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Laryngeal Pacing

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Neurolaryngology

Abstract

Bilateral vocal fold paresis (BVFP) is a rare condition, potentially life-threatening when the associated airway obstruction symptoms are severe. The most frequent etiology is iatrogenic nerve lesion during thyroid gland surgery. Surgical glottic enlargement, even though associated with various degrees of voice impairment, still represents the golden therapeutic standard.

This chapter focuses on neurostimulation as potential alternative treatment strategy. Decades of clinical experience supported by the laryngeal electromyography (EMG) results have provided sound evidence that the majority of peripheral laryngeal nerve lesions do not cause paralysis with atrophy of the intrinsic laryngeal muscles. On the contrary they are generally associated with misdirected, mostly synkinetic reinnervation.

Basic research, including long-term results from animal trials, has shown that a synkinetically reinnervated larynx is the prerequisite for neuromuscular electrical stimulation (NMES). In general, the stimulation of terminal nerve branches near the target muscle can re-establish its original function. In the specific case of BFVP, stimulation of the posterior cricoarytenoid muscle (PCA) restores vocal fold abduction.

The concept of laryngeal pacing (LP) was introduced in the 1970s of the last century. The first proof of principle laryngeal pacing study in human evaluated the use of an implantable pulse generator (IPG) primarily designed for pain therapy. However, due to various technical problems, such as electrode corrosion, this early clinical research was referred back to animal trials after 2003.

On account of the technological advancements of the last decade, a new type of medical device for laryngeal pacing has been recently developed. With this device, electrode placement is done in a minimally invasive procedure, thus preventing the occurrence of the technical problems observed in earlier attempts. The first feasibility study in human with this new LP system has been recently published and showed promising results.

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References

  1. Crumley RL, McCabe BF. Regeneration of the recurrent laryngeal nerve. Otolaryngol Head Neck Surg. 1982;90:442–7.

    Article  CAS  PubMed  Google Scholar 

  2. Crumley RL. Laryngeal synkinesis: its significance to the laryngologist. Ann Otol Rhinol Laryngol. 1989;98:87–92.

    Article  CAS  PubMed  Google Scholar 

  3. Crumley RL. Laryngeal synkinesis revisited. Ann Otol Rhinol Laryngol. 2000;109:365–71.

    Article  CAS  PubMed  Google Scholar 

  4. Baker SE, Sapienza CM, Martin D, Davenport S, Hoffman-Ruddy B, Woodson G. Inspiratory pressure threshold training for upper airway limitation: a case of bilateral abductor vocal fold paralysis. J Voice. 2003;17:384–94.

    Article  PubMed  Google Scholar 

  5. de Corgnol AC, Guerout N, Duclos C, Verin E, Marie JP. Olfactory ensheathing cells in a rat model of laryngeal reinnervation. Ann Otol Rhinol Laryngol. 2011;120:273–80.

    Article  PubMed  Google Scholar 

  6. Zealear DL, Mainthia R, Li Y, et al. Stimulation of denervated muscle promotes selective reinnervation, prevents synkinesis, and restores function. Laryngoscope. 2014;124:E180–7.

    Article  PubMed  Google Scholar 

  7. Cheetham J, Perkins JD, Jarvis JC, et al. Effects of functional electrical stimulation on denervated laryngeal muscle in a large animal model. Artif Organs. 2015;39:876–85.

    Article  CAS  PubMed  Google Scholar 

  8. Hydman J, Remahl S, Bjorck G, Svensson M, Mattsson P. Nimodipine improves reinnervation and neuromuscular function after injury to the recurrent laryngeal nerve in the rat. Ann Otol Rhinol Laryngol. 2007;116:623–30.

    Article  PubMed  Google Scholar 

  9. Rosen CA, Smith L, Young V, Krishna P, Muldoon MF, Munin MC. Prospective investigation of nimodipine for acute vocal fold paralysis. Muscle Nerve. 2014;50:114–8.

    Article  CAS  PubMed  Google Scholar 

  10. Iakovleva I, Iliutovich GM, Iuvalova ND. On the use of sinusoidal low-frequency modulated currents in vocal disorders in patients with paralysis and paresis of the laryngeal muscles. Vestn Otorinolaringol. 1965;27:93–8.

    PubMed  Google Scholar 

  11. Scarabicchi S. Isolated left diaphragmatic paresis; improvement after galvanic stimulation. Minerva Pediatr. 1952;4:1026–7.

    CAS  PubMed  Google Scholar 

  12. Guntinas-Lichius O. Rehabilitation options for lesions of the facial nerve. HNO. 2007;55:605–12.

    Article  CAS  PubMed  Google Scholar 

  13. Kim Y, Zieber HG, Wang FE. Uniformity of current density under stimulating electrodes. Crit Rev. Biomed Eng. 1990;17:585–619.

    CAS  PubMed  Google Scholar 

  14. Bruegmann T, van Bremen T, Vogt CC, Send T, Fleischmann BK, Sasse P. Optogenetic control of contractile function in skeletal muscle. Nat Commun. 2015;6:7153.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Miller S, Kuhn D, Jungheim M, Schwemmle C, Ptok M. Neuromuscular electric stimulation therapy in otorhinolaryngology. HNO. 2014;62:131–8. quiz 139-140

    Article  CAS  PubMed  Google Scholar 

  16. Low J, Reed A. Electrical stimulation of nerve and muscle. In: Low J, Reed A, editors. Electrotherapy explained: principles and practice. Oxford: Elsevier LTD; 2000. p. 53–140.

    Google Scholar 

  17. Ptok M, Strack D. Electrical stimulation-supported voice exercises are superior to voice exercise therapy alone in patients with unilateral recurrent laryngeal nerve paresis: results from a prospective, randomized clinical trial. Muscle Nerve. 2008;38:1005–11.

    Article  PubMed  Google Scholar 

  18. Garcia Perez A, Hernandez Lopez X, Valadez Jimenez VM, Minor Martinez A, Ysunza PA. Synchronous electrical stimulation of laryngeal muscles: an alternative for enhancing recovery of unilateral recurrent laryngeal nerve paralysis. J Voice. 2014;28:524 e521–7.

    Article  Google Scholar 

  19. Rushton DN. Functional electrical stimulation and rehabilitation—an hypothesis. Med Eng Phys. 2003;25:75–8.

    Article  CAS  PubMed  Google Scholar 

  20. Urban PP. Transcranial magnetic stimulation in brainstem lesions and lesions of the cranial nerves. Suppl Clin Neurophysiol. 2003;56:341–57.

    Article  PubMed  Google Scholar 

  21. Zealear DL, Dedo HH. Control of paralysed axial muscles by electrical stimulation. Acta Otolaryngol. 1977;83:514–27.

    Article  CAS  PubMed  Google Scholar 

  22. Bergmann K, Warzel H, Eckhardt HU, Gerhardt HJ. Respiratory rhythmically regulated electrical stimulation of paralyzed laryngeal muscles. Laryngoscope. 1984;94:1376–80.

    Article  CAS  PubMed  Google Scholar 

  23. Bergmann K, Warzel H, Eckhardt HU, Hopstock U, Hermann V, Gerhardt HJ. Long-term implantation of a system of electrical stimulation of paralyzed laryngeal muscles in dogs. Laryngoscope. 1988;98:455–9.

    Article  CAS  PubMed  Google Scholar 

  24. Obert PM, Young KA, Tobey DN. Use of direct posterior cricoarytenoid stimulation in laryngeal paralysis. Arch Otolaryngol. 1984;110:88–92.

    Article  CAS  PubMed  Google Scholar 

  25. Otto RA, Templer J, Davis W, Homeyer D, Stroble M. Coordinated electrical pacing of vocal cord abductors in recurrent laryngeal nerve paralysis. Otolaryngol Head Neck Surg. 1985;93:634–8.

    Article  CAS  PubMed  Google Scholar 

  26. Zrunek M, Carraro U, Catani C, et al. Functional electrostimulation of the denervated posticus muscle in an animal experiment: histo- and biochemical results. Laryngo-Rhino-Otologie. 1986;65:621–7.

    Article  CAS  Google Scholar 

  27. Kano S, Sasaki CT. Pacing parameters of the canine posterior cricoarytenoid muscle. Ann Otol Rhinol Laryngol. 1991;100:584–8.

    Article  CAS  PubMed  Google Scholar 

  28. Sanders I. Electrical stimulation of laryngeal muscle. Otolaryngol Clin N Am. 1991;24:1253–74.

    CAS  Google Scholar 

  29. Bergmann K. History of the laryngeal pacing in the GDR in the 80th. FSU Jena: Jena/Gera; 2015.

    Google Scholar 

  30. Zealear DL, Billante CR, Courey MS, et al. Reanimation of the paralyzed human larynx with an implantable electrical stimulation device. Laryngoscope. 2003;113:1149–56.

    Article  PubMed  Google Scholar 

  31. Maranillo E, Leon X, Ibanez M, Orus C, Quer M, Sanudo JR. Variability of the nerve supply patterns of the human posterior cricoarytenoid muscle. Laryngoscope. 2003;113:602–6.

    Article  PubMed  Google Scholar 

  32. Martin-Oviedo C, Maranillo E, Lowy-Benoliel A, et al. Functional role of human laryngeal nerve connections. Laryngoscope. 2011;121:2338–43.

    Article  PubMed  Google Scholar 

  33. Zealear DL, Rainey CL, Jerles ML, Tanabe T, Herzon GD. Technical approach for reanimation of the chronically denervated larynx by means of functional electrical stimulation. Ann Otol Rhinol Laryngol. 1994;103:705–12.

    Article  CAS  PubMed  Google Scholar 

  34. Foerster G, Arnold D, Bischoff SJ, Schubert H, Scholle HC, Mueller AH. Laryngeal pacing in minipigs: in vivo test of a new minimal invasive transcricoidal electrode insertion method for functional electrical stimulation of the PCA. Eur Arch Otorhinolaryngol. 2013;270:225–31.

    Article  Google Scholar 

  35. Mueller AH, Blechschmidt K. Laryngeal pacing in RLNP. In: ELS, ed. 5th ELS Congress, 10. Lisboa, Portugal: ELS; 13 Jul 2004.

    Google Scholar 

  36. Marina MB, Marie JP, Birchall MA. Laryngeal reinnervation for bilateral vocal fold paralysis. Curr Opin Otolaryngol Head Neck Surg. 2011;19:434–8.

    Article  PubMed  Google Scholar 

  37. Farwell DG, Birchall MA, Macchiarini P, et al. Laryngotracheal transplantation: technical modifications and functional outcomes. Laryngoscope. 2013;123:2502–8.

    PubMed  Google Scholar 

  38. Mueller AH, Foerster G. Who are suitable candidates for laryngeal pacing? In: 7th Congress of the European Laryngological Society. Barcelona, Spain: Eur Arch Otorhinolaryngol (2009), Springer; 2008. p. 586.

    Google Scholar 

  39. Grosheva M, Wittekindt C, Pototschnig C, Lindenthaler W, Guntinas-Lichius O. Evaluation of peripheral vocal cord paralysis by electromyography. Laryngoscope. 2008;118:987–90.

    Article  PubMed  Google Scholar 

  40. Foerster G, Arnold D, Bischoff S, Boltze K, Scholle HC, Schubert H, Mueller AH. Pre-clinical evaluation of a minimally invasive laryngeal pacemaker system in mini-pig. Eur Arch Otorhinolaryngol. 2016;273:151–8.

    Article  PubMed  Google Scholar 

  41. Mueller AH, Hagen R, Foerster G, Grossmann W, Baumbusch K, Pototschnig C. Laryngeal pacing via an implantable stimulator for the rehabilitation of subjects suffering from bilateral vocal fold paralysis: a prospective first-in-human study. Laryngoscope. 2016;126:1810–6.

    Article  PubMed  Google Scholar 

  42. Nawka T, Sittel C, Gugatschka M, Arens C, Lang-Roth R, Wittekindt C, Hagen R, Mueller AH, Volk GF, Guntinas-Lichius O. Permanent transoral surgery of bilateral vocal fold paralysis: a prospective multi-center trial. Laryngoscope. 2015;125:1401–8.

    Article  PubMed  Google Scholar 

  43. Nawka T, Sittel C, Arens C, Lang-Roth R, Wittekindt C, Hagen R, Nasr AI, Guntinas-Lichius O, Friedrich G, Gugatschka M. Voice and respiratory outcomes after permanent transoral surgery of bilateral vocal fold paralysis. Laryngoscope. 2015;125:2749–55.

    Article  PubMed  Google Scholar 

  44. Djugai S, Boeger D, Buentzel J, Esser D, Hoffmann K, Jecker P, Mueller AH, Radtke G, Bohne S, Finkensieper M, Volk GF, Guntinas-Lichius O. Chronic vocal cord palsy in Thuringia, Germany: a population-based study on epidemiology and outcome. Eur Arch Otorhinolaryngol. 2014;271:329–35.

    Article  CAS  PubMed  Google Scholar 

  45. Mueller AH, Hagen R, Pototschnig C et al. Laryngeal pacing for bilateral vocal fold paralysis: Voice and respiratory aspects. Laryngoscope. 2017;127:1838–1844.

    Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Otorhinolaryngology/Plastic Surgery, SRH Wald-Klinikum Gera, Strasse des Friedens 122, Gera, 07548, Germany

    Andreas H. Mueller

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  1. Andreas H. Mueller
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Correspondence to Andreas H. Mueller .

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Editors and Affiliations

  1. Department of Otorhinolaryngology/Head and Neck Surgery, Clinical Centre Stuttgart, Stuttgart, Germany

    Christian Sittel

  2. Department of Otorhinolaryngology and Institute of Phoniatry and Pedaudiology, Jena University Hospital, Jena, Germany

    Orlando Guntinas-Lichius

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Mueller, A.H. (2018). Laryngeal Pacing. In: Sittel, C., Guntinas-Lichius, O. (eds) Neurolaryngology. Springer, Cham. https://doi.org/10.1007/978-3-319-61724-4_14

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  • DOI: https://doi.org/10.1007/978-3-319-61724-4_14

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-61722-0

  • Online ISBN: 978-3-319-61724-4

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