| Vocal fold paralysis, also known as laryngeal paralysis, is a clinical manifestation, rather than a separate disease. When the recurrent laryngeal nerve damage, can occurs vocal cord abduction, adduction or muscle tension relaxation of the three types paralysis. Clinically, it is more common on the left vocal fold paralysis, because the left recurrent laryngeal nerve’s trip is longer. It is a common disease of Otorhinolaryngology, the main cause is iatrogenic, traumatic, tumor-derived and idiopathic etc. Clinical manifestations of unilateral vocal fold paralysis is hoarseness, eating, drinking choking and aspiration, etc. Clinical manifestations of bilateral vocal fold paralysis is difficult in breathing caused by progressive airway obstruction, with sound change or not. These symptoms seriously affect the quality of life of patients, especially dyspnea caused by bilateral vocal fold paralysis even threats patients’life.Clinical treatment methods are varied for vocal fold paralysis, the traditional method of unilateral vocal fold paralysis has vocal cord injection, thyroplasty and arytenoid adduction etc. These procedures can effectively improve the patient’s hoarseness, however, due to laryngeal muscle prolonged lack of innervation, will cause laryngeal muscle atrophy, long-term outcome is not guaranteed. Bilateral vocal fold paralysis traditional treatment methods have throat external approach arytenoid resection or vocal cord relocation fixation, laser arytenoid resection, vocal cord surgery, tracheotomy, permanent gastrostomy tube etc. Although these surgical methods can improve breathing difficulties, further damaged the throat pronunciation function, and increased risk of aspiration to some extent. So whether it is unilateral or bilateral vocal fold paralysis, the best treatment is through laryngeal nerve repair to make laryngeal muscles to get reinnervation, then allowing one or both vocal cords physiological motor function. For patients with unilateral vocal fold paralysis, neck loop recurrent laryngeal nerve transposition is the laryngeal nerve repair surgery which is currently the most commonly used and the success rate was unanimously affirmed. And for patients with bilateral vocal fold paralysis, the ideal treatment is also surgical nerve repair, but there is still no major breakthrough in the international.The purpose of this research:1. Comparison with long-term effect of throat external approach arytenoid resection; 2. Evaluate the treatment efficacy of endoscopic laser arytenoid resection of vocal fold paralysis; 3. Evaluate the treatment efficacy of endoscopic laser vocal amputation and discuss the feasibility of bilateral vocal posterior segment amputation and Unilateral vocal posterior segment amputation; 4. Evaluate difference in efficacy of bilateral vocal fold paralysis with throat external approach arytenoid resection, endoscopic laser arytenoid resection, endoscopic co2 laser posterior segment unilateral vocal cord. Therefore, this research is divided into four parts:Part One:Throat external approach surgical cures bilateral vocal fold paralysisObjective:To explore long-term effect of a large sample of Neck jets external approach arytenoid resection.Method:Since October 2000 to March 2014, patients with bilateral vocal fold paralysis in Otolaryngology Head and Neck Surgery of Changhai hospital, a total of 258 cases accepted throat external approach arytenoid resection. This research makes a retrospective study.Result:before the surgery, most of patients’ two sides vocal fixed at next to the middle position and middle position, no abduction, and glottis crack varying sizes during inhaling. Parts of patients’ vocal is with adductor function during pronunciation, but glottis often close incompletely with varying degrees of glottal fissure.4 months after surgery, vocal cord at surgery side position has varying degrees of relocation when inhaling. Semi-quantitative results statistics indicate bilateral vocal cord position of this group of patients were significantly higher than the preoperative abduction, the difference has statistical significance (P<0.05),12 months after surgery, semi-quantitative results statistics indicate bilateral vocal cord position of this group of patients were significantly higher than the preoperative abduction too, the difference has statistical significance (P<0.05); The patient’s degree of glottal closure has the difference has statistical significance (P<0.05) on 4 months and 12 months after surgery comparing with preoperative. Evaluation index with RBH after surgery:RBH three index can be seen in further damage to varying degrees of voice compared with preoperative. Postoperative 4 months and 12 months, RBH index’s median significantly reduced than preoperative, the difference has statistical significance (P<0.05). MPT of postoperative 4 months MPT of postoperative 12 months decreased than Preoperative MPT, the difference has statistical significance (P<0.05).258 cases of bilateral vocal fold paralysis patients which accepted throat external approach arytenoid resection,235 cases of successful extubation after four months, first extubation rate was 91%.23 cases of patients unable to extubation executed second arytenoid surgery on the other side four months later after initial surgery,14 cases of successful extubation after second surgery, second extubation rate was 60.8%, total extubation rate was 96.5%. Conclusion:In this study, a comprehensive evaluation of the parameters system of laryngeal function between preoperative and postoperative indicates satisfactory long-term efficacy of throat external approach arytenoid resection, patients’dyspnea status had been improved significantly, at the same time the sense of voice in the postoperative recovery meet the daily needs.Part two:endoscopic CO2 laser arytenoid resection cures bilateral vocal fold paralysisObjective:Comparison of endoscopic CO2 laser arytenoid resection of bilateral vocal fold paralysis.Method:Since Jan 2009 to March 2014,36 cases of bilateral vocal fold paralysis patients used endoscopic CO2 laser arytenoid resection (Laser resection group, n=36), all patients accepted inspection with dynamic laryngoscope, RBH, maximum phonation time (MPT), and extubation rate analysis to evaluate the clinical efficacy.Result:before the surgery, most of patients’ vocal fixed at next to the middle position and middle position, no abduction, and glottis crack varying sizes during inhaling. Parts of patients’ vocal is with adductor function during pronunciation, but glottis often close incompletely with varying degrees of glottal fissure. Vocal cord at surgery side position has varying degrees of relocation when inhaling. Postoperative 4 months and 12 months, semi-quantitative results statistics indicate bilateral vocal cord position of this group of patients were significantly higher than the preoperative abduction, the difference has statistical significance (P<0.05). Most of patients’ vocal keeps at next to the middle position and middle position, with varying sizes of glottis crack, the difference has statistically significant (P<0.05), voice disorders became worse with varying severity in this group of patients. RBH index of postoperative 4 months and 12 months indicates RBH’s median significantly decreased than preoperative, the difference has statistical significance (P<0.05). Postoperative 4 months and 12 months decreased than preoperative, the difference has statistical significance (P<0.05).31 cases of successful extubation after four months, first extubation rate was 86.1%.5 cases of patients unable to extubation executed second surgery after initial surgery four months later,4 cases of successful extubation after second surgery, second extubation rate was 80%, total extubation rate was 97.2%.Conclusion:In this study, a comprehensive evaluation of the parameters system of laryngeal function between preoperative and postoperative indicates patients’dyspnea status had been improved significantly by endoscopic CO2 laser arytenoid resection, but always with the high probability of secondary surgery and postoperative severe cough. Although the sense of voice in the postoperative recovery meet the daily needs, significantly decreased than preoperative.Part Three:endoscopic CO2 laser posterior segment resection cures bilateral vocal fold paralysisObjective:Evaluate the treatment efficacy of endoscopic laser vocal amputation and discuss the feasibility of bilateral vocal posterior segment amputation and unilateral vocal posterior segment amputation.Method:Since October 2012 to April 2015, patients with bilateral vocal fold paralysis in Otolaryngology Head and Neck Surgery of Changhai hospital accepted, a total of 94 cases accepted endoscopic CO2 laser posterior segment resection. This research makes a retrospective study. Surgery used bilateral vocal posterior segment amputation and Unilateral vocal posterior segment amputation, all patients accepted inspection with dynamic laryngoscope, RBH, maximum phonation time (MPT), and extubation rate analysis to evaluate the clinical efficacy with follow-up 1 years at least.Result:before the surgery, most of patients’vocal fixed at next to the middle position and middle position, no abduction, and glottis crack varying sizes during inhaling. Parts of patients’vocal is with adductor function during pronunciation, but glottis often close incompletely with varying degrees of glottal fissure. Vocal cord at surgery side position has varying degrees of relocation when inhaling. Postoperative 4 months and 12 months, semi-quantitative results statistics indicate bilateral vocal cord position of this group of patients were significantly higher than the preoperative abduction, the difference has statistical significance (P<0.05), but the difference of glottal closure degree has no statistically significant (P>0.05), (because 10 cases occurred after surgery, so vocal position and voice analysis can’t be measured, and only 28 patients made preoperative and postoperative analysis). RBH index of postoperative 4 months and 12 months indicates RBH’s median significantly decreased than preoperative, the difference has statistical significance (P<0.001), but the difference B increased has no statistically significant (P>0.5), postoperative MPT significantly increased than preoperative, the difference has statistical significance (P<0.001).28 cases of successful extubation after first surgery in 38 cases bilateral vocal posterior segment amputation, first extubation rate was 73.6%,10 cases of patients unable to extubation executed second surgery after initial surgery four months later,7 cases of successful extubation after second surgery, second extubation rate was 70%, total extubation rate was 92.1%.56 cases of successful extubation after first surgery in 58 cases unilateral vocal posterior segment amputation, first extubation rate was 92.9%,4 cases of patients unable to extubation executed second surgery after initial surgery four months later,2 cases of successful extubation after second surgery, second extubation rate was 50%, total extubation rate was 96.4%. Comparison between the first extubation rate of two surgical operation indicate unilateral amputation was significantly higher than bilateral amputation, the difference has statistical significance (P<0.05), the total of extubation rate between two surgical operation has no statistical significance. In all of patients,12 cases’ glottis can’t be closed during swallowing due to glottis open bigger to cause mild cough, most of them eased within two weeks, two of cases keep cough until two months, only 1 cases of above caused recurrent pneumonia, the other patients recovered swallowing function.Part Three:endoscopic CO2 laser posterior segment resection cures bilateral vocal fold paralysisObjective:Evaluate the treatment efficacy of endoscopic laser vocal amputation and discuss the feasibility of bilateral vocal posterior segment amputation and unilateral vocal posterior segment amputation.Method:Since October 2011 to March 2014, patients with bilateral vocal fold paralysis in Otolaryngology Head and Neck Surgery of Changhai hospital accepted, a total of 94 cases accepted endoscopic CO2 laser posterior segment resection. This research makes a retrospective study.Result:before the surgery, most of patients’ vocal fixed at next to the middle position and middle position, no abduction, and glottis crack varying sizes during inhaling. Parts of patients’ vocal is with adductor function during pronunciation, but glottis often close incompletely with varying degrees of glottal fissure. Vocal cord at surgery side position has varying degrees of relocation when inhaling. Postoperative 4 months and 12 months, semi-quantitative results statistics indicate bilateral vocal cord position of this group of patients were significantly higher than the preoperative abduction, the difference has statistical significance (P<0.05), the difference of glottal closure degree has statistically significant (P<0.05), (because 7 cases occurred after surgery, so vocal position and voice analysis can’t be measured, and only 31 patients made preoperative and postoperative analysis). RBH index of postoperative 4 months and 12 months indicates RBH’s median significantly decreased than preoperative, the difference has statistical significance (P<0.05). Postoperative MPT significantly decreased than preoperative, the difference has statistical significance (P<0.05).31 cases of successful extubation after first surgery in 38 cases bilateral vocal posterior segment amputation, first extubation rate was 81.5%, 7 cases of patients unable to extubation executed second surgery after initial surgery four months later,4 cases of successful extubation after second surgery, second extubation rate was 57.1%, total extubation rate was 92.1%.46 cases of successful extubation after first surgery in 56 cases unilateral vocal posterior segment amputation, first extubation rate was 82.1%,10 cases of patients unable to extubation executed second surgery after initial surgery four months later,7 cases of successful extubation after second surgery, second extubation rate was 70%, total extubation rate was 96.4%.Conclusion:endoscopic vocal segment amputation after CO2 laser treatment of bilateral vocal fold paralysis operation method is simple, the operation recovery time is short, the unilateral vocal cord after a period of amputation for optimum, not only ensure the decannulation rate therapy at a time, and as much as possible in the protection of the former the pronunciation of the glottis, postoperative curative effect is satisfied.Part Four:thethree the curative effect of surgical treatment of bilateral vocal fold paralysisObjective:to evaluate road throat diameter arytenoid resection and endoscopy, endoscopic laser arytenoid resection CO2 laser unilateral vocal cord after a period of vocal cord amputation surgery treatment of bilateral vocal fold paralysis curative effects.Methods:From October 2000 to March 2014 changhai hospital otolaryngology head and neck surgery treated patients with bilateral vocal fold paralysis of vocal fold paralysis, accept the throat diameter road arytenoid resection with endoscopic CO2 laser cut period after unilateral vocal performer, a total of 350 cases were retrospectively studied.Results:most patients with preoperative vocal fixed in the midline and midline, no function of outreach, inhale the glottis crack sizes, pronounce with some patients vocal cords adduction function but the glottis closure is not complete, often accompanied by varying degrees of glottis fissure.Three groups of patients after operation on the inhale side vocal position all have different degrees of offshoring, semi-quantitative result statistics show that three groups but side vocal cords of a preoperative oflfshoring are significant, differences were statistically significant (P< 0.05), but there was no statistical significance in difference between three groups (P> 0.05); Pronounce with bilateral vocal cord is located in the midline or midline, with varying degrees of glottis fracture, and fracture compared with preoperative all have varying degrees of increase, the increase of scoop laser cutting and laser vocal group has no statistically significant difference (P> 0.05), and throat increase group with statistical significance (P< 0.05);But there was no statistical significance in the glottis closure difference between three groups (P> 0.05).Total of three groups of patients after 4 months hoarse degree RBH compared with preoperative were significantly heavier, the difference was statistically significant (p< 0.05).Postoperative RBH comparing differences between three groups had no statistical significance (P> 0.05).Of three groups of patients after the extension of MPT to some extent, compared with the preoperative were significantly decreased, the difference was statistically significant (P< 0.05), while there was no statistical significance in the MPT differences between three groups (P> 0.05)350 patients with bilateral vocal fold paralysis, of which 258 routine road throat diameter arytenoid offshoring debarking fixation,235 cases of postoperative extubation success at a time, once the decannulation rate was 91.0%,23 cases of patients with secondary operation,14 cases of urethral casing, secondary decannulation rate was 60.8%, total decannulation rate was 96.5%.36 routine endoscopic laser arytenoid resection, four months after successful decannulation 31 cases, once the decannulation rate was 86.1%, 5 patients for the first time in four months after the second surgery after the surgery, two successful extubation (4 cases), secondary decannulation rate was 80%, total decannulation rate was 97.2%.56 underwent endoscopic laser unilateral vocal cord amputation, four months after successful decannulation 46 cases, once the decannulation rate was 82.1%, for the first time in 10 patients in 4 months after the second surgery after the surgery, two successful extubation in 7 cases, secondary decannulation rate was 70% total decannulation rate was 96.4%.Postoperative extubation rate difference between three groups have no statistical significance (P> 0.05).Conclusion:throat diameter road arytenoid resection, resection of endoscopic laser arytenoid resection and endoscopic laser bilateral vocal cords ablation treatment of bilateral vocal fold paralysis caused by breathing difficulties of laryngeal function disorder can effectively reduce the breathing difficulties, endoscopic arytenoid resection group and laser endoscopy after vocal cord cutting more minimally invasive, operation simple, easy recovery fast, patient’s spirit and to reduce the economic burden. |
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