Vocal fold atrophy after resection of a parapharyngeal space sarcoma.A 43-year-old casino waitress complained of hoarseness, difficulty gliding down in pitch, and difficulty breathing. Nine years earlier, she had undergone removal of a synovial sarcoma synovial sarcoma Surgery A mesenchymal malignancy that comprises ±10% of all soft tissue tumors; it is most common in young–age 20-40 ♂, knee, ankle, foot, etc Prognosis 50% 5-yr survival; extensively calcified SSs have a higher–84% 5-yr of the right parapharyngeal space, followed by external-beam radiation for positive surgical margins. Since then, her voice had progressively worsened. She had undergone three injection medializations with collagen and fat, the most recent of which was performed 2 years earlier. Her current Voice Handicap Index was 61/120. Her current medications included cevimeline for mucositis and oxycodone/acetaminophen as needed. Recent positron-emission tomography (PET) revealed a groin lesion, which was benign. Flexible and rigid stroboscopy demonstrated severe atrophy and weakness of the right thyroarytenoid muscle, incomplete adduction adduction /ad·duc·tion/ (ah-duk´shun) the act of adducting; the state of being adducted. adduction ( of the left vocal fold, bilateral vocal fold scarring, reflux laryngitis, a left vocal fold mass, supraglottic compression, and bilateral varicosities (figure). Laryngeal electromyography revealed mild paresis paresis /pa·re·sis/ (pah-re´sis) slight or incomplete paralysis. general paresis paralytic dementia; a form of neurosyphilis in which chronic meningoencephalitis causes gradual loss of cortical of the right superior laryngeal nerve superior laryngeal nerve n. A branch of the vagus nerve at the inferior ganglion. At the thyroid cartilage, it divides into two branches, the internal, which supplies the mucous membrane of the larynx above the vocal cords; and the external, which , moderate-to-severe paresis of the right recurrent laryngeal nerve recurrent laryngeal nerve n. A branch of the vagus nerve that supplies the cardiac, tracheal and esophageal branches and terminates as the inferior laryngeal nerve. , moderate paresis of the left superior laryngeal nerve, and normal function in the left recurrent laryngeal nerve. An assay for antinuclear antibodies was positive. Magnetic resonance imaging magnetic resonance imaging (MRI), noninvasive diagnostic technique that uses nuclear magnetic resonance to produce cross-sectional images of organs and other internal body structures. and whole-body PET were negative. Speaking and singing voice therapy was initiated prior to surgery. The patient then underwent microscopic direct laryngoscopy with bilateral vocal fold lipoinjections, bilateral dexamethasone dexamethasone /dex·a·meth·a·sone/ (dek?sah-meth´ah-son) a synthetic glucocorticoid used primarily as an antiinflammatory in various conditions, including collagen diseases and allergic states; it is the basis of a screening test in the injections, and an excisional biopsy of the left vocal fold mass. The mass was benign. In view of the muscle atrophy and the elevated risks of a foreign-body reaction and implant extrusion from previous radiation, type I thyroplasty was initially deferred in favor of lipoinjection. However, if further medialization is required in the future, the implanted fat will provide a thicker barrier against implant extrusion or mucosal erosion while providing more bulk to the vocal folds, and thyroplasty may be performed. |
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