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BACKGROUND Exercise-induced laryngeal obstruction (EILO) is an exercise-dependent dyspnoea, linked to a laryngeal closure during physical effort. It may concern from 5% to 7% of adolescents and young athletic adults. EILO is a quite recently described condition: standardized diagnostic criteria and consensual management are still to come. Formal diagnosis of EILO requires a continuous laryngoscopy during exercise (CLE). This test allows visualization of laryngeal abnormalities during an effort but is only accessible in specialized centres. AIMS We wanted to assess performance of a simplified CLE (sCLE) procedure for EILO diagnosis in everyday practice. MATERIAL AND METHODS The procedure consisted in a continuous flexible videolaryngoscopy during a cycloergometre cardio-pulmonary exercise test. Screening questionnaire and visual scoring of laryngeal abnormalities were performed. Patients clinically suspected of EILO were included from 2018 to 2020. RESULTS Seventeen consecutive subjects had an indication for sCLE. Fifteen patients underwent sCLE, and EILO-linked significative abnormalities were observed in 80% of them, thus confirming the diagnosis. CONCLUSIONS CLE can be done successfully in a simple way. Due to its simplicity, tolerance and contribution in EILO diagnosis, this simplified version of CLE may promote its widespread use in ENT and pulmonology practices, as an affordable confirmation test.

Intraoperative neuromonitoring of the laryngeal nerves during thyroidectomy is a reliable method to assess nerve function. After identification of the cricothyroid ligament, a bipolar electrode is selectively inserted through the ligament into the thyroarytenoid muscle (TAM) and cricothyroid muscle (CTM). Vagus nerve stimulation then allows precise monitoring of the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve (EBSLN) in the TAM and CTM, respectively. A significant muscle response (greater than 100 μV) is 100% predictive of preserved laryngeal mobility, while the absence of a muscle response is 70% predictive of vocal fold paralysis with 100% sensitivity and 98% specificity. A significant thyroarytenoid muscle response is only recorded ipsilateral to the stimulation with a shorter latency on the right side. A concomitant TAM and CTM response to vagus nerve stimulation or EBSLN stimulation is observed in more than 70% of cases.

The aim of this study was to validate a procedure to identify and preserve the external branch of the superior laryngeal nerve (EBSLN) during thyroid surgery. The present study also aimed to analyze the EBSLN and the vagus nerve activities after stimulation and demonstrate an operative association between all the laryngeal muscles. Dissection of the cervical region was performed bilaterally in four adult cadavers. In a second step, 144 patients undergoing total thyroidectomy were included. Intraoperative stimulations of the cervical vagus nerve and the EBSLN in the sternothyroid–laryngeal triangle were performed bilaterally. Potentials in the thyroarytenoid muscle and the cricothyroid muscle were registered on each side using the NIM3 Medtronic System. EBSLN was identified according to Cernea’s classification as type 1 in 62.5%, type 2a in 25%, and type 2b in 12.5% of cadaver’s dissection. According to Friedman’s classification, 50% of EBSLN were classified type 1, 25% type 2 and 25% type 3. The EBSLN was identified in 267 cases out of 288 peroperative dissections (92.7%). Direct stimulation (1 mA) of this branch led to a recordable contraction of the cricothyroid muscle with a mean latency of 1.42 ± 0.66 ms on the right side and 1.43 ± 0.61 ms on the left side. The stimulation of the EBSLN also led to a recordable contraction of the thyroarytenoid muscle in 211 cases (73.3%) with the same latencies. A contraction of the cricothyroid muscle was also recorded when the vagus nerve was stimulated in 219 cases (76.0%). The sole visual identification of the EBSLN during thyroid surgery is not a reliable method to prevent nerve injury. Direct stimulation of the EBSLN in the sternothyroid–laryngeal triangle is a simple and rapid procedure to detect and preserve the nerve during surgery. Functional associations between vagus nerve and EBSLN in laryngeal muscles’ contractions were also identified.

Introduction/objectifs Le traitement chirurgical d’une diplegie laryngee chronique chez l’homme peut faire appel a une innervation provenant de nerfs donneurs du plexus cervical, telle proposee par J.P. Marie (2009) [1] : une racine accessoire du nerf phrenique pour les muscles abducteurs du larynx, et le nerf du muscle thyrohyoidien pour les muscles adducteurs. Les variabilites d’origine des nerfs donneurs et leur longueur imposent d’avoir une strategie adaptee [2] , [3] . Materiels/patients et methodes Les microdissections nerveuses ont porte sur 10 corps donnes a la science (20 plexus cervicaux) : les variabilites des branches du nerf phrenique, du nerf du muscle thyrohyoidien et de l’anse cervicale sont notees. Resultats La dissection du nerf phrenique revele une grande variabilite d’origine et la necessite d’un greffon nerveux d’interposition : origine unique dans 70 % des cas provenant de C2, C4 ou C5 ; l’origine peut etre double de C3 ou de C4, plus rarement triple de C3–C4–C5. La participation de C4 est notee dans 75 % des cas. Une origine unique peut imposer de choisir la racine anastomotique C3–C4 comme nerf donneur abducteur. La confirmation electrophysiologique in vivo est toujours imperative. La dissection des racines anterieure et posterieure de l’anse cervicale montre de nombreuses variations mais toujours une branche collaterale distale est presente notamment pour les muscles sternothyroidiens comme nerf donneur adducteur sans interposition de greffon nerveux. La dissection du nerf du muscle thyrohyoidien revele un nerf constant, grele et court (> 20 mm) qui impose l’interposition de greffon nerveux. Conclusion La variabilite d’origine du nerf phrenique demande une adaptation dans le choix morphologique du nerf donneur abducteur et en regle un greffon d’interposition du fait de la longueur limitee des racines disponibles. La variabilite d’origine de l’anse cervicale n’empeche pas le choix d’une collaterale distale sans greffon d’interposition comme nerf adducteur.

The aim of this study was to validate a procedure to identify and preserve the external branch of the superior laryngeal nerve (EBSLN) during thyroid surgery. The present study also aimed to analyze the EBSLN and the vagus nerve activities after stimulation and demonstrate an operative association between all the laryngeal muscles. Dissection of the cervical region was performed bilaterally in four adult cadavers. In a second step, 144 patients undergoing total thyroidectomy were included. Intraoperative stimulations of the cervical vagus nerve and the EBSLN in the sternothyroid-laryngeal triangle were performed bilaterally. Potentials in the thyroarytenoid muscle and the cricothyroid muscle were registered on each side using the NIM3 Medtronic System. EBSLN was identified according to Cernea's classification as type 1 in 62.5%, type 2a in 25%, and type 2b in 12.5% of cadaver's dissection. According to Friedman's classification, 50% of EBSLN were classified type 1, 25% type 2 and 25% type 3. The EBSLN was identified in 267 cases out of 288 peroperative dissections (92.7%). Direct stimulation (1 mA) of this branch led to a recordable contraction of the cricothyroid muscle with a mean latency of 1.42 ± 0.66 ms on the right side and 1.43 ± 0.61 ms on the left side. The stimulation of the EBSLN also led to a recordable contraction of the thyroarytenoid muscle in 211 cases (73.3%) with the same latencies. A contraction of the cricothyroid muscle was also recorded when the vagus nerve was stimulated in 219 cases (76.0%). The sole visual identification of the EBSLN during thyroid surgery is not a reliable method to prevent nerve injury. Direct stimulation of the EBSLN in the sternothyroid-laryngeal triangle is a simple and rapid procedure to detect and preserve the nerve during surgery. Functional associations between vagus nerve and EBSLN in laryngeal muscles' contractions were also identified.

The aim of this study has been to obtain some data for the selection of which branch of the ansa cervicalis nerve (AC) could be an attractive candidate for a laryngeal reinnervation using AC to recurrent laryngeal nerve (RLN) neurorrhaphy. The AC was dissected in ten human head cadavers with an operating microscope. A vagal nerve stimulation was conducted during a bilateral thyroidectomy with normal vocal fold mobility in ten patients using a NIM Medtronic System® to record phasic activity within the thyroarytenoid muscle (vocal fold adduction) and one of the infrahyoid muscle (sternothyroid muscle or sternohyoid muscle). Despite reported variations of the roots of AC and location of its loop, the lower portion of the STM and SHM was innervated by a prominent common trunk in 80 % of cases, in a close vicinity of the RLN with an excellent size match to the RLN for a tension-free anastomosis. The STM displays slight but significant electrical activity during vocal fold adduction. The common trunk of the SHM and STM is the prime choice for laryngeal reinnervation using AC-RLN non-selective anastomosis. If the main trunk is missing, the branch to the STM can be an attractive candidate.

Resume But de l’etude Le but de ce travail a ete l’etude de la morphologie du muscle cricopharyngien et de son innervation par les nerfs larynges superieurs et larynges recurrents. L’integration de ces donnees morphologiques est importante a la comprehension de la physiologie du pharyngolarynx, notamment, au cours de la deglutition. Methodes Six pieces anatomiques (12 cotes) ont ete dissequees, comprenant le larynx et le pharynx depuis la base du crâne a l’incisure jugulaire du sternum et de facon solidaire l’axe vasculonerveux jugulocarotidovagal de chaque cote. Chaque piece a ete fixee au formol a 10 % et dissequee avec un microscope operatoire Leitz (Leica, Allemagne). Les microphotos ont ete faites grâce a un boitier Leica R4 sur le microscope. Les mesures de la musculeuse pharyngee ont utilise un calibreur digital. Resultats et conclusion A partir de la face posterolaterale de l’anneau cartilagineux cricoidien, les fibres musculaires du muscle cricopharyngien divergent en trois groupes : des fibres obliques superieures rejoignent le muscle constricteur inferieur du pharynx, des fibres horizontales constituent un anneau musculaire de 11 a 12 mm de hauteur et de 3 mm d’epaisseur, des fibres obliques inferieures se poursuivent avec les fibres longitudinales externes de l’œsophage cervical. La branche dorsale pharyngo-œsophagienne du nerf larynge recurrent donne des collaterales etagees « en peigne » sur la face laterale de l’œsophage cervical superieur et se termine a la partie posterolaterale des faisceaux du muscle cricopharyngien. Le rameau externe du nerf larynge superieur, grele se termine dans le muscle cricothyroidien mais a donne auparavant un ou deux rameaux nerveux pour la partie ventrale d’insertion cricoidienne du muscle cricopharyngien. Cette double innervation vagale du muscle cricopharyngien par les nerfs larynges superieurs et larynges recurrents s’integre dans la coordination fonctionnelle du pharyngopharynx.

L’atteinte du nerf larynge superieur (NLS) est une complication souvent meconnue de la chirurgie thyroidienne. La lesion de sa branche externe (BE) survient lors de la ligature du pedicule thyroidien superieur [1] . Les objectifs de ce travail ont ete de dissequer le NLS puis de mettre en place une methode peroperatoire d’analyse fonctionnelle de sa BE et de montrer une association fonctionnelle musculaire laryngee. Sept dissections cervicales ont ete realisees sous microscope operatoire. La topographie du NLS a ete decrite selon les classifications de Friedman et Cernea [2] , [3] . Une neurostimulation peroperatoire a ete realisee chez 25 patients operes d’une thyroidectomie. Une electrode de recueil etait placee dans le muscle crico-thyroidien et une autre dans le muscle thyro-arytenoidien vocal (n = 47). Dans un premier temps, la BE du NLS distal etait stimulee a 1 mA, dans le triangle laryngo-sternothyroidien [4] . Puis le nerf vague etait stimule. Quatre dissections (57 %) ont permis de retrouver la branche externe du NLS dans une topographie de type 1 selon la classification de Cernea et 2 selon Friedman. Chez les 25 patients operes, la stimulation de la BE du NLS est a l’origine d’une contraction du muscle crico-thyroidien dans 94 % des cas (n = 44/47). Les stimulations du nerf vague ont montre une reponse du muscle vocal dans 98 % des cas (n = 46/47) associee a une reponse du muscle crico-thyroidien dans 72 % des cas (n = 37/47). Les dissections cervicales ont montre une grande variabilite topographique et un aspect grele de la BE du NLS, rendant toute dissection peroperatoire de cette branche a risque sur le plan fonctionnel. La stimulation directe de la BE du NLS distal dans le triangle laryngo-sternothyroidien offre une methode simple de detection et de controle de la fonction nerveuse. La stimulation du nerf vague objective l’association fonctionnelle des muscles adducteurs et tenseurs du plan glottique.

The vocal folds, which are an important element of phonation, vibrate at the slightest sound. In order to provide a correct vibration, vocal folds have a complex histological structure which is continuously being unveiled thanks to the advancement of research techniques. Therefore, for about forty years, lots of works have permitted to define its qualitative and quantitative composition. Here, we are trying to make a synthesis of this literature, to point out how the histological structure of the vocal fold is used to produce a quality vibration. We used information acknowledged by most scientists, and other ones, more recent, developed thanks to new techniques of micro structural elements identification. These abundant information are, sometimes, in contradiction, given that lacunae are still numerous.

The aim of our study has been to describe the cricopharyngeal muscle and its nerve supply from the recurrent laryngeal nerve and from the superior laryngeal nerve.Six normal adult human pharynges (12 sides) obtained from cadavers were studied. Micro-dissections were carried out thanks to a Leica microscope. Measures were obtained with a micro-digital caliber.The morphological feature of the cricopharyngeal muscle (CPM) showed three different muscular bundles: superior oblique muscle fibers are joining the inferior pharyngeal constrictor muscle, horizontal circular muscle fibers are 11 to 12mm high, and 3mm thick, inferior oblique muscle fibers are joining external layer of the superior oesophagus. The recurrent laryngeal nerve through its dorsal branch supplies the posterior part of the muscular bundles of the CPM. The superior laryngeal nerve by its lateral branch supplies the anterior part of the CPM. So this double vagal innervation of the CPM from superior and inferior laryngeal nerves participates in the laryngo-pharyngeal coordination specially for swallowing.

The aim of this prospective investigation was to analyse the voice and the vocal handicap for patients who received concomitant chemoradiation therapy in piriform sinus epidermoid carcinoma (T2, T3).This study included two males populations: Twelve patients aged from 48 to 71 years old were evaluated between 6 and 30 months after the end of chemo-radiotherapy and ten normal subjects, matched in age. The evaluation consisted in firstly a vocal recording (vowel and text) allowing an objective acoustic analysis (temporal and frequential parameters) and a perceptive evaluation of the voice quality by means of GRBAS scale. Secondly an evaluation of the quality of life by means of the voice handicap index (VHI).The acoustic parameters of instability for the fundamental frequency (FO) and the maximum phonation time of the patients were statistically different (p0.05) related to the normal subjects. On the other hand, the FO (patients - 130 Hz, subjects = 121 Hz) as well as the speech rate (patients = 142 words/mn, subject = 148 words/mn) were not statistically different. The perspective indexes showed a deterioration of the vocal quality while the handicap expressed was minor.This preliminary study showed the interest of evaluations of the vocal function and the quality of life after chemo-radiotherapy for piriform sinus carcinomas allowing patients to conserve a phonation and eventually the propose a speech therapy.

The functional results of a partial laryngeal surgery or a laryngeal reinnervation depend on the precise knowledge of the intra laryngeal anatomy of the inferior laryngeal nerve (ILN). Ten human larynges without known laryngeal disorders were obtained from human cadavers for ILN microdissection. Intra laryngeal ILN branching patterns were determined bilaterally. The lengths of the vertical, genu and oblique segments of the anterior division of ILN and the distance between the nerve within the paraglottic space and the cricothyroid articulation (CTA) were measured with a digital microcaliper. The mean lengths of the vertical, genu and oblique segments were 10.82, 5.89 and 9.29 mm, respectively. The mean distance between the nerve in the paraglottic space and the CTA was 11.20 mm. Key anatomical landmarks of the abductor division (vertical and genu segments of ILN) were the lateral border of posterior cricoarytenoid (PCA) muscle and the superior ligament of the CTA. The two-branch pattern for the lateral border of the PCA muscle has been the most frequent (50%). A branch of interarytenoid muscle (IA) originated from the genu segment. One or two branches for the PCA muscle has been identified in 75% of cases from the IA neural plexus on the front side of PCA muscle. The adductor division for the thyroarytenoid muscle and the lateral cricoarytenoid muscle was the oblique segment of the nerve. We conclude that abductor and adductor divisions of intra laryngeal ILN can be readily identified and the knowledge of key landmarks allows preservation of the ILN during partial surgery of the larynx and possibly selective muscle reinnervation.

Introduction Classiquement, la corde vocale ou pli vocal (PV) est constituee de la superposition de trois structures distinctes : une muqueuse superficielle epidermoide decollable d’une zone intermediaire dense, le ligament vocal, lui-meme recouvrant le muscle vocal, partie mediale du muscle thyro-arytenoidien. L’exploration micro-endoscopique, stroboscopique mais aussi l’histologie objectivent une structure vibratoire plus complexe. Le travail en cours a pour but l’analyse de la « lamina propria » (LP) (zone inter epithelio-musculaire) du tiers moyen du PV. Materiel et methode Cinq pieces de pharyngo-laryngectomie totale pour carcinome epidermoide epargnant les PV ont ete etudiees par une methode histologique traditionnelle (HES). Une analyse d’images de la densite conjonctive est prevue. Resultats – Discussion La LP est constituee de 3 zones de densite inegale : une zone profonde au contact du muscle vocal avec une forte densite conjonctive (ligament vocal) ; une zone intermediaire de faible densite (espace de Reinke) ; une zone superficielle sous epitheliale avec une densite conjonctive intermediaire. Il existe une continuite de ces differentes zones : la zone profonde penetre dans le muscle vocal et la zone superficielle se poursuit avec la membrane basale de l’epithelium. Dans la litterature, l’agencement des fibres de collagene montre aussi des differences d’organisation : un maillage lâche et regulier de la zone superficielle s’oppose a un maillage serre et irregulier de la zone profonde. Cette organisation rend compte des caracteristiques vibratoires des PV.