Aryepiglottic fold: normal topography and clinical implications

The aryepiglottic folds extend between the arytenoid cartilage and the lateral margin of the epiglottis on each side and constitute the lateral borders of the laryngeal inlet. They are involved in physiologic closure mechanisms of the larynx and in pathologic conditions such as inspiratory stridor. Information on the normal topography of the aryepiglottic folds is poor and controversial. Therefore, this region was reinvestigated in serial whole-organ sections of 25 plastinated normal adult human larynges. Dorsally, the right and the left aryepiglottic folds are separated by the interarytenoid notch and comprise the corniculate and cuneiform cartilages, as well as numerous groups of mucous glands. Ventrally, the aryepiglottic folds are adjacent to the peri-epiglottic adipose tissue. Both regions are clearly separated by several layers of transversely oriented collagenous fiber layers. The muscular constituent of the aryepiglottic folds is only poorly developed, and no muscle fibers insert at the epiglottis. A coherent quadrangular membrane representing a ligamentous "skeleton" of the aryepiglottic folds is absent. A conspicuous collagenous fiber layer is found only to strengthen the free dorsal margin of the fold. Both muscular and ligamentous components may render the aryepiglottic folds sufficiently tense as to resist inspiratory inward suction in normal cases. However, pliability must be preserved to guarantee adequate folding in approximation of the aryepiglottic folds during deglutition. Thereby, the posterior part of the laryngeal inlet is closed, whereas the anterior part is probably closed by independent inward bulging of the peri-epiglottic adipose tissue.     

The muscular tissue of the vestibular folds of the larynx

The muscular tissue of the vestibular folds was investigated in plastinated serial sections of 32 normal adult larynges. Three muscular systems could be distinguished. A posterolateral muscle layer was found to be developed at the lateral margin of the posterior part of the vestibular fold. Its fibers extended in a sagittal direction, and their contraction probably resulted in an adduction of the entire tissue of the vestibular fold towards the midline. Within the anterior part of the vestibular fold, an anterolateral muscle sheet was seen to attach to the thyroid cartilage. An anteromedial muscular system consisted of scattered groups of muscle fibers situated medially and dorsally to the laryngeal ventricle and saccule. These fibers were presumed to exert a downward pressure on the vestibular folds, in addition to an adductor function. According to clinical experience, adductor movements of the vestibular folds can be trained, even in cases with a recurrent laryngeal nerve lesion, in order to produce a compensatory voice. Thus, the muscles of the vestibular folds are probably innervated by the superior laryngeal nerve.     

Anatomy of the human internal superior laryngeal nerve

The mucosa of the larynx contains one of the most dense concentrations of sensory receptors in the human body. This sensitivity is used for reflexes that protect the lungs, and even momentary loss of this function is followed rapidly by life-threatening pneumonia. The internal superior laryngeal nerve (ISLN) supplies the innervation to this area, and, to date, the distribution and branching pattern of this nerve is unknown. Five adult human larynges were processed by using Sihler's stain, a technique that clears soft tissue while counterstaining nerves. The whole-mount specimens were then dissected to demonstrate the branching of the ISLN from its main trunk down to the level of terminal axons. The human ISLN is divided into three divisions: The superior division supplies mainly the mucosa of the laryngeal surface of the epiglottis; the middle division supplies the mucosa of the true and false vocal folds and the aryepiglottic fold; and the inferior division supplies the mucosa of the arytenoid region, subglottis, anterior wall of the hypopharynx, and upper esophageal sphincter. Several dense sensory plexi that cross the midline were seen on the laryngeal surface of the epiglottis and arytenoid region. The human ISLN also appears to supply motor innervation to the interarytenoid (IA) muscle. A detailed map is presented of the distribution of the ISLN within the human larynx. The areas seen to receive the greatest innervation are the same areas that have been shown by physiological experiments to be the most sensate: the laryngeal surface of the epiglottis, the false and true vocal folds, and the arytenoid region. The observation that the human ISLN appears to supply motor innervation to the IA muscle is contrary to current concepts of the ISLN as a purely sensory nerve. These findings are relevant to understanding how the laryngeal protective reflexes work during activities like swallowing. The nerve maps can be used to guide surgical attempts to reinnervate the laryngeal mucosa when sensation is lost due to neurological disease.     

Congenital laryngeal stridor secondary to flaccid epiglottis, anomalous accessory cartilages and redundant aryepiglottic folds

Most laryngeal anomalies are supraglottic and laryngomalacia is the most common. Cysts, bifid epiglottis and absence of the epiglottis are uncommon. An 18-year-old Caucasian man had long-standing stridor caused by anomalous supraglottic structures: a small floppy epiglottis, enlarged accessory cartilages and redundant aryepiglottic folds. These structures were excised and the airway was improved. The ventral portions of the fourth arches become the aryepiglottic folds and lateral segments of the epiglottis. A disturbance in this portion of the fourth arch may explain the anomaly. The cartilaginous contributions to the epiglottis were possibly isolated as accessory cartilages. Epiglottic anomalies may be associated with other anomalies, especially the digits of the hand. This patient had a short lingual frenulum and mild macroglossia.     

Swallow recovery in an oral cancer patient following surgery, radiotherapy, and hyperthermia

BACKGROUND: No study has examined the nature and extent of swallowing impairment in oral cancer patients following treatment with combined hyperthermia and interstitial radiotherapy. Few studies have examined the effects of voluntary swallow maneuvers (supersupraglottic and Mendelsohn) on pharyngeal phase swallowing in the oral cancer patient treated with surgery or radiotherapy. This study examined the effects of combined radiotherapeutic salvage treatments of hyperthermia and interstitial implantation and swallow recovery using swallow maneuvers in a surgically treated and irradiated oral cancer patient. METHODS: The patient under study, a 51-year-old man, underwent radiotherapy, according to Radiation Therapy Oncology Group (RTOG) protocol #8419, consisting of a combination of interstitial irradiation and hyperthermia to the base of tongue, for a recurrent squamous cell cancer. He underwent videofluorographic (VFG) examination of his swallowing, a modified barium swallow at three time points: 2 days following radiotherapy treatment (VFG1), 4 weeks later (VFG2), and 8 months later (VFG3). Temporal and biomechanical analyses of swallows were performed at each time point. RESULTS: Swallow maneuvers and time resulted in improved laryngeal elevation and laryngeal vestibule closure during the swallows on VFG2. Maximum upper esophageal sphincter (UES) opening width and duration were more normal. Fewer swallows were required for bolus clearance through the pharynx. Base of tongue tissue necrosis occurred as a complication of radiotherapy between VFG2 and VFG3, with resultant severe reduction in posterior movement of the tongue base, incomplete tongue base contact to the posterior pharyngeal wall, reduced laryngeal elevation, and incomplete laryngeal vestibule closure during swallowing at VFG3. UES opening became less normal and a greater number of swallows were required for bolus clearance through the pharynx. CONCLUSIONS: Combined interstitial irradiation and hyperthermia can cause oropharyngeal swallowing problems. Time and swallow therapy can improve these swallow disorders. Tongue base tissue necrosis can cause further swallow impairment, emphasizing the importance of the tongue base in normal deglutition. Further studies are needed to examine the impact of combined hyperthermia and interstitial implantation for treatment of tongue base tumors on swallow functioning in a larger group of patients.     

Our experience in the surgery of otosclerosis

A retrospective study of 613 operations on 495 patients with otosclerosis was made in the Department of Otorhinolaryngology of Hospital General Universitario of Alicante between 1974 to 1992. The clinical-pathological characteristics of this series were studied. Statistical analysis of the results was made. The improvement in air-bone gap for conversational frequencies was 27 dB. Closure of the postoperative air-bone gap for conversational frequencies was 7.6 dB and the overall percentage of closure of this gap was 80.5%. Better auditory results were obtained with partial platinectomy than with stapedectomy. Nothing was inserted between the prosthesis and the vestibule, permitting a shorter, easier operation with no occurrence of perilympathic fistule.     

Anteroposterior gradient of epithelial transformation during amphibian intestinal remodeling: immunohistochemical detection of intestinal fatty acid-binding protein

To determine whether the remodeling of the well-organized intestinal epithelium during amphibian metamorphosis is regionally regulated along the anteroposterior axis of the intestine, we raised a polyclonal antibody against the Xenopus laevis intestinal fatty acid-binding protein (IFABP), which is known to be specifically expressed in intestinal absorptive cells, and examined immunohistochemically the differentiation, proliferation, and apoptosis of the epithelial cells throughout X. laevis small intestine. During pre- and prometamorphosis, IFABP-immunoreactive (ir) epithelial cells were localized only in the anterior half of the larval intestine. At the beginning of metamorphic climax, apoptotic cells detected by nick end-labeling (TUNEL) suddenly increased in number in the entire larval epithelium, concurrently with the appearance of adult epithelial primordia. Subsequently, the adult primordia in the anterior part of the intestine developed more rapidly by active cell proliferation than those in the posterior part, and replaced the larval epithelial cells earlier than those in the posterior part. IFABP-ir cells in the adult epithelium were first detectable at the tips of newly formed folds in the proximal part of the intestine. Thereafter, IFABP expression gradually progressed both in the anteroposterior direction and in the crest-trough direction of the folds. These results suggest that developmental processes of the adult epithelium in the X. laevis intestine are regionally regulated along the anteroposterior axis of the intestine, which is maintained throughout metamorphosis, and along the trough-crest axis of the epithelial folds, which is newly established during metamorphosis. Furthermore, the regional differences in IFABP expression along the anteroposterior axis of the intestine were reproduced in organ cultures in vitro. In addition, IFABP expression was first down-regulated and then reactivated in vitro when the anterior part, but not the posterior part, of the larval intestine was treated with thyroid hormone (TH) for extended periods. Therefore, it seems that, in addition to TH, an endogenous factor(s) localized in the intestine itself with an anteroposterior gradient participates in the development of the adult epithelium during amphibian metamorphosis.     

Bifid epiglottis: a rare laryngeal anomaly

Two cases of bifid epiglottis are presented: one with an associated laryngeal cyst and another with an associated cricoid stenosis. The occurrence of multiple laryngeal anomalies in association with bifid epiglottis has not previously been described. The occurrence of an extra digit is noted to be statistically significant both in the current series and in a review of the literature. A brief review of the embryologic classification and staging by the Carnegie System, and the correlation of the time sequence of development of the epiglottis is presented. No correlation is made as to the mechanism of the origin of this laryngeal anomaly, as adequate embryologic knowledge of the development of the pharynx is not available at this time.     

Use of the CO2-laser micropoint micromanipulator for the treatment of laryngomalacia

Between September 1989 and June 1994, 21 children (17 boys, 4 girls) with moderate to severe symptoms due to laryngomalacia underwent endoscopic surgery using the CO2-laser micropoint manipulator (shot-by-shot, 0.1 s, super-pulse, 2-3 W power; 280 microns beam; 400 mm working distance). Mean age of the children was 5 months (range, 1-11 months). The procedure was performed under high-frequency jet ventilation and consisted in the resection and/or vaporization of the aryepiglottic folds. This tissue removal could be extended to the laryngeal mucosa of the arytenoids and the lateral edge of the epiglottis. Results of surgery were excellent with normalization (8 patients) or, at worst, a very definite improvement of symptoms (4 patients). Furthermore, no complications occurred due to the technique used. These results have convinced us that the CO2-laser micropoint manipulator technique, with the "super-pulse" shooting mode and high-frequency jet ventilation, is by far superior to microsurgery with cold instruments when endoscopic treatment of laryngomalacia is indicated.     

Orthostatic hypotension with syncope--a problem of hypertensive therapy in the aged

STUDY OBJECTIVE: To assess the efficacy of the "laryngeal lift" maneuver in improving laryngoscopic visualization to facilitate endotracheal intubation. DESIGN: Blinded study. SETTING: Operating room at Meridia Huron Hospital. PATIENTS: 305 patients receiving general anesthesia for elective surgery requiring intubation. (Five patients were eliminated from the study because we elected to intubate these patients awake and sedated.) INTERVENTIONS: Following induction of anesthesia and paralysis with muscle relaxants, laryngoscopic views of each patient were evaluated by the laryngoscopist before and after the laryngeal lift was performed by an anesthesiologist assisting the laryngoscopist. Each patient served as his or her own control group. The anesthesiologist was blinded to the results obtained by the laryngoscopist. All Grade I laryngoscopic views were eliminated (198 patients). Five patients were eliminated on the basis of obesity or atlantoaxial subluxation. The laryngeal lift was performed on the remaining 102 patients, representing Grade II to Grade V laryngoscopic views. MEASUREMENTS AND MAIN RESULTS: A modification of the original classification of laryngoscopic views by Cormack and Lehane was used: Grade I = full view of glottis; Grade II = only posterior commissure visible; Grade III = arytenoids visible; Grade IV = epiglottis visible; Grade V = no glottic structure visible. In 98 of 102 cases (96%), the maneuver improved visualization by at least 1 grade. There was no evidence of change in the 4 remaining cases. CONCLUSIONS: The laryngeal lift should be part of the anesthesiologists' armamentarium in helping the laryngoscopist who is faced with Grades II, III, IV, and V laryngoscopic views to enhance visualization of the larynx and thus facilitate endotracheal intubation.     

Ebstein's anomaly (morphologic and morphometric study

12 hearts with Ebstein's anomaly were studied. This disease is a combined anomaly of heart formation with dysplasia of the folds of the tricuspid valve (TV), its tendinous chordas and papillary muscles, dysplasia of the trabecular part of the right ventricle and dysplastic interrelationships between TV and the right ventricle: attachment by short chordas of posterior and septal folds of TV with the right ventricle walls, anomalous distal attachment of the anterior fold of TV. "Atrialisation" of the right ventricle is the reflection of the folds dysplasia the extreme form of which is the loss of communication between TV and trabecular part and formation of the direct communication between TV and the infundibular part of the right ventricle.     

Repeatedly successful closure of the larynx for the treatment of chronic aspiration with the use of botulinum toxin A

Botulinum toxin A was used preoperatively to temporarily paralyze the intrinsic laryngeal muscles to hinder movements during the healing period after operation. In addition, toxin was injected into the cricopharyngeal muscle to allow a better passive drainage of the saliva into the esophagus. We treated six patients. Three suffered from chronic aspiration problems after multiple lower cranial nerve lesions, and three patients were apallic (after stroke and major brain injury). Two weeks before scheduled operation, we injected the toxin into the posterior cricoarytenoid muscles, the aryepiglottic muscles, and the vocalis muscle on both sides, as well as the cricopharyngeal muscle. The amount of injected toxin varied between 1.0 and 1.4 mL, equal to 200 to 280 units of botulinum toxin A (Dysport). After a complete palsy of these muscles (controlled by direct electromyography), a closure of the larynx was performed. After laminotomy and exposure of the intralaryngeal structures, the false vocal cords were mobilized and adapted with sutures. Because involuntary movements of the intralaryngeal musculature were absent, primary healing without complications occurred in all cases. Aspiration and related complications disappeared in all patients. In addition, the intensity of patient care could be considerably reduced. Preoperative use of botulinum toxin A allows sufficient laryngeal closure. This procedure is especially useful in the treatment of children and young adults, preserving the ability of later speech rehabilitation because of the return of voluntary movements of the intrinsic laryngeal muscles 6 months after the injection. Furthermore, this technique, as minimal surgical intervention, can be performed in high-risk patients.     

Functional damage of the larynx

INTRODUCTION: The basic mechanism of the development of functional voice disorders is an excessive collision pressure between the vocal folds during phonation, which occurs between the membranous folds, and/or the vocal processes. Functional-traumatic lesions of the vocal folds appear mainly at the junction between the anterior and the middle thirds of the vocal folds, slightly below the free edge. This is the "predilection site" of the vocal folds, which is the most active part of the vocal folds during phonation, and is therefore mostly exposed to functional-traumatic changes. This study is aimed at establishing the most frequent benign lesions of the vocal folds, which appear at the predilection sites of the vocal folds, and discussing their functional-traumatic aetiology. MATERIAL AND METHODS: During the past 10 years 1550 patients underwent various microsurgical procedures for benign lesions of the vocal folds. They were studied for the precise localization of the lesions by the use of indirect videostroboscopy or microstroboscopy, and direct microlaryngoscopy related to the technique which has been used in each particular patient. In this way an overall number of lesions was established, which were located at the predilection sites of the vocal folds, indicating their functional-traumatic aetiology. RESULTS: It has been established that 1068 lesions (68.6%) were located at the predilection site of the vocal folds (Table 1). Namely, these were nodular lesions, polyps, cysts, and haematoma. Contact hyperplasia appeared at the posterior third of the vocal folds due to a special mechanism of its development. DISCUSSION: Functional-traumatic lesions are mucous stranding, nodular lesions, polyps, cysts, contact hyperplasia and haematoma. All these lesions are either of functional origin or functional voice disorders which contribute, to some degree, to their development.     

Properties of lens epithelial cells in albino rabbits--morphological alteration and its influence

We studied changes of epithelial cells in injured lens, after extracapsular cataract extraction (ECCE) in culture solution and in vivo changes in epithelial cells after phacoemulsification and aspiration (PEA) using light and electron microscopy. The epithelial cells at the injured site of the lens were transformed into spindle cells indicating healing and contraction of the lesion. In the culture solution, epithelial cells which had been seen only on the side of the anterior capsule extended and proliferated over the equatorial zone to the posterior capsule covering the whole posterior capsule 6 weeks after an ECCE. Spindle cells were seen in the region with folds in the posterior capsule. In vivo, formation of Soemmering's ring was observed in the equatorial zone after PEA suggesting regeneration of the lens in the electron microscopic aspect. At the edge of the anterior capsule, appearance of spindle cells formation of folds in the anterior and posterior capsules at this site as well as formation of membrane similar to the lens capsule could be seen, and this phenomenon resembled the healing process of the injured lens. Observation of the spindle cells at the cut edge of the anterior capsule showed cells which were extending psudopodia into collagen and they appeared to be engaged in ameboid movement. We considered that this ameboid movement would trigger off contraction of the wound and formation of folds at the cut edge of the anterior capsule.     

Bone mineral density of the internal auditory meatus by quantitative computed tomography

The bone mineral density of the internal auditory meatus was investigated by means of quantitative computed tomography in 20 normal subjects (40 ears). Investigated portions of the internal auditory meatus were the porus anterior and posterior and the fundus anterior and posterior. Two other portions of the ear, the bony vestibule and lateral wall of the mastoid, were also investigated. The bone density values (calcium carbonate equivalent value) for each portion were analyzed statistically. The following results were obtained: 1) There was no significant difference between the right and left values in any portion. 2) The highest mean value was found in the fundus posterior, the lowest in the porus anterior. There was a significant difference between the values of the fundus and porus. Bone hardness generally correlates with bone density. Thus, the bone hardness of the porus of the internal auditory meatus was appraised to be lower than that of the fundus. These results suggest that this is one of the factors promoting enlargement of the internal auditory meatus in acoustic neuroma.     

Motion of mitral apparatus in hypertrophic cardiomyopathy with obstruction

Motion of the mitral apparatus in hypertrophic cardiomyopathy with obstruction was investigated by conventional single dimensional and multidimensional echocardiography. In systole, anterosuperior displacement of the posterior papillary muscle, failure of mitral valve closure, and anterior motion of both mitral leaflets were shown. The anterior leaflet was seen to impinge on the posterior papillary muscle but not on the interventricular septum in systole. The abnormality of the single dimensional mitral echogram, previously ascribed to systolic anterior motion of the mitral anterior leaflet, was found to be a complex of echoes from the chordae tendineae, the papillary muscle, and, furthest from the septum, the mitral anterior leaflet. It is concluded that systolic anterior motion of the mitral anterior leaflet is of smaller amplitude than others have suggested, and that obstruction to left ventricular outflow in hypertrophic cardiomyopathy is produced by systolic contact between the mitral anterior cusp and the posterior papillary muscle. The theory is put forward that displacement of the posterior papillary muscle above and in front of the mitral leaflets produces chordal slackening, and that it is displacement of the chordae tendineae by the blood flowing to the aortic root during left ventricular ejection, which is responsible for systolic anterior motion of the mitral leaflets.     

Damage to the inguino-femoral nerves in the treatment of hernias. An anatomical hazard of traditional and laparoscopic techniques

Laparoscopic techniques currently constitute an alternative proposed for the repair of hernias of the inguinofemoral region. Nerve injuries have led some teams to recommend technical principles based on the anatomical relations of these nerves with the subperitoneal fascia transversalis and inguinal fossae. An anatomical study consisting of dissection of nonembalmed cadavres, allowed, after evisceration, dissection of the lumbar plexus and its terminal branches, particularly those supplying the inguinofemoral region: iliohypogastric and ilio-inguinal nerves, the genitofemoral nerve, the femoral nerve and the lateral cutaneous nerve of the thigh. Via transperitoneal laparoscopy, the posterior surface of the anterior abdominal wall is centered on the deep inguinal ring, containing testicular vessels and the vas deferens. This deep inguinal ring receives the genitofemoral nerve. Medially, the anterior parietal peritoneum describes three folds formed by the outline of the epigastric artery, umbilical artery and urachus on the midline. The outline of Hesselbach's ligament separates the deep inguinal ring from Hesselbach's triangle, the zone of weakness of direct inguinal hernia. The iliac psoas muscle pass laterally underneath the inguinal ligament, while the external iliac vessels, subsequently becoming the femoral vessels, are located medially. Pectineal ligament lies on the posterior surface of the femoral ring between the umbilical artery and the epigastric artery. Installation of an abdominal wall prosthesis, either transperitoneally or retroperitoneally, must be centered on the deep inguinal ring, and its solid sutures are located medially to the pectineal ligament and anterior abdominal wall. On the other hand, the nerves at risk of being damaged are situated laterally: the ilio-inguinal and ilio-hypogastric nerves in the plane between external oblique and internal oblique above the anterior superior iliac spine, lateral cutaneous nerve of the thigh under the inguinal ligament close to the anterior superior iliac spine, genitofemoral nerve with the spermatic cord in the deep inguinal ring and femoral nerve underneath the inguinal ligament with the psoas muscle lateral to the external iliac artery. No stapling must be performed under the plane of the inguinal ligament to avoid damage to the femoral vessels and lateral to the deep inguinal ring to avoid nerve damage.     

In vivo anteroposterior femorotibial translation of total knee arthroplasty: a multicenter analysis

A study was conducted to determine in vivo femorotibial contact patterns for subjects having a posterior cruciate retaining or posterior cruciate substituting total knee arthroplasty. Femorotibial contact of 72 subjects implanted with a total knee replacement, performed by five surgeons, was analyzed using video fluoroscopy. Thirty-one subjects were implanted with a posterior cruciate retaining total knee replacement with a flat polyethylene posterior lipped insert, 12 with a posterior cruciate retaining total knee replacement with a curved insert, and 29 with a posterior cruciate substituting total knee replacement. Each subject performed successive deep knee bends to maximum flexion. Video images at 0 degree, 30 degrees, 60 degrees, and 90 degrees flexion were downloaded onto a workstation computer. Femorotibial contact paths were determined for the medial and lateral condyles using an interactive model fitting technique. Femorotibial contact anterior to the tibial midline in the sagittal plane was denoted as positive and contact posterior was denoted as negative. Analysis of average femorotibial contact pathways of both posterior cruciate retaining designs revealed posterior femorotibial contact in full extension with anterior translation of femorotibial contact commonly observed in midflexion and terminal flexion. In posterior cruciate substituting designs, anterior femoral translation was seen medially at 30 degrees to 60 degrees flexion but rarely was observed laterally. Posterior femoral rollback laterally from full extension to 90 degrees flexion was seen in 100% of subjects implanted with a posterior cruciate substituting total knee replacement, versus 51.6% (posterior lipped polyethylene insert) and 58.3% (curved insert) of those with a posterior cruciate retaining total knee replacement. Data from this multicenter study are remarkably similar to previous fluoroscopy data from a single surgeon series, showing a lack of customary posterior femoral rollback in both posterior cruciate retaining designs, and conversely showing an average anterior femoral translation with knee flexion. Posterior femoral rollback, less than in normal knees, routinely was observed in posterior cruciate substituting total knee arthroplasty, attributed to engagement of the femoral component cam with the tibial post. The abnormal anterior femoral translation observed in posterior cruciate retaining total knee arthroplasty may be a factor in premature polyethylene wear observed in retrieval studies.