Advances in Oto-Rhino-Laryngology最新文献

Particle therapy is a comparatively new radiotherapy treatment form allowing the application of extremely conformal treatment plans. In head and neck malignancies, especially in the paranasal sinus and anterior skull base, this technology is very valuable in order to maintain normal tissue tolerance of critical structures while still applying high doses to the tumour. The following paper will further explore the rationale of particle therapy and available clinical experience of the most commonly treated malignancies arising in these anatomical sites. The potential of particle therapy for re-irradiation in tumours of the paranasal sinus and anterior skull base will also be summarised.

Laryngeal synkinesis as a form of defective healing is the rule rather than the exception in persistent vocal fold paralysis. It typically occurs 4-6 months after the onset of the recurrent laryngeal nerve paralysis. The incidence is up to 85%. Not all laryngeal muscles need to be equally affected. Reliable evidence can only be provided by a laryngeal electromyography. Physiological co-activation of the laryngeal muscles during antagonistic maneuvers must be considered. Although synkinesis undeniably worsens the prognosis for a motion recovery, it protects the muscle fibers from degeneration. A differentiation is required between favorable synkinesis (type I according to Crumley), which does not always require further therapy in the case of unilateral paralysis, and unfavorable forms of synkinesis (type II-IV) according to Crumley, which are associated with a functionally relevant malposition of the vocal fold(s) or with vocal fold jerks. Particularly when bilateral vocal fold motion does not return, type I synkinesis can be a good prerequisite for new dynamic therapy approaches, such as laryngeal pacing. The rarely occurring type II-IV synkinesis should, whenever possible, be transformed into a more favorable type I synkinesis by selective or non-selective reinnervation at an early stage of the disease. The latter applies to expected muscle atrophy with insufficient regrowth of nerve fibers.

Injection laryngoplasty as used in this chapter is synonymous with the term "injection augmentation." Injection augmentation is a technique designed to enhance glottic closure in patients with glottic insufficiency, or failure of glottic closure, by injecting material into the lateral aspect of the vocal fold to move the vibrating surface to the midline. This type of injection augments the vocal fold and improves glottic closure. Injection augmentation originated over 100 years ago. However, the current indications, techniques, and materials have changed significantly. Paralysis, defined as loss of function due to neu-rological injury, remains a common cause of glottic insufficiency. In cases of paralysis, nerve function to adduct the vocal folds for voice production and coughing is interrupted, bilaterally or unilaterally, and the glottis becomes insufficient. While unilateral vocal fold paralysis remains the most common indication for vocal fold injection augmentation, due to the development of newer injectable materials and less invasive injectable techniques, surgeons routinely perform injection augmentation for glottic insufficiency due to other causes such as vocal fold paresis, vocal fold atrophy, presbylarynx, vocal fold scar, and soft tissue loss. Additionally, there is an increasing performance of vocal fold injection in the awake patient. This allows for immediate feedback and reduced anesthetic risk. Outcomes assessment for injection augmentation remains varied by lack of consensus and large-scale studies to identify the factors most instrumental in documenting optimal results. We review the history of injection laryngoplasty, the indications for injection, choice of injectate, outcomes, complications, and future directions of injection laryngoplasty for augmentation.

Sinonasal tumours are rare, and among these there exist a small number of histologic subtypes that are infrequently encountered and rarely mentioned in the literature. These have been presented as either case reports or small case series, and their very low incidence makes prospective studies practically impossible. This review analyses the available literature, including our own experience and endeavours to outline management strategies, which involve a high index of suspicion and counselling of patients. In most instances, these tumours require aggressive multimodal treatment to improve survival outcomes. The overall prognosis remains dismal.

Vocal fold immobility can be either unilateral or bilateral and partial or complete. The aim of this chapter is to discuss the management of unilateral paresis using medialization thyroplasty with or without arytenoid adduction as a means of treating neurogenic causes as opposed to mechanical fixation. Medialization thyroplasty is an open surgical procedure that is performed under local or general anesthesia. Essentially, it aims to close the glottic gap, approximating both vocal folds together and thereby allowing for restoration of the efficiency of the larynx. The glottic gap results from atrophy of the affected vocal fold and in so doing results in glottic insufficiency which causes voice breathiness, strain, fatigue, aspiration, and swallowing difficulties that make up the bulk of symptoms associated with this condition. Unlike injection laryngoplasty, medialization thyroplasty does not increase the "bulk" of the atrophic vocal fold but merely brings the fold closer to its unaffected partner. Besides the obvious lateralization, there is occasionally a third dimensional component to the affected fold. The slipping and prolapse forward of the arytenoid cartilage due to atrophy of the muscles supporting it and the natural declination of the facet joint it rests on cause a vertical drop of the level of the affected vocal fold that may not be remedied with the medialization procedure, hence requiring arytenoid adduction. Although attempts to medialize the vocal fold have been described in the past with limited access, the basic premise of creating a window in the thyroid cartilage remains central. The differences between materials used, their respective strengths and weaknesses, the pitfalls and pearls in achieving a good closure and improvement in voice, swallow, and safety of the airway are all discussed accordingly.

We here summarize the structures of the laryngeal vocal fold as well as its insertion structures at the anterior commissure and at the area of the vocal process and place these findings within the context of biomechanical, functional, and clinical implications.

In the setting of a voice clinic, the voice may be assessed in a number of different ways. As a bare minimum, assessment should include stroboscopic examination, patient self-reported questionnaires, and clinician-reported perceptual evaluation. In addition, recordings of the voice may be analyzed using computer software: several different measures exist, but the most widely used are jitter, shimmer, and noise-to-harmonic ratio. There are, however, significant limitations of these measures, including access to the equipment, inter-test reliability of the measurements, and a lack of correlation with clinical improvement. Other mathematical techniques (nonlinear algorithms) may provide more robust measurements. A pragmatic approach to assessment in the voice clinic suggests that stroboscopic examination should be accompanied by patient-reported questionnaires and clinician-rated voice assessments.

Neuromuscular diseases (NMDs) are diseases involving the motor nuclei of the cranial nerves and anterior horn cells of the spinal cord, the peripheral nerves, the neuromuscular junction, and/or muscle itself. The following groups of disorders from the WHO International Classification of Diseases are usually included in the classification of NMDs: (1) Motor neuron diseases or related disorders; (2) Disorders of nerve root, plexus or peripheral nerves; (3) Diseases of neuromuscular junction or muscle. These diseases include myasthenia gravis or certain specified neuromuscular junction disorders, primary disorders of muscle, and secondary myopathies. The following discussion selects NMDs from each group, which may have unique laryngeal features and more commonly involve the laryngologist and highlights different diagnostic and treatment considerations related to the larynx.