Injection laryngoplasty with autologous fascia for treatment of unilateral vocal fold paralysis

The purpose of this dissertation was to study the applicability of minced autologous fascia graft for injection laryngoplasty of unilateral vocal fold paralysis (UVFP). Permanence of augmentation and host versus graft tissue reactions were of special interest. The topic deals with phonosurgery, which is a subdivision of the Ear, Nose and Throat-speciality of medicine. UVFP results from an injury to the recurrent or the vagal nerve. The main symptom is a hoarse and weak voice. Surgery is warranted for patients in whom spontaneous reinnervation and a course of voice therapy fails to improve the voice. Injection laryngoplasty is a widespread surgical technique which aims to restore glottic closure by augmenting the atrophied vocal muscle, and also by turning the paralyzed vocal fold towards midline. Currently, there exists a great diversity of synthetic, xenologous, homologous, and autologous substances available for injection. An autologous graft is perfect in terms of biocompatibility. Free fascia grafts have been successfully used in the head and neck surgery for decades, but fascia had not been previously applied into the vocal fold. The fascia is harvested from the lateral thigh under local anesthesia and minced into paste by scissors. Injection of the vocal fold is performed in laryngomicroscopy under general anesthesia. Three series of clinical trials of injection laryngoplasty with autologous fascia (ILAF) for patients with UVFP were conducted at the Department of Otorhinolaryngology of the Helsinki University Central Hospital. The follow-up ranged from a few months to ten years. The aim was to document the vocal results and possible morbidity related to graft harvesting and vocal fold injection. To address the tissue reactions and the degree of reabsoprtion of the graft, an animal study with a follow-up ranging from 3 days to 12 months was performed at the National Laboratory Animal Center, University of Kuopio. Harvesting of the graft and injection was met with minor morbidity. Histological analysis of the vocal fold tissue showed that fascia was well tolerated. Although some resorption or compaction of the graft during the first months is evident, graft volume is maintained well. When injected deep and laterally into the vocalis muscle, the fascia graft allows normal vibration of the vocal fold mucosa to occur during phonation. Improvement of voice quality was seen in all series by multiple objective parameters of voice evaluation. However, the vocal results were poor in cases where the nerve trauma was severe, such as UVFP after chest surgery. ILAF is most suitable for correction of mild to moderate glottic gaps related to less severe nerve damage. Our results indicate that autologous fascia is a feasible and safe new injection material with good and stable vocal results. It offers a practical solution for surgeons who treat this complex issue.HYKS Korvaklinikalla toteutetussa väitöstutkimuksessa selvitettiin autologisen faskian eli omaa kudosta olevan vapaan lihaskalvosiirteen soveltuvuutta äänihuulihalvauksen kirurgisessa hoidossa. Väitösaihe käsittelee äänihuulikirurgiaa, joka kuuluu korva-, nenä- ja kurkkutautien erikoisalaan. Äänihuulihalvaus on yleisimmin seurausta kasvaimen tai leikkauskomplikaation aiheuttamasta hermovammasta. Pääoire on käheä ja heikko ääni, josta aiheutuu potilaille merkittävä kommunikaatiohaitta. Käheyden voimakkuus ja paranemisennuste riippuu vamman vaikeusasteesta. Lievemmät tapaukset kuntoutuvat puheterapeutin toimesta ääniterapialla. Kirurgiaa tarvitaan vaurioissa, joissa hermon toiminta ei spontaanisti palaudu riittävästi. Injektiolaryngoplastiassa halvaantuneeseen äänihuuleen ruiskutetaan ainetta, joka korvaa surkastuneen lihasmassan ja kääntää äänihuulen keskiviivaan. Toimiva äänihuuli saa siihen näin kontaktin ja ääni palautuu. Täyteaineita on tarjolla laaja valikoima. Potilaan omaa kudosta l. autologista siirrettä käyttämällä vältetään monia ongelmia, joita on liittynyt aiemmin paljon käytettyihin synteettisiin materiaaleihin, kuten Tefloniin ja silikoniin. Kun kokeilut 1990-luvun alussa rasvakudoksella eivät antaneet pysyvää tulosta äänihuulessa, päätettiin Korvaklinikalla kokeilla faskiaa l. lihaskalvoa. Faskiasta on pitkä kokemus mm. tärykalvon paikkausleikkauksista, mutta äänihuulessa sitä ei ollut aiemmin käytetty. Faskiasiirre otetaan paikallispuudutuksessa potilaan reisilihaksesta. Se pilkotaan saksilla pastaksi, potilas nukutetaan ja faskia injisoidaan äänihuuleen leikkausmikroskoopin ja erikoisruiskun avulla. Väitöstutkimus aloitettiin Korvaklinikalla v.1998. Se koostuu eläinkokeesta ja kolmesta potilastutkimuksesta. Eläintyön tavoite oli selvittää faskian aiheuttamat kudosreaktiot ja siirteen pysyvyys äänihuulessa. Potilastutkimusten seuranta-aika vaihteli muutamasta kuukaudesta 10 vuoteen. Niissä tavoitteena oli mitata objektiivisin menetelmin leikkaustulos eli äänen laatu sekä arvioida leikkaustekniikan turvallisuutta ja mahdollisia myöhäisongelmia. Tutkimuksessa osoitettiin, että faskia on hyvin siedetty ja stabiili siirre äänihuulessa. Se ei aiheuta vierasesinereaktiota. Alkuvaiheessa todettiin lievä tulehdus, joka ei vaadi antibioottihoitoa. Leikkaustekniikka on kirurgille verrattain helppo omaksua ja potilaalle turvallinen. Merkittäviä leikkauskomplikaatioita ei esiintynyt, myös leikkauksen jälkeinen haitta siirteen ottokohdalla on vähäinen. Äänitulokset olivat hyvät kaikissa tutkimuksissa, joskin pitkän seuranta-ajan (3-10 v.) tuloksissa oli enemmän vaihtelevuutta. Johtopäätös tästä oli että injektiotekniikka faskialla ei ole käyttökelpoinen vaikeimmissa hermovammoissa. Tulostemme perusteella faskiainjektio on käyttökelpoinen ja turvallinen äänihuulihalvauksen kirurginen hoito, joka soveltuu parhaiten lievien ja keskivaikeiden hermovammojen aiheuttaman käheyden korjaamiseen. Se tarjoaa äänikirurgille uuden käytännöllisen tekniikan tämän monimuotoisen ja usein vaikeahoitoisen vamman korjaamiseksi

Pan European Voice Conference - PEVOC 11

The Pan European VOice Conference (PEVOC) was born in 1995 and therefore in 2015 it celebrates the 20th anniversary of its establishment: an important milestone that clearly expresses the strength and interest of the scientific community for the topics of this conference. The most significant themes of PEVOC are singing pedagogy and art, but also occupational voice disorders, neurology, rehabilitation, image and video analysis. PEVOC takes place in different European cities every two years (www.pevoc.org). The PEVOC 11 conference includes a symposium of the Collegium Medicorum Theatri (www.comet collegium.com

General Anesthesia as a Multimodal Individualized Clinical Concept

In this book, a series of modern multimodal monitoring techniques during general anesthesia are presented, with a focus on patient-oriented anesthesia based on the individual needs of each patient reflected in the degree of hypnosis, the nociception–antinociception balance, and neuromuscular transmission. Moreover, a series of secondary implications for hemodynamic status, post-anesthetic recovery, and patient satisfaction are highlighted

Development of micro fluidic based devices for studying tumour biology and evaluating treatment response in head and neck cancer biopsies

Head and Neck Squamous Cell Carcinoma (HNSCC) presents particular challenges to both the researcher and the clinician. Encompassing a group of tumours with distinct epidemiological and oncological behaviour, each sub site differs greatly in its management and prognosis. However, due to insufficient tissue quantities and culture techniques, research studies commonly group together different sub sites, limiting our understanding of the biological behaviour and treatment response of tumours from distinct sites.Micro fluidics relates to the science of systems that process or manipulate small amounts of fluids within micro channels. When applied in biology, the technology enables the production of simple, robust and highly versatile systems for studying cells and tissues. The aim of the work in this thesis was to maintain small biopsies of tumour in a physiological state, more comparable to the in vivo environment than traditional tissue culture techniques, for up to 9 days. This recreation of the ‘tumour microenvironment’ in vitro provided a platform for the testing of chemotherapy agents and analysing individual tumour behaviour. Initial optimisation studies were performed to demonstrate tissue viability within this novel culture method. Based on LDH excretion as a marker of cell death and WST-1 metabolism as a marker of viability, tumour and nodal biopsies from a variety of sub sites remained viable within the device until the addition of cell lysis buffer at 68 h. Histo-architectural examination of tissue incubated within the device for 96 h demonstrated that original tissue structure is largely maintained. In addition, comparison of viability between fresh and frozen tissues showed little difference, thus the clinical applicability of the technique was significantly enhanced, as biopsies could be collected and stored prior to use at a later date.Using clinically relevant combinations of chemotherapy drugs, nodal biopsies (n=50 micro chips from n=2 tumours with all experiments duplicated) were interrogated with cisplatin, 5-Fluorouracil and docetaxel within the micro device for up to 9 days. The addition of each chemotherapeutic agent resulted in increased cell death compared to control, with a synergistic effect seen when agents were given in combination; results in agreement with clinical trial data.This study demonstrates a robust and reproducible system for the maintenance and ‘interrogation’ of individual tumour biopsies. The innovative model provides a new platform for testing individual patient responses to chemotherapy, paving the way for ‘personalised’ treatment regimens

The development of a new rating scale for the perceptual assessment of tracheoesophageal voice quality outcome following total laryngectomy

PhD ThesisPerceptual assessment of voice in people with surgical voice restoration (SVR) is essential to evaluate surgical and other interventions aimed at delivering optimal voice quality. Currently there are no tools to measure this that do not have issues of validity and reliability. This work describes the development and trialling of investigatory versions of three scales to address this situation: a) the Sunderland Tracheoesophageal Perceptual Scale (SToPS) for professional raters, b) the Naïve Rater Scale for non-specialist raters and c) the Patient and Carer Scale. In the final testing of the pilot version 55 speakers using tracheoesophageal voice were evaluated by twelve Speech and Language Therapists (SLT’s) and ten Ear, Nose and Throat (ENT) surgeons, divided into experienced or not at assessing voice. Ten naïve raters assessed the voice stimuli within a test-retest design. Forty tracheoesophageal speakers and thirty-seven carers attended an interview to rate their own or their relative’s voice. Inter rater agreement was then calculated between SLT, ENT, naïve, patient and carer groups with weighted kappa co-efficients Strength of agreement values (Landis and Koch 1977) were compared to profession and expertise. Expert SLT’s achieved “good” agreement for nine of fourteen parameters. Naïve judges attained “good” levels of inter and intra-rater agreement for the parameters Overall Grade and Social Acceptability. The greatest inter group consensus was for patients and carers, with “good” agreement for Intelligibility, Volume and Wetness. The only other “good” agreement was between naïve/ENT and naïve/ SLT groups for Overall Grade. The scales are ready for clinical use with the proviso that future work will determine whether it is possible to enhance agreement so less experienced judges can achieve “good” levels of agreement for more parameters and examine which perceptual parameters might be more prominent or vital for outcomes for different groups.City Hospitals Sunderland NHS Foundation Trust

Anatomical Variation and Clinical Diagnosis

In the anatomical sciences, it has long been recognized that the human body displays a range of morphological patterns and arrangements, often termed “anatomical variation”. Variations are relatively common throughout the body and may cause or contribute to significant medical conditions. An understanding of normal anatomical variation is vital for performing a broad range of surgical and other medical procedures and treatment modalities. However, despite their importance to effective diagnosis and treatment, such variations are often overlooked in medical school curricula and clinical practice. Recent advances in imaging techniques and a renewed interest in variation in dissection-based gross anatomy laboratories have facilitated the identification of many such variants. The aim of this Special Issue of Diagnostics is to highlight previously under-recognized anatomical variations and to discuss them in a clinical context. In particular, this Special Issue focuses on variants that have specific implications for diagnosis and treatment and explores their potential consequences. The scope of this Special Issue includes studies on gross anatomy, radiology, surgical anatomy, histology, and neuroanatomy

Comparison of Haemodynamic Responses to Laryngeal Mask Airway Insertion and Laryngoscopy with Endotracheal Intubation in Adults Undergoing Elective Surgery at Muhimbili

Airway management is of utmost importance during delivery of general anaesthesia. Traditionally, laryngoscopy and endotracheal tube (ETT) insertion has been the mainstay in providing adequate airway management and delivering anaesthesia. The laryngeal mask airway (LMA) offers a much less invasive way of maintaining the airway as it does not pass through the glottis but is placed over the glottis. It does not require the use of the laryngoscope. Laryngoscopy and tracheal intubation or laryngeal mask airway insertion are noxious stimuli which provoke a transient but marked sympathetic response manifesting as hypertension and tachycardia. In susceptible patients particularly those with systemic hypertension, coronary heart disease, cerebrovascular disease and intracranial aneurysm, even these transient changes can result in potentially deleterious effects like left ventricular failure, arrhythmias, myocardial ischaemia, cerebral haemorrhage and rupture of cerebral aneurysm. To determine the haemodynamic response elicited by laryngoscopy and endotracheal intubation and compare it with that elicited by laryngeal mask insertion in ASA I and ASA II patients, undergoing elective surgeries at Muhimbili national Hospital (MNH) and Muhimbili Orthopaedic Institute (MOI) in 2011. A hospital based prospective randomized comparative study was conducted to determine the haemodynamic response elicited by laryngoscopy and endotracheal intubation and compare it with that elicited by laryngeal mask insertion in ASA I and ASA II patients, undergoing elective surgeries at MNH and MOI . After induction of anaesthesia either an ETT or LMA was inserted. Evaluations included measurement of blood pressure and heart rates before insertion, after insertion of device, 1 minute, 3 minutes and 5 minutes after insertion. Measuments were taken from the Drager infinity gamma XL monitor. Time and ease of insertion was also noted.Results There was an increase in HR, SBP and DBP seen after laryngoscopy and ETT insertion as well as after laryngeal mask insertion. The change in haemodynamic parameters after laryngoscopy and ETT insertion were significantly greater than those elicited by LMA insertion (p<0.0001). The increase took about 5 minutes to return to pre insertion values in the ETT group, while it took about 3 minutes for the same values to return to pre insertion values in the LMA group. It took a significantly shorter time to insert an LMA (12.63 sec) as compared to time taken to insert an ETT (22.76 sec). Insertion of an LMA was rated easy in 84% of the patients while it was rated easy in 60% of the ETT patients. The haemodynamic changes elicited by LMA insertion are less and short lived compared to those elicited by laryngoscopy and ETT insertion. It takes a shorter time and is much easier to insert an LMA as compared to laryngoscopy and ETT insertion. These changes might be insignificant in a normotensive patient, but could be harmful in a patient with cerebrovascular or cardiovascular abnormalities. The use of an LMA is recommended in these groups of patient

Treatment of Exercise-induced Laryngeal Obstruction : Exploring modalities in short and long term

Background: Exercise-induced laryngeal obstruction (EILO) is an umbrella term describing inappropriate and transient closure of laryngeal structures during exercise, causing breathlessness and/or noisy respiration (stridor). EILO is a relatively prevalent entity, affecting adolescents or young adults in all activity levels. The condition has been reported to have a considerable functional impact, particularly as a limitation of physical activity in an effort to minimize the occurrence and severity of inspiratory symptoms. Objective visualization of the laryngeal obstruction and determining the level of obstruction within the larynx (supraglottic and/or glottic) during ongoing exercise is considered gold-standard for diagnosing EILO and seems of importance for subsequent treatment planning. Treatment options are based on weak evidence, with evaluation of different modalities mainly based on subjective outcomes. Information about the diagnosis and breathing advice (IBA) seems to be fundamental elements. Small studies and case reports suggests effect from speech therapy, biofeedback, inspiratory muscle training (IMT) and surgical supraglottoplasty. Robust treatment algorithms and follow-up streams are yet to be established. Aims: The overall aim of the thesis was to explore improvement of symptoms and laryngeal obstruction in EILO patients treated with IMT and supraglottoplasty in short- and long term. Study #I: To investigate laryngeal response pattern(s) during inspiratory muscle training (IMT) in healthy subjects using laryngoscopic evaluation and imaging. Study #II: To expand our knowledge and to explore possible effects from inspiratory muscle training in patients diagnosed with EILO. Study #III: To investigate the efficacy and safety of laser supraglottoplasty for patients with supraglottic EILO, using continuous laryngoscopy exercise (CLE) tests before and after surgery. Study #IV: To assess changes of self-reported symptoms and laryngeal outcomes shortly after IMT, and to compare self-reported symptoms with a control group 4-6 years later. Methods: Study design: An explorative approach with combined descriptive and quasi-experimental observational design. Study #I: cross-sectional study, Study #II: prospective pre-post study Study #III: retrospective pre-post study. Study #IV: follow-up study. Subjects and study procedures: Study #I: Twenty healthy volunteers examined with laryngoscopy during inspiratory muscle training (IMT). The laryngeal movements were retrospectively assessed from video files. Study# II and #III: EILO patients examined with continuous laryngoscopy exercise (CLE)-test before and after a treatment; six-week training program with IMT or supraglottoplasty. Outcome data were self-reported symptom scores and laryngeal obstruction (by CLE-scores from video recordings). Study #IV: Two groups were retrospectively identified from the EILO-register; one group receiving IBA only at diagnosis, and the other additionally receiving six weeks of IMT (IBA+IMT). Laryngeal outcome was assessed shortly after IMT, and the two groups’ self-reported symptoms were compared with a new questionnaire 4-6 years later. Results: Study #I: IMT facilitated laryngeal abduction in the investigated healthy subjects and application of medium intensity resistance seemed superior to higher resistance in opening of the laryngeal aperture. Study #II: IMT was safe and the perceived symptoms and laryngeal obstruction improved in subgroups of EILO after IMT, with improvement mainly observed at the glottic level. Study #III: Supraglottoplasty improved symptoms and reduced laryngeal obstruction in the investigated patients with predominantly supraglottic EILO and appeared safe in highly selected severe cases. Notably, supraglottoplasty might improve also glottic obstruction in patients with combined supraglottic and glottic obstruction. Study #IV: The response rate after 4-6 years was 40 % in the IBA-group and 55% in IBA+IMT-group. After 2-4 weeks, 23/32 in the IBA+IMT-group reported symptom improvements, associated mainly with glottic changes, contrasting unchanged laryngeal scores in 9/32 without symptom improvements. After 4-6 years, self-reported exercise-related symptoms and activity had decreased to similar levels in both groups. Full symptom resolution was reported by 8/55. Conclusion: Self-reported symptoms and laryngeal obstruction as observed and rated in CLE-tests can improve in EILO patients treated with IBA, IMT or supraglottoplasty. Heterogeneous responses to treatment were observed and substantiates that EILO is a heterogeneous condition, thus it is unlikely that one mode of treatment will work in all. Individual treatment and follow-up based on laryngeal findings seems essential. Future controlled studies with longer follow-up time are needed to establish effects from the treatment modalities applied in EILO patients. This work provides hypotheses that may serve as a basis in doing so.Doktorgradsavhandlin

Relationship of the cricothyroid space with vocal range in female singers

It is well documented that the cricothyroid (CT) space opens and closes with changes in pitch, narrowing with rising pitch and widening with falling pitch. Indeed, cricothyroid approximation surgery, a procedure where the CT space is deliberately made smaller, is used in male to female transgender subjects to successfully elevate vocal pitch. The present study focuses on investigating the relationship between the anterior CT space at rest and vocal range in female singers. Laryngeal dimensions (anterior CT space and heights of the thyroid and cricoid cartilages) were measured using ultrasound in 43 healthy, classically trained, female singers. Potential associations with and between age, ethnicity, anthropometric indices (height, weight, body mass index), neck dimensions (circumference and length), vocal data (practice and performance vocal range, lowest and highest practice and performance notes) along with usual speaking fundamental frequency were also explored. The main finding was that mezzo-sopranos have a significantly wider resting CT space than sopranos (11.6 mm versus 10.4 mm; P=0.007). Mezzo-sopranos also had significantly lower ‘lowest and highest’ performance notes and speaking fundamental frequencies than sopranos. Furthermore, there was a weak but significant negative correlation between the magnitude of the anterior CT space and the lowest performance note (r=-0.448; P=0.003) but there was no significant correlation with either the highest performance note or vocal range. These results suggest there is a relationship between the CT space and the lowest note a female can sing. This was evident in the correlation of a small CT space with a higher ‘lowest performance note’. It appears that the CT space influences how low female singers can sing, but not how high they can sing

CIR-Myo News: Proceedings of the 2014 Spring Padua Muscle Days

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