Vocal cord paralysis as a presenting sign of autosomal recessive spinocerebellar atrophy type 10

Acquired vocal cord paralysis (VCP) is caused by dysfunction or injury of one or both recurrent laryngeal nerves. Here we report a 41-year-old man with spinocerebellar atrophy, autosomal recessive type 10 (SCAR10) due to an autosomal recessive mutation in the ANO10 gene, with VCP as the presenting symptom. He later developed ataxia and speech disturbance.

Characteristics And Prognostic Value of Lymph Node Metastasis Along Recurrent Laryngeal Nerves in Thoracic Esophageal Squamous Cell Carcinoma

Background: Though the value of lymph node (LN) dissection along bilateral recurrent laryngeal nerve (RLN) has been debated and emphasized in recent years in thoracic esophageal squamous cell carcinoma (ESCC). However, the characteristics of nodal metastasis along RLN chain has not been clarified. This study aimed to investigate the characteristics of nodal metastasis along recurrent laryngeal nerves and the influence of these metastasis on the prognosis of thoracic ESCC.Patients and Methods: 339 eligible patients with thoracic ESCC who underwent esophagectomy with a three-field(3-FL) or two-field(2-FL) lymph node dissection from March 2015 to December 2018 were included in this study, consisting of 282 males and 57 females with a mean age of 60.6 years (range,40-80 years). The association of LN metastasis near RLN with clinicopathologic factors and its influence on survival were analyzed. Results: Among the 339 patients, 96 (28.3%) had LN metastasis along bilateral recurrent laryngeal nerves, 76 (22.4%) with positive LNs along right RLN and 47 (13.9%) along the left RLN. There was a significant difference in the metastasis rate between the LNs along right RLN and along the left RLN (P=0.004). The LN metastasis rate along RLN was significantly correlated with primary tumor locations (upper vs middle vs lower: 35.1% vs 30.9% vs 15.6%; P=0.015), tumor invasion depth (T3/T4 vs T1 vs T2: 36.2% vs 15.8% vs 26.2%, P=0.001 ) and degree of differentiation (well vs moderately vs poorly: 9.3% vs 29.3% vs 33.9%; P=0.009), subcarinal and left tracheobronchial lymph node metastasis (positive vs negative:58.1% vs 25.3%, P＜0.001), abdominal LN metastasis (positive vs negative:41.2% vs 24.0%, P=0.003 ), but was not significantly correlated with age, gender and tumor length. The median follow-up time for this study was 34 months. The cumulative 1-, 2- and 3-year overall survival rates were 95.7%, 86.6% and 82.2% in RLN-LN(-) group versus 81.5%, 67.4% and 53.7% in the RLN-LN(+) group, with a significant difference between two group (HR=2.975,95% CI:1.918-4.614, P＜0.01). Conclusions: The lymph node metastasis along RLNs was significantly correlated with primary tumor locations, tumor invasion depth, tumor differentiation, metastasis in the LNs of other stations, and indicate poor prognosis in ESCC.

Assessment of Voice Changes of Patients after Thyroidectomy Without Inferior and Superior Laryngeal Nerves Injury According to the Intraoperative Neuromonitoring

Objectives: to assess voice changes of patients after thyroidectomy without inferior and superior laryngeal nerves injury according to the intraoperative neuromonitoring. Material and methods: This monocentric study included all patients who underwent thyroidectomy with laryngeal nerves neuromonitoring between September, 2018 and December, 2019. The voice assessment was performed 1 month before and 3 months after surgery. It was both subjective (with Voice Handicap Index 10 and GRBAS scale) and objective (Dysphonia Severity Index). Voice was considered impaired if there was an increase ≥ 4 points of the Voice Handicap Index 10 score or ≥ 1 point of the GRBAS scale score or a decrease ≥ 2 points of the Dysphonia Severity Index score between the two vocal assessments. A composite score was created, combining both subjective and objective scores. Predictive factors of altered voice were seek. Results: Fifty-nine patients were analyzed. Mean Voice Handicap Index 10 varied from 3.39 ± 5.40 to 2.90 ± 5.29 (p = 0.62) before and after the surgery respectively, mean GRBAS from 0.64 ± 0.76 to 0.73 ± 0.85 (p = 0.57) and mean Dysphonia Severity Index from 8.47 ± 1.15 to 8.31 ± 1.03 (p = 0.42). Voice impairment composite score identified 14 patients with an impaired voice (23.7%). Age ≥65 years, preoperative Voice Handicap Index 10 score ≥ 3 and thyroidectomy past history were independent risk factors of voice impairment. Conclusions: the voice quality 3 months after thyroidectomy was not significantly subjectively and objectively changed compared to before thyroidectomy. When grouping voice impairment scores, age ≥65 years, preoperative Voice Handicap Index 10 score ≥ 3 and thyroidectomy past history were independent risk factors of voice impairment.

Does neuromonitoring affect voice quality in patients subjected to a complete thyroidectomy ?

Voice dysfunction is the most common complication of thyroid surgery. The use of intraoperative neuromonitoring (IONM) is to protect the recurrent laryngeal nerves, the damage of which causes voice dysfunction. The aim of the study was to evaluate voice quality in patients who underwent complete thyroidectomy operated on with the application of IONM as well as a group of patients operated on with only macroscopic nerve visualization. In the analysis, clinical voice assessment was performed with particular focus on voice efficiency using the Voice Handicap Index (VHI), Vocal Tract Discomfort (VTD) and GRBAS scale. The study group consisted of 205 patients operated on with IONM. The control group consisted of 162 patients subjected to surgery only with macroscopic visualization of recurrent laryngeal nerves, without IONM. During the follow-up period from 2 to 10 years after surgery, checkups were performed. Each patient who came for a checkup was subjected to perceptual voice evaluation with the use of the GRBAS scale, indirect laryngoscopy procedure and voice selfevaluation with two questionnaires (VHI and VTD). The frequency of vocal fold palsy did not differ significantly statistically in the study group and the control group. Both in the study group and in the control group, patients with vocal fold paralysis had statistically significantly higher results in the VHI and VTD questionnaires as well as in the GRBAS study. Patients with recurrent laryngeal nerve injury show significant differences in the scope of voice handicap, both in the voice quality assessment with the use of the GRBAS scale, and self-evaluation questionnaires: VHI and VTD. All voice disorders evaluated with self-assessment are medium voice disability.

Neuromonitoring of recurrent laryngeal nerves in thyroid surgery − comparative study of visualisation and electrophysiology methods

Introduction: Recurrent laryngeal nerve (RLN) injury one of the most serious complications of thyroid, parathyroid and cervical spine surgery. Injuries to external branches of superior laryngeal nerves are described as uncommon. This complication is so severe that it may actually result in disability of voice professionals (like teachers, singers, actors, speakers, managers, etc.). Enhanced efforts are developed in the current clinical practice to increase intraoperative RLN protection through electrophysiological monitoring of laryngeal innervation and simultaneous RLN visualisation. Methods: The study was designed as a prospective observational study. A set of 100 consecutive procedures was selected from the overall set, randomised by surgeons to two groups: A – neuromonitoring (IONM) was used; B – RLN identification and visualisation without IONM. One team included an expert (more than 1000 procedures) and a surgeon in training (less than 100 procedures), and the other team includeda two experienced surgeons (one with more than 150 procedures and the other with more than 500 procedures). Each team performed several procedures a week. The comparison was performed using statistical methods and using the Index of Recurrent Injury (IRI). The purpose of the study was to compare the incidence of RLN paresis in procedures using neuromonitoring (IONM) and intraoperative visualisation of the anatomic non-injured nerve, performed by the two teams. Results: We analysed 100 consecutive thyroid surgeries, 50 procedures both in group A and B. Group A included 43 total thyroidectomies and 7 hemithyroidectomies. Two cases of one-side temporary RLN palsy were found and IRI was 1.075. Group B included 48 total thyroidectomies and 2 hemithyroidectomies. Two cases of one-side temporary RLN palsy were found, as well, and IRI was 1.02. The IRI values thus characterise asymmetric patient sets, and although minor, the asymmetry is reflected in the result. Overall incidence of RLN injuries in the entire set of selected procedures followed during the given year was 1.3%. The set included 16 temporary and 4 permanent RLN palsies, unilateral in all cases. No bilateral permanent or temporary palsy was observed in the followed period. Thyroid surgery IRI was 2.26 in this period. The set was compared to group A and group B patients; the results show no statistically significant differences on 1% significance level (p=0.01). Conclusions: The study showed no statistically significant differences in RLN incidence (permanent unilateral palsy) between procedures without and with IONM, performed by surgeons with different levels of experience in thyroid surgery. As shown by the study, IONM can be helpful for surgeons in training and less experienced surgeons and it can limit the incidence of RLN morbidity in thyroid surgery.

The Effect of Intraoperative Neuromonitoring on Damage to the Laryngeal Nerves in Patients Undergoing Total Thyroidectomy.

Background: Assessment of intraoperative neuromonitoring in the prevention of damage to the recurrent laryngeal nerve during total thyroidectomy.Material and methods: A group of 367 patients qualified for the study, including 312 women (85.01%) and 55 (14.99%) men, aged 18-79, having undergone total thyroidectomy due to a neutral nodular goiter. The patients were operated on by one surgeon. The study group consisted of 205 patients, including 173 (84.39%) women and 32 (15.61%) men, aged 19-79, who were operated on with the use of intraoperative neuromonitoring. The control group consisted of 162 patients, including 139 (85.80%) women and 23 (14.20%) men, aged 18-77 years, who had undergone surgery only with macroscopic visualization of the recurrent laryngeal nerve without the application of intraoperative neuromonitoring. Then, in the period from 2 to 10 years after the surgery, follow-up examinations were performed, which included 153 patients from the control group (74.6% [153/205]) and 122 patients from the study group (75.3% [122 / 162] Results: The frequency of vocal fold palsy did not differ significantly statistically in the study group and the control group (study group: 4.9% [10/205], control group: 4.9% [8/162]; p = 0.979). In the follow-up study, the incidence of laryngeal fold palsy did not show statistically significant differences between the study and control groups. Most of the damage to the recurrent laryngeal nerves was persistent.Conclusions: Neuromonitoring did not reduce the number of recurrent laryngeal nerve injuries in relation to the nerve visualization alone in noncapsular total thyroidectomy for benign nodular goiter, performed by the same experienced surgeon.

Involvement of capsaicin-sensitive nerves in the initiation of swallowing evoked by carbonated water in anesthetized rats

The initiation of swallowing evoked by laryngeal capsaicin and carbonated water application was diminished by the coapplication of QX-314 and capsaicin. Carbonated water-evoked swallows were also abolished by transection of the superior laryngeal nerves and were inhibited by the acid-sensing ion channel-3 inhibitor. Capsaicin-sensitive nerves are involved in the initiation of carbonated-water-evoked swallows.