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TRANSCRANIAL MAGNETIC STIMULATION IN LARYNGEAL PARALYSIS: A SINGLE INSTITUTION EXPERIENCE
No full textThe paralysis of the vocal cords is still today a diagnostic-therapeutic challenge in the field of
otolaryngology, placing doctors and voice professionals in continuous search of non-invasive
therapeutic solutions to ensure patients an adequate quality of life. It can result from
neurological damage or mechanical fixity of the true vocal cord. It can be monolateral or bilateral.
In 96% of cases, it will be unilateral paralysis (UVFP), while only 4% will be bilateral
paralysis (BVFP). The most common cause of UVFP is neoplastic lesions (35.5%). Among these,
cancer that most frequently causes UVFP is lung cancer. The second cause of UVFP is
represented by iatrogenic damage to the recurrent laryngeal nerve (24.6%), especially during
thyroid surgery.
About 13% of UVFP are related to systemic pathologies, 6% are a consequence of laryngeal
trauma, and in 14% of cases, it is impossible to identify the cause of paralysis, so they are defined
as idiopathic. Long-term survival data suggest that patients with idiopathic UVFP have no change
in life expectancy, with a 33% chance of progressive vocal improvement over time. Most of these
patients spontaneously recover laryngeal motility in less than one year, but in a small
percentage of cases, a motility recovery can be observed even after one year from the onset of
symptomatology.
The neuromuscular system of the larynx can be damaged both at the motor level (efferent) and
the sensory level (afferent). In clinical practice, motor damage results in a complete or partial loss
of motility of one or both vocal cords, resulting in an apparent glottic asymmetry. Although the
clinical evaluation allows an adequate evaluation of laryngeal motility, it is not always possible to
accurately assess the cause and degree of motor disorders of the vocal cords with
a videolaryngoscope alone. Neurophysiological methods, especially laryngeal electromyography
(LEMG), can help us understand the pathological condition underlying the laryngeal motor
disorder. Transcranial magnetic stimulation (TMS) has recently been proposed as a non-invasive
and painless tool capable of activating the motor pathways. This technology is based on
magnetic stimuli that can induce a flow of current at the tissue level and, therefore, activate the
excitable structures, especially the neurons of the cerebral cortex, of the spinal cord or directly the
motor axons of the peripheral nervous system. The motor pathways' activation consequently
generates muscle activation, where bioelectric signals can be recorded by surface or needle
electromyography. TMS is currently used for the functional study of the motor pathways, allowing,
for example, to target lesions of the first neuron in encephalic diseases (e.g., multiple sclerosis,
stroke, amyotrophic lateral sclerosis) and spinal cord.
Used to stimulate the cerebral cortex, TMS has been shown to change neuronal excitability in the
short to medium term, both excitatory and inhibitory, and to induce changes in neuronal plasticity.
For example, repetitive TMS has been shown to treat the major depressive disorder. Few data exis
in the literature regarding the study of the motor pathways directed to the laryngeal musculature.
Then study on which this thesis is based aims to set up at our laboratory a technique to evaluate the
function of the motor pathways directed to the vocal muscles with the ultimate aim of objectifying
lesions of the cortical-laryngeal in patients with idiopathic paralysis of the vocal muscles
Office-based procedures in laryngology
No full textDevelopment of transnasal fiberoptic laryngoscopy, integration of an operative channel (OC), the advent of high-definition television imaging, with improvements in laser technology, cleared the way for office-based laryngology. Three treatment categories can be identified: bioendoscopy-guided biopsy; laryngeal injection; laser-assisted surgery
Evone(®) Flow controlled ventilation: a new device for laryngotracheal surgery
No full textThe success of laryngotracheal surgery is mainly related to adequate exposure of the airway lumen. To render airway surgery more efficient, many efforts have been made in recent decades to obtain a safe ventilation system which uses an orotracheal tube that is as small as possible. The first attempt was made by introducing the high frequency jet ventilation (HFJV) technology in clinical practice. Nonetheless, HFJV has some risks related to the high pressure needed for ventilation in the catheter. First, during HFJV, the expiration of air from the lungs is a passive backflow on the trachea wall, potentially causing hypercapnia and air trapping. Second, HFJV creates an open ventilation system that leads to aerosolisation of airborne particles with an increased infectious risk for the surgeon. To overcome these issues, an innovative flow-controlled ventilation (FCV) system with a narrow-cuffed catheter (Evone(®); Ventinova, Eindhoven, The Netherlands) was introduced in clinical practice. This paper describes our initial experience with the Evone(®) FCV system, reporting the first 5 cases ventilated with this technology. In this observational study, we evaluate the feasibility and safety of the Evone(®) system and deliver a critical appraisal of this novel method of ventilation
Functional outcomes after transoral CO2 laser treatment for posterior glottic stenosis: a bicentric case series
Full text linkPurpose The aim of this study is to evaluate functional outcomes in terms of decannulation rate and quality of life of patients affected by PGS (Grades I-IV) treated only by transoral CO2 laser microsurgery (TOLMS) in two tertiary centers. Methods An observational retrospective study was carried out, enrolling 22 patients affected by PGS who were treated by a transoral approach at two tertiary referral centers. Surgical treatment included TOLMS with tailored laser resection of the scar tissue combined with posterior cordotomy, resurfacing of the raw area with mucosal microflap, or placement of a Montgomery T-tube or Keel stent. All patients were evaluated and staged preoperatively and postoperatively, at least 6 months after the surgery. Functional outcomes were objectively evaluated by the Airway-Dysphonia-Voice-Swallowing (ADVS) staging system, Voice Handicap Index-30 (VHI-30), and Eating Assessment Tool-10 (EAT-10) questionnaires. Results Quality of life significantly improved as measured by the VHI-30 questionnaire with a median variation of - 31.0 (p = 0.003), the EAT-10 with a median variation of - 4.0 (p = 0.042), and the ADVS with a median variation of - 3.5 (p < 0.001). No significant changes were observed in swallowing scores. We were able to decannulate 7 of 9 patients (almost 80%) with previous tracheotomy. Conclusion In conclusion, even if there is still no general agreement on an exact therapeutic algorithm to treat PGS, our results confirm that transoral surgery, in terms of scar tissue removal, combined in selected patients with posterior cordotomy and pedicled local flaps and/or placement of stents, represents a safe and effective surgical approach even for more severe PGS
Technological refinements in transoral laser exoscopic surgery: the VITOM EAGLE
Full text linkTraditionally, microscopes have been the primary magnification tools in head and neck surgery, offering excellent illumination, augmentation, and three-dimensional (3D) visualisation. More recently, exoscopes such as the VITOM 3D from Karl Storz, have emerged. These devices utilise high-definition cameras to project 3D views onto a screen, enabling the entire surgical team to observe the procedure while the first operator assumes a more ergonomic position during surgery. VITOM 3D enhances surgical accuracy and team collaboration, although it presents challenges including difficulties with focus at high magnification and less stable coupling with adjunctive tools. To address these limitations, the VITOM EAGLE exoscope was recently introduced. Weighing 4 kg, it features a 6X optical and 2X digital zoom, 4K resolution, stepless focus adjustment, and a 90° viewing angle. It offers improved ergonomics even compared to the previous VITOM 3D, better laser coupling stability, and enhanced visualisation capabilities, especially at higher magnification. The VITOM EAGLE’s controls include an IMAGE1 PILOT, footswitch, and head buttons, managing functions like focus, zoom, brightness, and image capture. Despite its advancements, some details, like the smoothness of the robotic arm, still require refinement. In our clinical practice, several cases were managed with the use of the VITOM 3D and, more recently, with VITOM EAGLE, some of which are illustrated herein
Recurrent laryngeal papillomatosis: multimodal therapeutic strategies. Literature review and multicentre retrospective study
No full textObjectives. Recurrent respiratory papillomatosis (RRP) is a benign, rare disease caused by Human Papilloma Virus (HPV) that can be divided into juvenile and adult forms. The course of the disease is variable, but is usually more aggressive in the juvenile form. The standard surgical treatment is represented by CO2 laser resection, although photoangiolytic lasers represent a valid alternative. Adjuvant therapies have been proposed for disease control in case of frequent surgical resections or spreading into the lower airways. In recent years, the development of immunotherapy led to the use of bevacizumab either intratumorally or intravenously, but the most promising therapeutic development is represented by HPV vaccination. This paper aims to present a narrative review of the literature and the experience of three different University Centres in the treatment of RRP. Methods. A retrospective analysis of the clinical charts of all patients affected by laryngeal papillomatosis and treated in three different University Centres between 2002 and 2022 was performed. The following parameters were collected: sex, age at first evaluation, sites of larynx involved, HPV type, type of first surgical treatment, presence and number of recurrences, surgical treatment of recurrences, adjuvant therapies, side effects and status at last follow-up. Results. Seventy-eight patients were available for evaluation. Of these, 88% had adult onset RRP (Ao-RRP) and 12% juvenile onset RRP (Jo-RRP). The glottis was the most frequently involved subsite; all patients were submitted to surgical resection with CO2 laser under general anaesthesia. Recurrences appeared in 79% of the patients, the patients who did not recur were all adults. The mean number of recurrences was 9 (range 1-110). Recurrences were more frequent in children (M = 20; range 2-110) than adults (M = 5; range 1-21). Thirty-two (52%) of the 62 patients who recurred were re-treated with CO2 laser under general anaesthesia, while office-based treatment with a photoangiolytic laser was preferred in the remaining 30 (48%) patients. Adjuvant treatments were applied in 26 patients. The analysis of the course of the disease showed that in the 9 patients with Jo-RRP, 6 (67%) were free of lesions at the last follow-up, while the other 3 (33%) had papillomas. Of the 69 patients with Ao-RRP, 53 (77%) were alive and free of disease at the last visit, 14 (21%) were alive with disease, 1 (1%) was lost at follow-up and 1 (1%) died for other disease. Severe side effects were not observed except for 2 patients, who developed posterior glottic stenosis. Conclusions. Our results confirmed the literature review. RRP is a potentially aggressive disease, especially in juvenile onset. Surgical resection is still first-line treatment, but in case of multiple recurrences the use of adjuvant therapies must be taken into consideration
Post-COVID-19 airway stenosis treated by tracheal resection and anastomosis: a bicentric experience
Full text linkOBJECTIVE: The COVID-19 pandemic was an extraordinary challenge for the global healthcare system not only for the number of patients affected by pulmonary disease, but also for the incidence of long-term sequalae. In this regard, laryngo-tracheal stenosis (LTS) represents one of the most common complications of invasive ventilation. METHODS: A case series of patients who underwent tracheal resection and anastomosis (TRA) for post-COVID-19 LTS was collected from June 2020 to September 2021. RESULTS: Among 14 patients included, 50% had diabetes and 64.3% were obese. During intensive care unit stay, mean duration of orotracheal intubation (OTI) was 15.2 days and 10 patients (71.4%) underwent tracheostomy, which was maintained in 7 for an average of 31 days. According to the European Laryngological Society classification, 13 patients (92.9%) had a grade IIIa LTS and one a grade IIIa+. All patients underwent Type A TRA, according to the authors’ classification. No major perioperative complications were reported and at the last follow-up all patients were asymptomatic. CONCLUSIONS: With the appropriate indications, TRA represents an effective treatment in post-COVID-19 LTS patients. Short OTI times and careful tracheostomy are required in order to reduce the incidence of airway injury
Endoscopic Preoperative Assessment, Classification of Stenosis, Decision-Making
Full text linkPediatric Laryngo-Tracheal Stenosis (LTS) comprises different conditions that require precise preoperative assessment and classification. According to the guidelines, the optimal diagnostic work-up of LTS patients relies both on a comprehensive anamnesis and on endoscopic and radiological assessments. All the causes of LTS result in an impairment in airflow, mucociliary clearance, phonation, and sometimes in swallowing disorders. The main goals of treatment are to maintain an adequate respiratory space and restore the Upper Aero-Digestive Tract (UADT) physiology. The first step when dealing with LTS patients is to properly assess their medical history. The main causes of pediatric LTS can be divided into two groups, i.e., congenital and acquired. The most common causes of congenital LTS are: laryngomalacia (60%), vocal fold paralysis (15-20%), subglottic stenosis (SGS) (10-15%), laryngeal webs and atresia (5%), subglottic hemangioma (1.5-3%), and others. On the other hand, 90% of acquired pediatric LTS cases are subsequent to post-intubation injuries. Other less frequent causes are: iatrogenic complications from endoscopic laryngeal interventions, benign tumors, caustic or thermal injuries, external blunt force injury or trauma, chronic inflammatory disorders, or idiopathic causes. Diagnostic work-up consists in a step-by-step investigation: awake and asleep transnasal fiberoptic laryngoscopy (TNFL), direct laryngoscopy with 0° and angled telescopes to investigate the type of stenosis (arytenoid mobility, craniocaudal extension, involved anatomical sites, and active or mature scar tissue), and broncho-esophagoscopy to rule out associated mediastinal malformations. To date there are several available classifications for each of the involved sites: Cohen's classification for anterior glottic stenosis, Bogdasarian's for posterior glottic stenosis (PGS) and Myer-Cotton's for subglottic stenosis, even though others are used in daily practice (Lano-Netterville, FLECS, etc.). The European Laryngological Society recently proposed a new classification which is applicable in all LTS cases. In this chapter we deal with preoperative assessment and staging, reviewing the most relevant classifications applicable in patients affected by LTS, conditio sine qua non in order to tailor the best treatment modality to each subject. We'll also detail the comprehensive radiological, endoscopic and functional assessment for the correct use of each staging classification
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
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