Paulo Augusto de Lima Pontes

Identification of the external branch of the superior laryngeal nerve during thyroidectomy.

Seventy-six patients underwent preoperative vocal evaluation and were randomized into 3 groups: (1) those with the superior thyroid pole dissected by the first author, with the external branch of the superior laryngeal nerve (EBSLN) identified by means of a nerve stimulator; (2) those patients whose dissection was executed by a resident, with no nerve search; and (3) those whose dissection was undertaken by the first author, without any nerve search. Postoperative analysis consisted of voice evaluation and electromyography of the cricothyroid muscle. No lesion occurred in patients in group 1. Twenty-eight percent of patients in group 2 and 12% in group 3 experienced a complete lesion of the EBSLN (p = 0.0123). When the patients in group 1 were compared with the patients with 62 nerves corresponding to nonoperated thyroid lobes, patients in group 1 exhibited no increased risk, whereas a significantly increased hazard was evident in both groups 2 (p = 0.0002776) and 3 (p = 0.0346393). In this study, effective prevention of iatrogenic EBSLN lesions during thyroidectomies was achieved only by the intraoperative identification of the nerve with the nerve stimulator.

Results of a prospective trial on elective modified radical classical versus supraomohyoid neck dissection in the management of oral squamous carcinoma

BACKGROUND Elective treatment of the neck in oral squamous cell carcinoma has changed over the last 20 years. The main object of this report is to present the results of a multi-institutional prospective study designed to compare standard treatment with modified radical classical neck dissection (MRND) to supraomohyoid neck dissection (SOH) in the management of the clinically negative neck in oral cancer patients. PATIENTS AND METHODS A total of 148 patients were included in the trial. All patients had previously untreated T2 to T4 N0 squamous cell carcinoma of the oral tongue (62 cases), floor of the mouth (49 cases), inferior gingiva (12 cases), or retromolar trigone (25 cases). Tumor stages were T2, 91; T3, 27; and T4, 30. There were no significant imbalances between groups. RESULTS The false-negative rate was 28%, and most positive nodes were sited at level II and III. Complications were seen in 41% of MRND patients and in 25% of SOH patients (P = 0.043). Median total duration of hospitalization was 9 days in MRND patients and 7 days in the SOH group. To date, 19 and 16 patients presented with local and neck recurrences, respectively. The 60-month actuarial survival rates were 63% in the MRND group and 67% in the SOH group (P = 0.7150). CONCLUSIONS This study demonstrates that the recurrence and survival rates were similar in both groups. SOH neck dissection can be recommended as standard elective treatment for patients with T2-T4 oral squamous cell carcinomas.

End results of a prospective trial on elective lateral neck dissection vs type III modified radical neck dissection in the management of supraglottic and transglottic carcinomas

Either modified type III radical neck dissection (MRND) or lateral neck dissections (LNDs) are considered valid treatments for patients with laryngeal carcinoma with clinically negative neck findings (N0). The object of this prospective study was to compare complications, neck recurrences, and survival results of elective MRND and LND on the management of laryngeal cancer patients.

Morphological and Functional Aspects of the Senile Larynx

Objective: To analyze the senile larynx, considering morphological aspects during respiration and functional aspects during phonation, comparing it to the young adult larynx. Patients and Methods: A retrospective study was conducted of 100 laryngeal images of adults without vocal complaints, 50 laryngeal images of young adults aged 20–45 years and 50 laryngeal images of elderly individuals aged 65–85 years, of both genders. Images were produced by means of a rigid endoscope and stroboscopy. The morphological aspects analyzed were: laryngeal symmetry, vocal fold bowing, prominence of the vocal process and glottic proportion. The functional aspects analyzed were glottic closure, laryngeal vestibule behavior, phase (timing of closure) and amplitude symmetry of mucosal wave and tremor of laryngeal structures. Results: Significant differences between the young adult larynx and the geriatric larynx were found for the following parameters: vocal fold bowing, prominence of the vocal process, glottic proportion, phase and amplitude symmetry of mucosal wave and tremor of laryngeal structures. Conclusion: The data suggests that the geriatric larynx differs from the young adult larynx in many characteristic aspects.

Treatment of sulcus vocalis: Auditory perceptual and acoustical analysis of the slicing mucosa surgical technique**

Sulcus vocalis is a furrow in the mucosa of the vocal folds that causes glottic insufficiency, irregular vibrations, and a distinctive dysphonia of variable severity. Treatment of sulcus vocalis needs to achieve anatomical and functional improvements that satisfy the behavior of the larynx and vocal quality. We suggest a combined approach, which includes vocal fold mucosal surgery through a technique called slicing mucosa, followed by intensive vocal rehabilitation. The aim of the surgery is to detach the mucosa of the sulcus and to interrupt the longitudinal fibrotic tension lines. The results of this procedure in 10 patients were analyzed through visual, auditory, and acoustical methods, and the data lead us to conclude that the treatment proposed offered a good anatomical result, a better vibratory pattern, and an improvement in overall vocal quality.

Clinical Evolution of Laryngeal Granulomas: Treatment and Prognosis

Objective/Hypothesis: To study the response to treatment by patients with granulomas not related to surgery, considering their respective causes. Methods: Retrospective study of larynx granulomas seen at the Institute da Laringe (Sǎo Paulo, Brazil) from June 1996, totaling 66 patients, being 20 (30,3%) diagnosed with gastroesophageal reflux syndrome, 22 (33,3%) due to vocal abuse, 15 (22,7%) to postorotracheal intubation, and 9 (13,6%) of idiopathic cause. Findings: Of the 66 patients diagnosed, 10 did not start the treatment, with only 56 being analyzed, 6 of whom later abandoned the treatment. The cause‐oriented treatment showed 100% control in postintubation granulomas. In the cases of reflux and vocal abuse, the success rates when considering only the cause were 75% and 87.5%, respectively. In the cases of undefined cause, all were subjected to surgical removal with or without clinical or speech‐therapy treatment; we attained only a 37.5% success rate in the first trial. Of these, after various unsuccessful rescue treatments, three which were treated with botulinum toxin type A had 100% resolution. The recurrence percentage varied according to the cause, being nonexistent in the postintubation cases, 21.4% in patients with reflux esophagitis, 35.2% in vocal abuse, and 62.5% in those of idiopathic etiology. Conclusion: Of the laryngeal granulomas, the best prognoses were given by the postintubation ones, whereas the worst were those of undefined cause. Those ascribed to gastroesophageal reflux and vocal abuse have a high resolution rate, although some cases need rescue procedures.

Vestibular vocal fold behavior during phonation in unilateral vocal fold paralysis

Voice quality in patients with vocal fold paralysis can be affected by several factors, such as the position of the paralyzed vocal fold, its degree of atrophy, the configuration of its free edge, and the level differences between both vocal folds. Depending on the related vocal deficiency the patient will attempt to compensate using different maneuvers, such as increment of vocal tract and neck muscle contraction to improve glottal closure. This is probably one of the reasons why ventricular folds are frequently requested. The objective of this study is to analyze the behavior of the homolateral and contralateral vestibular folds to delineate patterns of vestibular motion during sustained phonation, in cases of unilateral vocal fold paralysis.

Vocal Nodules and Laryngeal Morphology

Our purpose was to study the occurrence of vocal fold nodules under conditions of habitual vocal abuse associated with increased laryngeal muscle tension, to identify the existence of a relationship between vocal nodules and laryngeal morphology. We studied one group of 30 subjects with vocal nodules, 18 to 50 years old, who were compared with two control groups, one of females and one of males, consisting of 30 subjects each. The parameters evaluated were: type of vocal folds coaptation, glottic proportion (GP) and abduction angle (AA), obtained by videotelelaryngoscopy. In the nodules group, the larynges presented a mean value of GP similar to that of the female group, both of which were lower than the mean GP value of the male group. On the other hand, the mean AA was lower than the one in the female group, and closer to the one in the male group. We concluded that vocal nodules were present only in larynges with a predominantly young female morphology, with functional limitations of abduction.

Acoustic and Long-Term Average Spectrum Measures to Detect Vocal Aging in Women

Along the normal aging process, voice tends to become weak, breathy, and loses projection, which may interfere in the communication process. One reliable way to evaluate voice quality is through acoustical analysis using, for instance, the long-term average spectrum (LTAS). The aim of this study was to identify acoustic measures, particularly LTASs, which characterize vocal aging in women without vocal complaints. For this purpose, 30 elderly and 30 young women were included in this study. All spoke standard Portuguese and none had a history of vocal and laryngeal alterations or respiratory diseases. On the basis of the reading task, in habitual and loud levels, the following parameters were assessed: the equivalent sound level (L(eq)), the speaking fundamental frequency (SFF) and, at the LTAS window, the difference between the levels of the regions of the first formant and fundamental frequency F(0) (L(1) - L(0)), alpha ratio, and the amplitude levels obtained at equal intervals of 160 Hz, ranging from 0 to 8 kHz. There were significant differences between young and old voices for SFF and L(eq) in both levels. In the LTAS window, amplitude levels were higher for young voices, comprising all frequencies except those in the regions between 4.6-6.7 and 4.8-6.5 kHz, in habitual and loud levels, respectively. There were also significant differences regarding L(1) - L(0) and alpha ratio between groups, in both levels.The observed differences in LTASs slopes, L(1) - L(0) measures, and even L(eq) and SFF measures, may be attributed, to some extent, to lower subglottal pressure or a glottal setting providing a slower glottal closing speed for the elderly group.

Importance of glottic configuration in the development of posterior laryngeal granuloma.

Posterior laryngeal granuloma is frequently related to 3 predisposing factors: vocal abuse, gastroesophageal reflux disease, and orotracheal intubation. It is strongly predominant in men and rare in women, except under postintubation circumstances, in which the incidence is higher in women. The aim of this study was to characterize laryngeal conformations for each sex that, whenever associated with different causes, may lead to the onset and particular location of granulomas, according to a main predisposing factor. Sixty-six subjects whose ages ranged from 18 to 73 years were studied. They were distributed into 4 groups according to the predominant cause of granuloma: intubation, vocal abuse, gastroesophageal reflux, and idiopathic causes. The larynx was evaluated during breathing, and the glottic proportion (GP) was measured. Glottic proportion is the mathematical ratio between the midsagittal dimension of the intermembranous region and that of the intercartilaginous region of the larynx during inhalation. Its measurement was feasible in 57 patients. The groups that had a causative factor other than laryngeal orotracheal intubation had GP values statistically similar to those of each other and to the control group of men, ie, close to 1.2. The postintubation group had GP values similar to the control group of women, ie, close to 1.0; this proportion protects the arytenoid region in womens larynges when there is effort during vocal production, but makes women susceptible to orotracheal postintubation granuloma.