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PubMed1996

Cricoarytenoid joint mobility after chronic vocal cord paralysis.

Eleven whole organ laryngeal specimens (10 human and 1 dog) with a history of long-standing (6 months to 17 years) paralysis were studied histopathologically for changes in the cricoarytenoid (CA) joints and the intrinsic laryngeal musculature. In 9 cases the paralysis was unilateral and in 2 bilateral. No evidence of CA joint ankylosis (fibrous/osseous obliteration of joint space or degeneration of articular surfaces) was seen in the specimens. The absence of CA joint ankylosis permits the efficacy of thyroplasty medialization procedures.

Aged↗
PubMed1999

Voice acoustics after autologous fascia injection for vocal fold paralysis.

OBJECTIVES: The present study was carried out to assess the impact of fascial injection on voice acoustics Preliminary results had suggested that voice, as rated by a panel of listeners, was significantly improved after autologous fascia augmentation of a paralyzed vocal fold. STUDY DESIGN: A prospective study among patients with unilateral vocal fold paralysis was carried out. Eighteen subjects were analyzed 9 months (mean) after the procedure. METHODS: The preoperative and postoperative samples of vowel /a/ were analyzed by Key Elemetrics (Lincoln Park, NJ). Computerized Speech Lab. RESULTS: There was a significant improvement (P<.05) in all parameters measured, including jitter, shimmer, noise-to-harmonic ratio, and maximum phonation time. No laryngeal complications were seen. CONCLUSIONS: According to these preliminary results, vocal fold augmentation by an injection of autologous fascia seems a simple, inexpensive, reliable and safe method to restore voice quality after unilateral vocal fold paralysis.

Adult↗
PubMed2000

Corticosteroid treatment for idiopathic facial nerve paralysis: a meta-analysis.

OBJECTIVE: A meta-analysis was designed to evaluate facial recovery in patients with complete idiopathic facial nerve paralysis (IFNP) by comparing outcomes of those treated with corticosteroid therapy with outcomes of those treated with placebo or no treatment. STUDY DESIGN: Meta-analysis of prospective trials evaluating corticosteroid therapy for idiopathic facial nerve paralysis. METHODS: A protocol was followed outlining methods for trial selection, data extraction, and statistical analysis. A MEDLINE search of the English language literature was performed to identify clinical trials evaluating steroid treatment of IFNP. Three independent observers used an eight-point analysis to determine inclusion criteria. Data analysis was limited to individuals with clinically complete IFNP. The endpoints measured were clinically complete or incomplete facial motor recovery. Effect magnitude and significance were evaluated by calculating the rate difference and Fisher's Exact Test P value. Pooled analysis was performed with a random effects model. RESULTS: Forty-seven trials were identified. Of those, 27 were prospective and 20 retrospective. Three prospective trials met the inclusion criteria Tests of heterogeneity indicate the trial with the smallest sample size (RD = -0.19; 95% CI, -0.58-0.20), to be an outlier. It was excluded from the final analysis. Analyses of data from the remaining two studies indicate corticosteroid treatment improves complete facial motor recovery for individuals with complete IFNP. Rate difference demonstrates a 17% (990% CI, 0.01-0.32) improvement in clinically complete recovery for the treatment group based on the random effects model. CONCLUSIONS: Corticosteroid treatment provides a clinically and statistically significant improvement in recovery of function in complete IFNP.

Adrenal Cortex Hormones↗
PubMed2000

Early arytenoid adduction for vagal paralysis after skull base surgery.

OBJECTIVES: To evaluate the efficacy of early arytenoid adduction in the management of vagal paralysis after skull base surgery. STUDY DESIGN: Retrospective evaluation at a tertiary care skull base center. METHODS: Aggressive surgical management of skull base lesions has become increasingly popular owing to advances in surgical technique and intraoperative monitoring. Temporary and permanent lower cranial neuropathies occur frequently, especially after the surgical management of lesions involving the vertebrobasilar system and the jugular foramen. An injury to the proximal vagus nerve is usually associated with dysphonia and swallowing dysfunction. An early arytenoid adduction has been employed in 26 patients with a vagal paralysis after skull base surgery. Most commonly, the neurosurgical patient underwent an arytenoid adduction under general anesthesia on postoperative day 2. RESULTS: Videostroboscopy after arytenoid adduction demonstrated 76% of patients had complete glottic closure. Of those with inadequate glottic closure, all demonstrated a well-medialized posterior glottis with a persistent anterior glottal gap. These patients were easily treated with a secondary type I thyroplasty under local anesthesia with sedation resulting in complete glottic closure. Despite excellent voice outcomes, 66% of these patients had dysphagia requiring enteral feedings for nutritional support. CONCLUSIONS: An early arytenoid adduction is an excellent medialization technique that can be performed safely in the early postoperative period under general anesthesia after skull base surgery.

Anesthesia, General↗
PubMed2001

Validation of a patient-graded instrument for facial nerve paralysis: the FaCE scale.

OBJECTIVE: To develop and validate a patient-based instrument to measure both facial impairment and disability, the Facial Clinimetric Evaluation (FaCE) Scale. STUDY DESIGN: Prospective instrument validation. METHODS: Eighty-six patients with a documented history of facial paralysis completed a preliminary, 51-item instrument (alpha FaCE Scale), as well as the previously developed Facial Disability Index (FDI) and the Medical Outcomes Study Short Form 36 Item Questionnaire (SF-36). Two weeks after completing these instruments, 76 patients again completed the alpha FaCE Scale. Forty-one of the patients were also evaluated using the House-Brackmann Grading System (HBGS) and the Facial Grading System (FGS). RESULTS: Exploratory principal component factor analysis grouped 15 FaCE Scale items into 6 impairment and disability categories (domains), forming the beta FaCE Scale. Overall, the test-retest reliability of the FaCE Scale was high (Spearman's correlation coefficient (r) = 0.88, P <.01), as were the reliability coefficients of the individual domains (r = 0.81-0.92, P <.01). The FaCE Scale domains showed appropriate correlation to global visual analogue scale questions posed on the original alpha FaCE Scale (r = 0.65-0.81, P <.01). Overall, the FaCE Scale showed significant correlation with HBGS and FGS scores (r = -0.55 and 0.57, respectively; P <.01). However, not all FaCE Scale domains correlated with the HBGS and FGS scores. CONCLUSIONS: A reliable and valid patient-based system to measure impairment and disability in facial paralysis has been developed. This system appears to be better than traditional, physician-graded scales for evaluating quality-of-life issues affected by facial disability.

Adolescent↗
PubMed2002

Autologous transplantation of fascia into the vocal fold as a treatment for recurrent nerve paralysis.

OBJECTIVES: To apply the technique of autologous transplantation of fascia graft into the vocal fold for glottal insufficiency due to recurrent nerve paralysis and to evaluate the results in eight patients who underwent the procedure. STUDY DESIGN: Technical modifications were made in transplantation of the temporal fascia into the paralyzed vocal fold. Eight patients underwent the surgery, and their phonatory function was examined preoperatively and postoperatively. METHODS: The following surgical techniques were applied to prevent the falling-off of the graft: 1) a roll-shaped fascia graft was prepared before the transplantation and 2) a pocket was made within the lamina propria mucosa using a newly devised special elevator. The maximum phonation time and airflow rate during sustained phonation (in four cases) were measured, and perceptual evaluation of voice quality was made using the GRBAS scale by speech pathologists before and after the surgery. RESULTS: All the cases showed no evidence of falling-off of the graft. Elongation of the maximum phonation time and improvement in voice quality were obtained in all cases postoperatively. CONCLUSION: The method proved to be useful for the treatment of glottal insufficiency due to recurrent nerve paralysis.

Aged↗
PubMed2004

Granulomatous inflammation and nerve necrosis in a case of apparent idiopathic vocal fold paralysis: report of a case.

OBJECTIVES: We will present clinical and pathologic findings of the recurrent laryngeal nerve of a 54-year-old man with apparent idiopathic vocal fold paralysis and discuss clinical and scientific implications of these findings. STUDY DESIGN: Our design is in the format of a case report with emphasis on the clinical, intraoperative, histologic, and neuropathologic findings, followed by a discussion of contemporary theories of idiopathic unilateral vocal fold immobility and the implications of our findings. METHODS: A 54-year-old man presented with a 2-year history of unilateral vocal fold motion impairment (VFMI) after an upper respiratory infection. Radiographic and laboratory data revealed no organic cause. The patient clinically appeared to have a classical unilateral vocal fold paralysis and had previously undergone collagen injection and medialization thyroplasty, each with only temporary improvement of voice. We performed ansa cervicalis-recurrent laryngeal nerve anastomosis. RESULTS: Intraoperative dissection revealed an indurated and thickened section of nerve approximately 15 mm in length, located at the beginning of the intralaryngeal segment, near the cricothyroid joint. Segments of this nerve were submitted for histologic evaluation, revealing necrosis with granulomatous inflammation. Postoperative electromyography and videostrobolaryngoscopy were consistent with successful reinnervation from the ansa procedure. CONCLUSIONS: The diagnosis of "idiopathic VFMI" likely represents a number of distinct pathologic entities. This case highlights our lack of understanding of idiopathic VFMI and raises many important questions regarding our current theories of this diagnosis. The clinical and pathologic implications are discussed, and continued investigation is recommended.

Anastomosis, Surgical↗
PubMed1977

Paralysis of accommodation in infectious mononucleosis.

A case report of a 22-year-old patient with accommodative paralysis is presented including (1) the five-year history beginning with infectious mononucleosis; (2) recent clinical examination showing accomodative paralysis and reduced pupilary responses to light and near; (3) objective recordings confirming both the absence of any accommodation and the presence of pupillary responses to monocular and binocular near stimuli and to light, the latter with pupillary escape; and finally (4) neuropharmacological tests showing 7-diopter accommodative responses to pilocarpine (an acetylcholine substitute acting directly on the ciliary muscle receptor sites) and absent responses to demecarium bromide (a cholinesterase blocking agent which potentiates neurally released acetylcholine). Infectious mononucleosis includes ocular signs and symptoms. In young persons with accommodative difficulties, infectious mononucleosis should be suspected.

Accommodation, Ocular↗
PubMed1994

Free neurovascular muscle transplantation for the treatment of facial paralysis using the hypoglossal nerve as a recipient motor source.

Seventeen cases of free-muscle transplantation using the hypoglossal nerve as a recipient motor nerve for the treatment of long-standing or irreversible facial paralysis are reported with details of a follow-up study. The muscle, usually the latissimus dorsi muscle, is transferred to the cheek with microvascular anastomoses. The muscle's motor nerve is sutured to the hypoglossal nerve. There are three classifications of hypoglossal nerve sectioning: total section, central section, and lower section. The results were compared on the basis of these three methods, leading to the recommendation that branches of the hypoglossal nerve diverging inferiorly to innervate the suprahyoid muscles be utilized as a recipient motor source. This method permits acceptably natural movement of the grafted muscle without functional disability of the tongue. Good candidates for this procedure are considered to be those patients for whom muscle transplantation combined with a cross-face nerve graft cannot be adopted because of bilateral paralysis or surgical intervention on the healthy side of the face or who are so old that the long two-stage operation holds no hope for them.

Adult↗
PubMed1997

Analysis of 100 cases of free-muscle transplantation for facial paralysis.

Free-muscle transplantation is the treatment of choice for long-standing facial paralysis. It enables the reconstructive surgeon to restore facial movement and some emotional animation. Despite all technical innovations and 20 years of experience with free-muscle transplantation, the aesthetic and functional outcomes of the surgery are still unpredictable. The present report reviews 100 free-muscle transplantations to the face by a single surgeon and analyzes various preoperative, intraoperative, and postoperative factors in relation to the functional recovery of the muscle transplants. These factors were demographic variables such as age, gender, and etiology as well as intraoperative variables such as choice of muscles, number of nerve coaptations, and ischemia time of the muscle. Additionally, four independent raters not involved in the care of these patients rated standardized preoperative and postoperative videos and judged the functional and aesthetic outcomes. From 1981 to 1993, 93 patients with facial paralysis underwent free-muscle transplantation. A total of 100 muscles were transplanted, since 7 patients received two muscle transplants. There were 33 male and 60 female patients ranging in age from 3 to 57 years, with an average of 22.2 +/- 14.9 years. The gracilis muscle was used in 63 cases of free-muscle transplantation, while the pectoralis minor was used in 34 cases. In 2 patients a segment of the rectus abdominis was transferred, and in 1 patient a small segment of the latissimus dorsi was transferred. In 89 patients the onset of muscle function was reported. The range was from 6 to 48 weeks postoperatively. The average was 21.6 +/- 9.14 weeks after muscle transplantation. The correlations showed a trend to earlier onset of function and higher aesthetic rating in young female patients. The intraoperative ischemia of the free muscle did not correlate with the onset of muscle function. Using a five-step scale of judgments, a higher postoperative rating was seen in 94 percent of the patients, and 80 percent of all patients achieved a moderate or better result.

Adolescent↗
PubMed1998

Hypokalemic paralysis.

Hypokalemia that leads to paralysis is extremely rare in children. We report a case of a young child with genetically inherited periodic hypokalemic paralysis. Hypokalemia should be considered in a child with acute onset of muscle weakness.

Female↗
PubMed1991

Thyrotoxic hypokalemic periodic paralysis in a white man.

Thyrotoxic periodic paralysis is an uncommon complication of hyperthyroidism. Hypokalemia, with associated flaccid paralysis, is the hallmark. Oriental men are most commonly affected. We have reported a case of TPP induced by Graves' disease in a white man with hypokalemia and hypophosphatemia. He was successfully treated with radioactive ablation and short-term administration of a beta blocker. The patient has remained asymptomatic for 12 months after treatment.

Adult↗
PubMed1998

Bilateral vocal cord paralysis after meningitis due to Streptococcus pneumoniae.

We report the clinical course of a 15-month-old boy who had fever, decreased activity, and weakness, with severe respiratory distress during transport to the hospital. Laboratory evaluation confirmed the diagnosis of meningitis due to Streptococcus pneumoniae. He was intubated on arrival and required 4 days of ventilatory support. Soon after extubation, he had marked stridor and dyspnea that were unresponsive to standard therapy with nebulized racemic epinephrine and intravenous dexamethasone. Magnetic resonance imaging of the brain revealed nonspecific findings, and airway endoscopy showed bilateral vocal cord paralysis. Repeated endoscopy showed no improvement in vocal cord function and a deficient swallowing mechanism. Tracheostomy was done to facilitate airway management before discharge from the pediatric intensive care unit. We propose that the diagnosis of vocal cord paralysis must be considered in patients with meningitis and respiratory compromise.

Bronchoscopy↗
PubMed2002

Desmoid tumor of the spinal canal causing scoliosis and paralysis.

STUDY DESIGN: This report describes a case of successful surgical excision of an intrathoracic paraspinal desmoid tumor with an intraspinous extension causing scoliosis and paralysis in a 12-year-old girl. OBJECTIVES: The purpose of this report is to illustrate the potential spectrum of disease of a desmoid tumor and to make physicians aware of the rare possibility of an intraspinal extension of a paraspinal desmoid tumor. SUMMARY OF BACKGROUND DATA: Surgical excision of desmoid tumors in the pediatric population is the standard of care for initial treatment. There have been no clinical reports in the spine literature of a desmoid tumor causing scoliosis or of a desmoid tumor with an intraspinous extension causing paralysis. METHODS: The tumor was decompressed from a posterior approach followed by an anterior resection and an anterior spinal fusion. Two weeks later a posterior spinal fusion was performed to correct the spinal deformity. The patient also received radiation therapy after surgery for 5 weeks. RESULTS: The patient tolerated the procedure well, has been free of recurrence for 9 years, and is currently doing well. CONCLUSION: This case report should help expand the understanding of the spectrum of this uncommon tumor.

Child↗
PubMed2002

Cerebellar arteriovenous malformation with facial paralysis, hearing loss, and tinnitus: a case report.

OBJECTIVE: To describe cerebellar arteriovenous malformation in a 21-year-old man with symptoms resembling those of ear disease and to discuss the relationship between the findings of neurotologic examination and magnetic resonance imaging. STUDY DESIGN: Case report. SETTING: Department of Otolaryngology, Head-and-Neck Surgery of the Kyoto University Hospital, which is a tertiary care center, in Kyoto, Japan. PATIENT: A 21-year-old man had cerebellar arteriovenous malformation and symptoms resembling those of ear disease: recurrent left facial paralysis, left retrocochlear hearing loss, and tinnitus. Auditory brainstem responses showed only waves I and II on his left side. Downbeat nystagmus was seen by anteflexion and retroflexion of his neck. He also experienced a slight sensory disturbance on the left side of his face and right lower extremity. Magnetic resonance imaging and vertebral angiography revealed a cerebellar arteriovenous malformation and a varix functioning as a drainer of the arteriovenous malformation surrounded by an edematous region probably induced by a small hemorrhage in the brainstem. INTERVENTION: Conservative treatment, including intravenous prednisolone, vitamin B12, and oral adenosine triphosphate was performed followed by total extirpation of the arteriovenous malformation. CONCLUSION: In examining patients with peripheral facial paralysis (sometimes recurrent with a short interval) and other symptoms resembling those of ear disease, especially those suggesting certain central disorders, it is important to take intracranial arteriovenous malformation into consideration because the condition may be sometimes life threatening if overlooked.

Adult↗
PubMed2002

Hysterical paralysis: a report of three cases and a review of the literature.

STUDY DESIGN: Three cases of hysterical paralysis are reported and the literature is reviewed. OBJECTIVE: To report and discuss three cases of psychogenic paraplegia in order to increase the awareness and assist in the diagnosis and treatment of this uncommon disorder. SUMMARY OF BACKGROUND DATA: Hysterical paralysis, a form of conversion disorder, is an uncommon psychogenic, nonorganic loss of motor function precipitated by a traumatic event. The prevalence of conversion disorder in the general population reportedly is between 5 and 22 per 100,000 persons. The pursuit of a diagnosis for the hysterical paraplegic patient necessarily consumes valuable resources and time. If early recognition can be facilitated, these resources may be conserved. METHODS: The medical records for three healthy young women who presented to the authors' service reporting complete loss of lower extremity function were reviewed retrospectively along with the related laboratory, electrodiagnostic, and imaging studies. Two of the women were involved in motor vehicle accidents. One had a history of a previous hysterical seizure. Inconsistencies in physical examination and studies were noted. RESULTS: All three patients had normal laboratory, electrodiagnostic, and imaging studies. Discrepancies included complete loss of motor control and sensation in the lower extremities in the face of normal deep tendon reflexes as well as incontinence of bowel and bladder despite intact rectal tone. The patients spontaneously recovered and ambulated out of the hospital without assistance after their normal test results and physical examination inconsistencies were presented to them. CONCLUSIONS: Hysterical paraplegia is a type of conversion disorder. It is a diagnosis of exclusion that typically presents as mono-, hemi-, para-, or quadriplegia. The pursuit of a diagnosis for the hysterical paraplegic patient necessarily consumes valuable resources and time. The typical patient is a female from a low socioeconomic background with limited education. The DSM-IV-TR criteria must be met to fulfill the diagnosis of conversion disorder. Electrodiagnostic and imaging studies can aid in the diagnosis. Treatment revolves around explaining the normal diagnostic results to the patients and guiding them to appropriate psychiatric and physiotherapy. Rapid recovery should be expected, but can take up to 6 months.

Accidents, Traffic↗
PubMed2004

Variations in injury patterns, treatment, and outcome for spinal fracture and paralysis in adult versus geriatric patients.

STUDY DESIGN: Retrospective cohort analysis of hospital discharge and mortality data for spinal fracture and spinal cord injury patients in a single state from 1990 to 1995. OBJECTIVES: Population-based review of preinjury patient factors, injury and treatment patterns, and in-hospital versus 60-day mortality in adult and geriatric spinal injury patients. SUMMARY OF BACKGROUND DATA: While population-based analyses of hospitalized injured patients indicate that geriatric patients are at higher risk for adverse outcome, less is known about the specific subset of patients with spinal fracture and spinal cord injury. A specific knowledge gap exists regarding factors that influence survival after hospital discharge of spine-injured patients. METHODS: Patients with cervical, thoracic, or lumbar spinal fracture were identified by ICD-9-CM discharge diagnosis codes. Age, gender, preexisting conditions, and injury severity were determined, and patients were divided into adult (ages 16-64 years; n = 6,029) and geriatric (ages >or=65 years; n = 3,973) groups. In-hospital and 60-day mortality rates and odds ratios of 60-day mortality were calculated relative to patient and injury characteristics, level of treating hospital, and surgical treatment. RESULTS: Increased 60-day mortality was associated with preexisting medical conditions, increased injury severity, and paralysis but reduced with surgical treatment. Geriatric patients had fewer cervical injures, lower force injuries, less severe overall injuries, decreased paralysis, increased preexisting conditions, decreased treatment at level 1 and 2 treatment centers, and decreased odds of surgical treatment. Geriatric patients also had increased 60-day versus in-hospital mortality and increased mortality associated with cervical spine injury. DISCUSSION: Differences exist in preinjury patient factors, injury and treatment patterns, and mortality between adult and geriatric patients following spinal injuries. The increased 60-day versus in-hospital mortality for the geriatric population suggests that 60-day mortality may be a better measure of outcome for these patients. While the possibility of selection bias exists, both geriatricand adult patients had reduced 60-day mortality associated with surgical intervention.

Adolescent↗
PubMed2004

Bilateral glossopharyngeal nerve paralysis after tonsillectomy: case report and anatomic study.

OBJECTIVE: To present a case report and to propose an anatomic explanation for a rare complication of tonsillectomy, severe dysphagia caused by bilateral paralysis of the glossopharyngeal nerve. STUDY DESIGN: Retrospective case review and prospective cadaveric dissection. METHODS: The medical record and radiologic data were reviewed from a patient who had severe dysphagia after tonsillectomy. In addition, 10 formalin-preserved cadaver head and neck specimens were dissected to identify the anatomic course of 20 glossopharyngeal nerves. The distance between the nerve and tonsillar fossa was measured at two sites. RESULTS: The patient was diagnosed with bilateral paralysis of the glossopharyngeal nerve and required use of gastrotomy tube for years postoperatively. The mean distance from the posterosuperior tonsillar fossa and the main trunk of the glossopharyngeal nerve was 10.7 mm, and the mean distance from the posteroinferior tonsillar fossa and the closest lingual branch of the glossopharyngeal nerve was 6.5 mm. CONCLUSIONS: Direct nerve injury seems the most plausible explanation for this rare complication of tonsillectomy. The proximity of the glossopharyngeal nerve to the tonsillar fossa emphasizes the importance of maintaining the correct surgical plane during surgery.

Adult↗