Wan-Fu Su

A clinical classification and histopathological study of sulcus vocalis.

a condition in which a furrow occurs along the upper medial edge of the vocal folds [3, 5]. Since both sulcus vocalis and sulcus vergenture produce a spindle-shaped glottic insufficiency [6], furrows and bowing and/or thyroarytenoid muscle atrophy are often considered together. To clarify this pathophysiology and develop a more rational approach to treatment, Ford et al. [4] divided sulcus vocalis into three types: type 1 (physiological), type 2 (sulcus vergenture), and type 3 (sulcus vocalis). The etiology of sulcus is controversial and reflects disagreement on terminology. A congenital theory considers vocal fold mucosal bridges as a spectrum of conditions with a common cause [1]. Bounchayer et al. [2] hypothesized that it is due to improper development of the fourth and sixth branchial arches. They found onset of dysphonia during childhood in 55% of sulcus patients, and this was frequently associated with a frequent familiar occurrence, cyst formation, and failure of lesions to return after adequate excision. An acquired theory was developed by Shin [8], who found that sulcus vocalis in adult patients was associated with traumatic or infectious factors. Nakayama et al. [7] found a 48% incidence of sulcus vocalis in surgical specimens of patients with laryngeal cancer, suggesting that irritation and inflammation play a significant role in the pathogensis. In an effort to clarify and quantify possible histopathological findings associated with sulcus vocalis, we examined of 72 cases of autopsied larynges, in which whole-mount laryngectomy specimens were sectioned serially in a coronal plane. From 1990 to 1999 approximately 100 autopsy laryngectomy specimens were processed as whole-organ sections at the Tri-Service General Hospital, Taiwan. The techniques used were described by Tucker [9]. Each specimen was decalcified, dehydrated, and embedded in paraffin. Larynges were then serially sectioned at 1-mm intervals in the coronal plane from the posterior edge of the thyroid lamina to the thyroid notch. An attempt was made to identify the location of a sulcus vocalis and calculate the length of the sulcus on the basis of the number of serial sections showing sulcus. Cases were excluded when slide records or medical information was incomplete, leaving 72 cases available for study (58 Chinese men and 14 women), aged 30– 72 years and a mean age of 55 years. To evaluate the morphological feature of sulcus in specimens we classified the sulcus into three groups based on the classifications of Ford et al. [4] and Nakayama et al. [7]. Type I was a physiological sulcus, which was a sulcus confined to the superficial layer of lamina propria (Reinke’s space). A sulcus vergenture (type II) was a sulcus penetrating the superficial layer and approximating the intermediate and deep layer (vocal ligament). A type III sulcus vocalis was a sulcus penetrating the intermediate and deep layer (vocal ligament) and exhibiting a pouchshaped configuration (Fig.1). ” Increased vascular proliferation” in subepithelial tissues was defined as the appearance of multiple enlarged capillaries identified microscopically at low-power field (Fig.2). “Increased fibrosis” was defined as an irregular thick or dense proliferation of fibrous tissue in the superficial lamina propria (Fig.3). The percentages of increased vascular Ming-Wang Hsiung · Peak Woo · Hsing-Won Wang · Wen-Yang Su

Retrograde axonal transport of true blue dye by the peripheral autonomic nerves in canine nasal mucosa.

SummaryIn this study we employed retrograde axonal transport of (E)-2,2′-vinylendi-benzofuran-5-carboxamidin-diaceturate or true blue (TB) to study the peripheral autonomic innervation of the canine nasal mucosa. After injection of TB into the nasal mucosa, labeled neurons were found in the ipsilateral sphenopalatine ganglion (SPG) and the superior cervical ganglion (SCG). There were no labeled neurons in the middle cervical or stellate ganglia. This indicated that the origin of the postganglionic sympathetic fibers of the nasal mucosa was only from the ipsilateral SCG. When TB was injected into the nasal mucosa of dogs following a caudal or ethmoidal neurectomy, labeled neurons could still be found in the SPG and SCG. When TB was injected into the nasal mucosa of dogs following ethmoidal and vidian neurectomies or with maxillary neurectomy added, some labeled neurons could still be found in both the ipsilateral SPG and SCG. These results support the concept that another pathway — perhaps perivascular — exists for postganglionic sympathetic fibers other than the vidian and ethmoidal nerves. Labeled neurons were still observed in SPG when TB was applied to the canine nasal mucosa following neurectomy of either the ethmoidal or the caudal nasal nerve. However, retrograde labeled neurons could not be found in SPG following simultaneous neurectomies of the ethmoidal and caudal nasal nerves. These results show that the postganglionic parasympathetic fibers originating in the SPG travel along the ethmoidal and caudal nasal nerves.

Distribution of noradrenergic nerve fibers in canine nasal mucosa following selective neurectomies

SummaryIn this study, we have used noradrenergic histofluorescence and selective neurectomies of the vidian, ethmoid and caudal nasal nerves to evaluate the distribution of postganglionic sympathetic fibers in the canine nasal mucosa. In conjunction with the histochemical localization of the noradrenergic fibers in the nasal mucosa after vidian neurectomy, the norepinephrine content of the mucosa was also evaluated using high-performance liquid chromatography. Unilateral neurectomy of the superior cervical ganglion (SCG) resulted in the unilateral disappearance of all noradrenergic histofluorescence in the nasal mucosa, while no morphological changes in noradrenergic fibers could be identified after neurectomy of the cervical sympathetic trunk 1 cm below the SCG. Ethmoid neurectomy caused the disappearance of noradrenergic fibers of the upper third of the nasal mucosa, while vidian neurectomy resulted in a partial loss of noradrenergic fibers in the lower two-thirds of the nasal mucosa. The loss was chiefly in the area adjacent to venous sinusoids and was responsible for 50% of the norepinephrine content of this tissue. We concluded that all the postganglionic sympathetic fibers are from the ipsilateral SCG. Some of them travel via the ethmoid nerve and innervate the upper third of the nasal mucosa. The remaining fibers travel via the vidian nerve and perhaps the vessel walls of the supplying arteries and innervate the lower two-thirds of the nasal mucosa. The vidian nerve chiefly innervates the venous sinusoids of the lower two-thirds of the nasal mucosa.

Multifocal carcinoma of the larynx presenting as subglottic carcinoma.

Abstract. The results of treating primary subglottic carcinoma (PSC) with radiation or surgery are disappointing, and recurrent disease is common. The purpose of this study was twofold: first, to present our experience of treating two multifocal patients with PSC and second, to report our treatment results using two different clinical treatment sequences. Between September 1991 and June 2002, we treated five patients with primary squamous cell carcinoma of the subglottis at the Tri-Service General Hospital, Taipei, Taiwan. It constitutes 5.2% of all 96 laryngeal cancers. Two patients were treated with primary surgery and planned postoperative radiation, and two patients were treated with primary radiation and salvage surgery. The fifth patient was treated with radiation alone. At the time of follow-up, four patients were alive without evidence of disease at 58 months, 28 months, 20 months and 11 months, respectively. One patient (T2N0) died of mediastinal lymph node and liver metastasis 2.5 years after being treated with primary surgery and postoperative radiation. In conclusion, our findings revealed that primary radiation in combination with salvage surgery resulted in a better survival rate than primary surgery with planned postoperative radiation. Primary surgery with postoperative radiation was unable to control the multifocal characteristics and occult mediastinal lymphatic drainage. It is important to point out that due to the small sample size and variation in cancer stages, analyses and conclusions regarding two different treatment sequences were not statistically feasible.

Nerve branches to the posterior cricoarytenoid muscle may complicate the laryngeal reinnervation procedure

To better understand the reason for the low success rate of posterior cricoarytenoid (PCA) muscle reinnervation, we attempted to identify the communicating branches that may exist between the nerve branch to the PCA muscle and the other laryngeal adductors in addition to the interarytenoid (IA) muscle.

The Role of Diode Laser in the Treatment of Ventricular Dysphonia

OBJECTIVES The treatment of ventricular dysphonia (VD) should be based on confirming the true folds pathology. In some patients, the ability of the true folds vibration remains unclear and decision making for performing aggressive surgical interventions can be difficult. STUDY DESIGN A retrospective study of surgery by chart review. METHODS Eight cases with suspicious compensatory type of VD were analyzed in this study. They were all symptom free until a history of endotracheal intubation for laryngeal irrelevant surgery. Their false fold adducted and constricted the supraglottic region sphincterically during phonation. Laser ablation of redundant false folds was performed. After confirming the true folds condition, a second procedure was carried out accordingly within 3 months. The outcome was determined by comparing the difference of the perceptual examination and acoustic parameters before and after each procedure. RESULTS Postoperation laryngoscopy revealed the underlying vocal atrophy in five cases and vocal fold palsy in the other three patients. Six of them were treated by medialization thyroplasty or fat augmentation. No significant change in the perceptual evaluation and maximum phonation time was found after laser ablation surgery. Meanwhile, there was no complication such as choking or aspiration after the laser ablation surgery. There was no recurrence of redundant false fold within the mean follow-up of 40 months. CONCLUSIONS The role of diode laser microlaryngosurgery is not to improve vocal quality but to offer a better visualization of underlying vocal behavior. This facilitated the subsequent prime vocal fold correction surgery. Therefore, we recommend this two-stage treatment modality for patients with compensatory VD.

Effects of amphetamine on human nasal mucosa

The present study was devised to determine the effects of amphetamine on the sympathetic function of human nasal mucosa. A tissue bath method was employed on the vitro preparations of nasal turbinate mucosa from adult patients with nasal allergies or hypertrophic rhinitis. The effects of amphetamine on the contractile response of isolated human nasal mucosal blood vessels were investigated following electrical field stimulation and methoxamine. The results showed that amphetamine inhibited field stimulation and antagonized the effects on mucosal contraction induced by methoxamine. Likewise, the drug increased mucosal basal tension but had local drug toxicity when a 10−4M solution was used. Amphetamine could potentiate mucosal contraction induced by norepinephrine or epinephrine. The study indicated that amphetamine may increase sympathetic function by potentiating the effect of norepinephrine and that high concentrations of amphetamine may actually antagonize a-adrenoceptors.

Noradrenergic innervation of vocal nodules and polyps

Sirs: Although vocal nodules and polyps are the most common voice disorders presenting to laryngologists, their differentiation is not well defined [5, 6]. Vocal polyps are often single and unilateral, are usually larger than nodules, and occur on the superior or undersurface of the vocal cord. The typical location of vocal nodules is at the junction of the anterior and middle third of the vocal cords [7, 10]. They are usually symmetrical and bilateral, although a unilateral nodule can also occur. In general, cord polyps and nodules are considered to be tissue reactions to chronic mechanical irritations due to vocal misuse or

Revised thyroplasty: The importance of inner perichondrium dissection

Purpose: The outcome of voice surgery on unilateral vocal cord paralysis (UVCP) by medialization laryngoplasty (ML) was various although the series of reports consistently claimed that the phonation ability restored well after their reconstructive surgery. We revised several unsatisfactory subjects and proposed a correct concept to facilitate a successful surgery. Patients and Methods: One hundred and forty subjects suffering from UVCP and undergoing ML procedure were reviewed. Eight of the 140 subjects underwent revised thyroplasty to improve their unsatisfactory voice. The time elapse from UVCP onset to first ML procedure and between first and second ML procedure was recorded and analyzed. Maximal phonation time (MPT) was used to evaluate the improvement of phonation ability. Result: Inappropriate size or location of the implant material were defined in two subjects, inappropriate management of the inner perichondrium of thyroid lamina (IPTL) were defined in 5, and cricoarytenoid joint (CAJ) fixation in one. MPT was increased from 3 s to 11 s in average after revised surgery. MPT more than 10 s was obtained in 7 subjects in their followup at mean 15 months. Conclusion: The management of IPTL actually determined the voice surgical outcome significantly. Preoperative evaluation of the CAJ mobility was still an important factor to determine the use of corrective methods.

Gastric Mucosa-associated Lymphoid Tissue Lymphoma Masquerading as Relapsed Deep Neck Infection

In the literature, malignant tumor has been described as the cause of deep neck infection. Most of these tumors were primary head and neck cancer. Deep neck infection as the presenting feature of gastric mucosa-associated lymphoid tissue lymphoma (MALToma) has not been reported in the literature. We report a case of repeated deep neck infection as the initial manifestation of gastric MALToma. An initial negative result of biopsy was found. After repeated biopsies of the neck abscess and subsequent discovery of gastric ulcer, the final diagnosis of gastric MALToma with neck involvement was confirmed. This case highlights that apart from carcinoma of the head and neck (pharynx, larynx, or thyroid gland), nonhead and neck (colon or esophagus), and non-Hodgkins lymphoma, the differential diagnosis of gastric MALToma may be considered when a patient presents with a deep neck infection.