Harvey M. Tucker

Human laryngeal reinnervation: long-term experience with the nerve-muscle pedicle technique.

The nerve‐muscle pedicle technique for reinnervation of bilateral vocal cord paralysis has now been applied in 45 cases over the past four years. EMG studies, volume flow loop, pulmonary function studies, and the ability to extubate the patient with good to excellent exercise tolerance for day‐to‐day activity have been used as parameters to judge success or failure of this procedure. To date there has been a primary success rate of 91.1% (41/45) and a long‐term success rate of 88.8% (40/45). There has been one serious complication in the entire series and no significant morbidity other than this. Age of the patient and length of paralysis are not necessarily contraindications to the procedure. These results suggest that the nerve‐muscle pedicle technique may be successfully used for reinnervation of bilaterally paralyzed vocal cords without sacrificing residual voice, as is the case with arytenoidectomy type procedures.

Glottic reconstruction after near total laryngectomy.

It is generally accepted that vertical partial laryngectomy can yield satisfactory cure rates in properly selected glottic carcinomas. Several authors have discussed different reconstructive techniques following extended vertical partial laryngectomy. These have included the use of stents, keels, various soft tissue “free” grafts, or muscle transplants. All of the above require prolonged tracheostomy and staged surgical procedures with the resultant upper airway sometimes being less than satisfactory.

Chondrosarcoma of the Larynx Case Report and Management Philosophy

Of the 250 cartilaginous tumors of the larynx reported in the literature, at least 69 (28%) were chondrosarcomas. Of these, 46 are sufficiently well documented to permit detailed analysis. One new case, previously reported as a benign chondroma, is added here. Initial diagnosis, type of treatment, and ultimate survival of these cases can be analyzed to arrive at a basis for treatment philosophy.

Tumors of the carotid body: Experience with 41 operative cases

Evaluation of a patient with a carotid body tumor requires a complete head and neck examination with special attention to the cranial nerves and careful search for additional paragangliomas in other sites. Angiography is very helpful in making the diagnosis and assessing the ipsilateral and contralateral carotid artery. Surgery should be performed early, since group I tumors are easily excised and are associated with a low surgical morbidity. Surgical excision shoud be performed by head and neck and vascular surgeons applying shunting or reconstructive techniques when appropriate. With improved diagnostic and surgical techniques, the morbidity and mortality should continue to approach zero.

Squamous cell carcinoma of the paranasal sinuses: The cleveland clinic experience 1977–1986

Fifty‐four of 103 malignancies of the paranasal sinuses treated at the Cleveland Clinic Foundation between 1977 and 1986 were squamous cell carcinomas. Six arose from the ethmoid sinus and 48 from the maxillary sinus. Of the maxillary sinus patients, 11 presented with Tl or T2 lesions, 20 with T3, 16 with T4, and 7 of these had nodal disease. Treatment was surgery and/or radiation therapy. There was local recurrence in 25 of 48 maxillary sinus patients and in 1 of 6 ethmoid patients. Overall 5‐year survival was 38.2% in the maxillary sinus group: Tl, 100.0%; T2, 85.7%; T3, 31.8%; and T4, 6.7%. Three of six patients with ethmoid tumors were cured. There was a statistical trend for better prognosis in those patients presenting with ethmoid primaries, with early lesions, treated with both radiation and surgery, and with history of inverting papilloma. There were complications of treatment in 10 patients, four of which resulted in death. Local control was the major problem for these patients; therefore, early detection and aggressive local treatment are desirable.

Anterior commissure laryngoplasty for adjustment of vocal fold tension.

An anterior commissure laryngoplasty with placement of a tantalum splint has been employed to adjust vocal fold tension in nine cases. As originally described, the procedure was designed only to tighten flaccid vocal folds. The technique has been modified, however, to allow loosening of tension in tight vocal folds. All nine cases have been successful, at least to some extent, and have shown no significant complications. The details of the procedure and a general discussion of selection and management of patients are included. This procedure may provide relatively safe and effective adjustment of vocal pitch as well as strengthening the voices of patients with flaccid vocal folds.

Reinnervation of the unilaterally paralyzed larynx.

Because of early success with reinnervation of the abductor musculature of bilaterally paralyzed larynges, experimental work and ultimately surgery in human patients has been undertaken to endeavor to apply the same basic concept to reinnervation of the unilaterally paralyzed larynx. A nerve-muscle pedicle is obtained from the omohyoid muscle in a manner identical to that previously reported. The lower 50% of the thyroid ala is carefully removed outside the perichondrial envelope and the lateral fibers of the thyroarytenoideus muscle (major laryngeal adductor) is exposed. The previously repaired nerve-muscle pedicle is inserted into this muscle to complete the procedure. The procedure has been undertaken in nine cases to date where the degree of posterior glottic chink, usually because of a concomitant superior nerve paralysis, was felt to be too great to be adequately managed by Teflon® injection. Some degree of spontaneous return of adduction was accomplished in all nine cases.

Factors in Successful Deglutition following Supraglottic Laryngeal Surgery

Aspiration is the major problem in deglutition associated with conservation laryngeal surgery. Closure of the glottic sphincter, depression of the epiglottis over the laryngeal inlet, elevation of the thyrohyoid complex under cover of the base of the tongue and appropriate relaxation of the cricopharyngeal muscle to permit unobstructed passage of food into the esophagus are important mechanisms that prevent food from entering the trachea. Partial laryngeal surgery can interfere with one or a combination of these mechanisms. Analysis of the records of all evaluable patients who underwent horizontal supraglottic resections from January 1976 to June 1981 was undertaken. The incidence of deglutition problems is reported. In addition, the effects of resection or preservation of the hyoid, arytenoid, base of tongue and branches of the vagus and the effect of cricopharyngeal myotomy upon ultimate swallowing function are analyzed.

Long-Term Results of Nerve-Muscle Pedicle Reinnervation for Laryngeal Paralysis

Between 1976 and 1986, 214 patients with bilateral vocal fold paralysis and 73 patients with unilateral vocal fold paralysis were managed by the author using the nerve-muscle pedicle technique for reinnervation. Follow-up of at least 2 years has been obtained on 202 of the bilaterally and 70 of the unilaterally involved patients. Long-term success has been achieved in 74% of the bilateral group and 88% of the unilateral group. Successful reinnervation of unilateral paralyses usually maintains voice correction indefinitely, but there is late (2 to 5 years postsurgery) deterioration of successful airway restoration in approximately 17% of bilateral cases, which appears to be due to development of cricoarytenoid arthritis.

Laryngeal pacemaker. II. Electronic pacing of reinnervated posterior cricoarytenoid muscles in the canine

A fully reliable means of rehabilitating patients with bilateral vocal cord paralysis has not yet been developed. In order to improve upon existing solutions to this problem, the authors have recently described a laryngeal pacemaker, initially tested through stimulation of a cross‐over nerve‐muscle pedicle from one sternohyoid muscle to the other in the canine. Afferent stimuli, initiated through elongation of the airway during inspiration, were detected by a linear strain gauge sutured to the tracheal rings and appropriately amplified. The current report deals with the application of this concept to pace a nerve‐muscle pedicle reinnervating the posterior cricoarytenoid muscle. Videoscopie and cinematographic documentation of electrically paced abduction of the reinnervated vocal fold, synchronous with inspiration, was clearly demonstrated. Only miniaturization of an implantable electronic amplifier remains to permit an attempt at pacing of the paralyzed larynx in humans.