of coexistence of gastroesophageal reflux disease and pathology of the posterior laryngeal commissure requires effective algorithms for management of these patients.

Chronic Disease↗

[Perforation of the laryngeal mucosa caused by closed trauma: comparison of laryngoscopic and CT findings].

INTRODUCTION: Laryngeal mucosal perforation is a frequent event whose diagnosis is based on clinical, laryngoscopic and CT findings. MATERIAL AND METHODS: We reviewed retrospectively the data relative to 77 patients with blunt neck trauma examined October, 1991, to June, 1996. All patients were submitted to clinical examination first and then, to fiberoptic laryngoscopy and CT on the clinician's request. RESULTS: Nineteen patients with small skin tears and no signs and symptoms of laryngeal injury were immediately discharged while 37 patients were submitted to surgery: 17 to remove cerebral hematomas, 13 to stabilize cervical fractures and 7 because of hemodynamic instability. Twenty-one patients underwent laryngoscopy which showed laryngeal lesions in 12: wide mucosal disruption with fractures of the laryngeal skeleton and hematomas were observed, which needed immediate surgery with airway reconstruction in 7 cases; small mucosal tears and hematomas were seen and laryngeal CT examination was requested to establish the possibility of conservative management in 5 cases which are the subject of the present study. Laryngoscopic findings were: 1) laryngeal mucosal tear near the thyroid cartilage with quadrangular membrane edema, 2) thyroid mucosal tear with thyrohyoid muscle edema, 3) edema of the left false vocal cord, 4) edema of the oblique arytenoid muscle, 5) posterior cricothyroid muscle edema with bleeding near the cricoid ring. In cases 1, 2 and 3 CT showed gas bubbles in the paralaryngeal space, where laryngeal tear or edema were indicated at laryngoscopy. DISCUSSION: CT does show the "gas bubbles" in the paralaryngeal space when laryngoscopy cannot distinguish laryngeal mucosal perforation from tear. CONCLUSIONS: The routine use of CT in minor, laryngeal injuries in the emergency department is useful for the early diagnosis of laryngeal mucosal perforation.

Adolescent↗

"Hidden" laryngeal injuries in homicidal strangulation: how to detect and interpret these findings.

These studies were designed to demonstrate that the usual method of laryngeal dissection carries a significant risk of overlooking important laryngeal injuries. Formalin-fixed hyoid-larynx complexes were prepared in a prospective forensic study involving 191 cases of homicidal strangulation, 1984 to 1997. The basic steps of the applied method included: complete resection of the thyroid cartilage, a horizontal incision through the cricoid cartilage before opening the larynx dorsally, inspection of the laryngeal joints, and incisions of the laryngeal muscles. Using this procedure allowed us to detect the following injuries, which otherwise would have been destroyed or overlooked: (a) 17 incomplete fractures restricted to the dorsal surfaces of the thyroid laminae and 10 incomplete or non-dislocated fractures of the cricoid cartilage. In 7 cases, such a "hidden" fracture was the only laryngeal injury resulting from neck compression. (b) Extensive laryngeal muscle hemorrhages, especially of the vocal folds, were found in almost half of all cases, more rarely in strangulation by ligature and more frequently in manual strangulation. Gross hemorrhages were the decisive local laryngeal finding in 19 cases. (c) Laryngeal joint injuries (bleedings) were found in 18% to 52% of the different strangulation types. (d) Hemorrhages of the laryngeal mucosa were common findings that occur in about 60% of all cases; only in rare cases do such bleedings have a special diagnostic value. The quantity and significance of findings obtainable from complete preparation clearly document Camps's demand made in 1976 to dispense with the usual laryngeal dissection technique (dorsal scissor incision through the cricoid cartilage), at least in (questionable) strangulation cases.

Asphyxia↗

Motor neurons of the laryngeal nerves.

The present study was undertaken to determine the relationship between the motor neurons of the superior and recurrent laryngeal nerves within the nucleus ambiguus. The retrograde transport of horseradish peroxidase was utilized to identify the motor neurons subsequent to its application to the proximal transected end of the superior and recurrent laryngeal nerves. Labeled superior laryngeal motor neurons were distributed ventrolaterally in the rostral portion the nucleus. The recurrent laryngeal motor neurons were distributed throughout the nucleus with two distinct populations: a rostral group and a caudal group. The rostral group overlaps the motor neurons of the superior laryngeal nerve. The caudal group occupies that portion of the nucleus that is classically described for the recurrent laryngeal nerve. Additional superior laryngeal nerve labeled perikarya were found in the dorsal motor nucleus of the vagus. This study defines the rostral distribution of the recurrent laryngeal nerve motor neurons and suggests that this rostral group is a component of the neuroanatomical substrate that is involved in the co-activation of the laryngeal abductors controlling the laryngeal aperture.

Animals↗

Identification of the non-recurrent inferior laryngeal nerve using intraoperative neurostimulation.

INTRODUCTION: The non-recurrent inferior laryngeal nerve occurs at a frequency of about 0.5% and usually on the right side. The identification of a non-recurrent laryngeal nerve may be difficult. We describe a new method for its identification using intraoperative neurostimulation. METHODS: We examined nine patients with a non-recurrent inferior laryngeal nerve and five patients with a normal inferior laryngeal nerve anatomy who were operated on trans-sternally. Neurostimulation of the vagal nerve producing electromyographic signal in the intrinsic laryngeal musculature was performed at different points proximally and distally. RESULTS: : Electromyographic signals were found proximally but not distally of the separation of the inferior laryngeal nerve from the vagus in 14 patients. In nine patients with a non-recurrent inferior laryngeal nerve, we performed neurostimulation of the vagus opposite the lower and the upper thyroid poles. In all patients we found no electromyographic signals at the distal stimulation point. In contrast, proximal neurostimulation of the vagus opposite the upper thyroid pole produced positive electromyographic signals. CONCLUSION: Neurostimulation of the vagal nerve distally of the separation of the inferior laryngeal nerve did not produce electromyographic signals in the intrinsic laryngeal musculature, perhaps due to the different modalities in the vagal fascicles. Negative electromyographic signals following neurostimulation of the distal vagal nerve opposite the lower thyroid pole should lead to proximal neurostimulation of the vagus opposite the upper thyroid pole. Positive electromyographic signals proximally and negative electromyographic signals distally predict the occurrence of a non-recurrent inferior laryngeal nerve which allows its diagnosis before surgical dissection of the thyroid gland and may prevent nerve palsy.

Adult↗

Laryngeal mask airway in neonatal resuscitation: a survey of current practice and perceived role by anaesthesiologists and paediatricians.

OBJECTIVES: To survey current practice and to compare the opinion of paediatricians and anaesthesiologists regarding laryngeal mask airway (LMA) in neonatal resuscitation. DESIGN: A structured postal questionnaire on the use of the laryngeal mask airway in neonatal resuscitation was sent to the heads of department of the paediatric and anaesthesiology services. SETTING: Forty-three hospitals in the Veneto Region, Italy. RESULTS: During the year 2000, 1526 out of 33708 (4.5%) neonates in our region needed resuscitation. Of these cases, 101 (6.6%) were ventilated using the LMA. Laryngeal mask airway availability was significantly greater in the anaesthesiology department compared to the paediatric department (90% versus 50%; P = 0.002). However, 52% of anaesthesiologists and 72% of paediatricians had never used the laryngeal mask airway in their practice. The laryngeal mask airway was considered as an essential device more frequently by the anaesthesiologists than by the paediatricians (27% versus 5%; P = 0.015); both groups considered the laryngeal mask airway particularly useful in specific situations. Interestingly, while 16% of the paediatricians described the laryngeal mask airway as having no value, none of the anaesthesiologists did (P = 0.002). Staff competence was considered low by 70% of anaesthesiology heads of department compared with 90% of their pediatric colleagues. In both specialties, use of the laryngeal mask airway was limited to medical staff. With regard to training, 35% of anaesthesiologists and 22.5% of paediatricians had attended a course on laryngeal mask airway use. CONCLUSIONS: Laryngeal mask airway availability and perceived value were higher amongst anaesthesiologists than their paediatric colleagues. However, educational level, competence and utilization rates of the LMA in neonatal resuscitation were low in both groups.

Anesthesiology↗

The augmentation of intrinsic laryngeal muscle activity by air-jet stimulation of the nasal cavity in decerebrate cats.

The purpose of this study was to examine the functional roles of nasal afferents in modulating the activity of the intrinsic laryngeal muscles. The electromyographic activities of the intrinsic laryngeal muscles and major respiratory muscles were recorded in cats during nasal air-jet stimulation. The activities of brainstem respiratory neurons were also recorded to determine which neurons transmit nasal afferent signals to the intrinsic laryngeal motoneurons. These axonal projections were identified by antidromic activation evoked by stimulation to the spinal cord at C4 level and the laryngeal nerve. The length of the respiratory cycle was prolonged and the diaphragmatic activity was decreased during air-jet stimulation of the nasal cavity. In contrast, the activities of both the intrinsic laryngeal adductor and abductor muscles were increased. Examination of the laryngeal reflexes revealed increase in the activities of intrinsic laryngeal motoneurons during both respiratory phases. Most of the respiratory neurons recorded decreased their peak firing rate during air-jet stimulation, reflecting decreased diaphragmatic activity; however, the peak firing rate of the bulbospinal expiratory neurons in the portion of the ventral respiratory group caudal to the obex did not decrease during stimulation. These findings demonstrate the nasal air-jet stimulation decreases the activities of major inspiratory muscles in order to avoid inspiration of foreign bodies into the nasal cavity and augments the activities of intrinsic laryngeal muscles, enabling prompt elicitation of the laryngeal airway reflex. Our findings also suggest that the nasal afferents suppress the major inspiratory activities by way of brainstem inspiratory neurons, but that the activities of intrinsic laryngeal muscles are controlled through undetermined pathway(s) other than the pathway through respiratory neurons.

Animals↗

Differential sensitivity of laryngeal and pharyngeal motoneurons to iontophoretic application of serotonin.

Serotonergic neurons decrease their activity during sleep, especially rapid eye movement sleep, thereby reducing their facilitatory effect on upper airway motoneurons. The magnitude of teh sleep-related loss of tone varies among upper airway muscles (e.g., pharyngeal dilator motoneurons are more suppressed than laryngeal motoneurons). We hypothesized that these differences may be related to the sensitivity of different groups of upper airway motoneurons to serotonin. Experiments were done on decerebrate, vagotomized, paralysed and artificially-ventilated cats. Hypoglossal and laryngeal motoneurons were recorded extracellularly using five-barrel pipettes filled with: serotonin, glutamate and methysergide (serotonergic antagonist) for iontophoresis, and NaCl for recording and current balancing. All but two of the 65 hypoglossal motoneurons (45 inspiratory, 10 expiratory, 10 tonic) and 27 out of 32 laryngeal motoneurons (14 inspiratory, 18 expiratory) were excited by serotonin, and the excitation was abolished by methysergide. To compare the magnitude of the excitatory effect among distinct motoneuronal groups, we applied small ejection currents in a standardized manner (+15 nA for 3 min; 10 mM serotonin in 150 NaCl) onto spontaneously active motoneurons (13 inspiratory hypoglossal, 11 inspiratory laryngeal and 11 expiratory laryngeal). Serotonin increased the number of spikes per respiratory burst of inspiratory hypoglossal motoneurons from 19 +/- 4.0 (S.E.M.) to 35 +/- 4.8, of inspiratory laryngeal motoneurons from 44 +/- 8.3 to 55 +/- 8.8, and of expiratory laryngeal motoneurons from 23 +/- 4.8 to 33 +/- 6.2. The relative increases in activity (to 220% +/- 24, 147% +/- 23 and 148% +/- 9 of control, respectively) were significantly higher in hypoglossal than in laryngeal motoneurons. In addition, the excitatory effect developed significantly faster in hypoglossal than in laryngeal motoneurons. Methysergide reduced the spontaneous activity of about half the hypoglossal and laryngeal motoneurons to 66% +/- 5 of control. Thus, the sensitivity to the excitatory effects of serotonin varies among different pools of upper airway motoneurons. These differences correlate with the pattern of airway muscle hypotonia seen during sleep.

Action Potentials↗

The reinforced laryngeal mask in paediatric outpatient dental surgery.

One hundred and twenty ASA I and II grade children aged 2-9 years scheduled for outpatient dental extractions under general anaesthesia were studied. They were allocated randomly to one of three groups for airway management: group R had anaesthesia with a reinforced laryngeal mask airway, group L with a standard laryngeal mask airway and group N with a nasal mask. Anaesthesia was induced in all children using halothane in 50% nitrous oxide with oxygen and maintained on halothane in 67% nitrous oxide with oxygen. An Ayre's T-piece with Jackson-Rees modification was used. The incidence of airway obstruction was significantly lower and surgical access significantly better with the reinforced laryngeal mask airway when compared with the standard laryngeal mask airway. However, the reinforced laryngeal mask airway was significantly more difficult to insert when compared with the standard laryngeal mask airway. On comparing the reinforced laryngeal mask airway with the nasal mask, there were significantly fewer episodes of airway obstruction, better oxygen saturation, less increase in heart rate and fewer arrhythmias in the reinforced laryngeal mask airway group. Total time for the procedures was the same for all three groups. Thus, the reinforced laryngeal mask airway was found to be a favourable alternative to the standard laryngeal mask airway and nasal mask for paediatric outpatient dental extractions.

Airway Obstruction↗

Silent reflux: ex juvantibus criteria for diagnosis and treatment of laryngeal disorders.

CONCLUSIONS: Some primary laryngeal pathologies with specific clinical presentation may be related to silent laryngeal reflux. An ex adjuvantibus proton pump inhibitor (PPI) treatment may be helpful for showing evidence of such a hidden laryngeal disorder. OBJECTIVE: To assess the validity of PPI as an ex adjuvantibus criterion for diagnosis and treatment of suspected reflux-associated laryngitis. PATIENTS AND METHODS: Sixty patients with clinical suspicion of laryngo-pharyngeal reflux (LPR) were identified on the grounds of laryngeal symptoms (dysphonia, cough, globus sensation, increased throat clearing, bad taste, and laryngeal spasm), laryngeal features (arytenoid edema/erythema, partial or total vocal fold erythema, and posterior glottic edema) with or without gastro-esophageal reflux disorder (GERD). They were consequently subdivided in three groups: type I, with LPR symptoms and features without GERD; type II with LPR symptoms and features with GERD; and type III with LPR features only. Types I and III were randomly treated with omeprazole (group A) or with immunostimulating vaccine (group B) for 3 months. Pre- and post-treatment laryngeal features and symptoms in all groups were evaluated by laryngo-stroboscopy and analyzed for statistical correlation. RESULTS: All omeprazole-treated patients showed improvement of laryngeal features and symptoms. With PPI treatment, a more significant improvement was noticed with respect to nonspecific immunostimulant therapy. Also, patients without LPR symptoms showed improvement of laryngeal features.

Adjuvants, Immunologic↗

Pharmacodynamic modeling of vecuronium-induced twitch depression. Rapid plasma-effect site equilibration explains faster onset at resistant laryngeal muscles than at the adductor pollicis.

BACKGROUND: After bolus doses of nondepolarizing muscle relaxants, the adductor pollicis recovers from paralysis more slowly than the diaphragm and the laryngeal adductors, suggesting that the adductor pollicis is more sensitive than the respiratory muscles to effects of those drugs. In contrast, during onset, the respiratory muscles are paralyzed more rapidly than the adductor pollicis, suggesting that the respiratory muscles are more sensitive than the adductor pollicis. To reconcile these apparently conflicting findings, we determined vecuronium's pharmacokinetics and its pharmacodynamics at both the adductor pollicis and the laryngeal adductors. METHODS: Six volunteers were studied on two occasions during anesthesia with propofol. Mechanical responses to train-of-four stimulation were measured at the adductor pollicis and at the laryngeal adductors. Vecuronium (15-60 micrograms/kg) was given and arterial plasma samples were obtained from 0.5-60 min. Vecuronium doses differed by twofold on the two occasions. A pharmacokinetic model accounting for the presence and potency of vecuronium's 3-desacetyl metabolite and a sigmoid e-max pharmacodynamic model were fit to the resulting plasma concentration and effect (adductor pollicis and laryngeal adductors) data to determine relative sensitivities and rates of equilibration between plasma and effect site concentrations. RESULTS: The steady-state plasma concentration depressing laryngeal adductor twitch tension by 50% was approximately 1.5 times larger than that for the adductor pollicis. The equilibration rate constant between plasma and laryngeal adductor concentrations was about 1.5 faster than that between plasma and adductor pollicis concentrations. The Hill factor (gamma) that describes the steepness of the laryngeal adductor concentration-effect relation was approximately 0.6 times that of the adductor pollicis. CONCLUSIONS: More rapid equilibration between plasma and laryngeal adductor vecuronium concentrations explains why onset is more rapid at the laryngeal adductors than at the adductor pollicis. During recovery, both rapid equilibration and lesser sensitivity of the laryngeal adductors contribute to earlier recovery.

Adult↗