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Neurolaringologia

Raluca Pacalu
MG II

Agenda
1)
2)
3)
4)
5)

Background
Fiziologia fonaiei
Controlul nervos
Evaluarea clinic
Patologie

Neurolaringologia-domeniu
interdisciplinar
acustica

neurologie

ORL

informatica

Pedro Gmez Vilda: Voice as a Vehicular Tool to Organic and Neurological


Disease Tracking: How Far we May Go?. BIOINFORMATICS 2013: IS-5

Istoric
Neurolaryngology Study Group (NLSG)
1989 -Drs. Gayle Woodson and Roger
Crumley
Au propus termenul neurolaringologie
pentru subdisciplina care se ocupa cu
tulburarile laringiene de origine
neurologic
NLSG are sediul la New Zork.

recomandri

Otolaryngol Head Neck Surg. 2009 Jun;140(6):782793. doi: 10.1016/j.otohns.2009.01.026. Epub 2009
Apr 9.

Recommendations of the
Neurolaryngology Study Group on
laryngeal electromyography.
Blitzer A, Crumley RL, Dailey SH, Ford CN, Floeter
MK, Hillel AD, Hoffmann HT, Ludlow CL, Merati A,
Munin MC, Robinson LR, Rosen C, Saxon KG, Sulica L,
Thibeault SL, Titze I, Woo P, Woodson GE.
Source
Head and Neck Surgical Group

New York, NY, USA.

Fiziologia fonaiei
Aciunea muchilor
intrinseci ai laringelui

Vibraia corzilor vocale

Sunete vocale:
nlime frecvena
fundamental
intensitate amplitudine
timbru anvelopa spectral

Controlul nervos al
vorbirii/fonaiei

Nervul laringeu superior


-origine: ggl plexiform
-ramura intern
- mucoasa epiglotei, rdcinii limbii,
vestibulului laringian, laringofaringelui
- anastomoz cu nervul laringeu
recurent (ansa Galen)
-ramura extern
- muchiul cricotiroidian
- mucoasa ventriculului i a etajului
infraglotic
-glanda tiroid, constrictor inferior
faringe

Nervul laringeu
recurent
-origine: baza gtului (dr),
torace (stg)
-anastomoze: n laringeu
superior (ansa Galen)
-teritoriu: muchii intrinseci
laringe, esofag, trahee,
constrictor inferior faringe

10

Evaluarea clinic
Istoric

Examen fizic
general: postur, tonus, mers
funcia nervilor cranieni
inspecia cavitii bucale i a orofaringelui
masaj circumlaringian

Endoscopie

Videostroboscopie

Teste speciale

Analize acustice
Electroglotografie
Teste aerodinamice
Electromiografie laringian
Imagistic

Analize acustice
perceptual: GRBAS (Grade Roughness
Breathiness Asthenic Strained)
computerizat:
spectrograma
filtrare invers
cepstrum
fonetograma
parametrii acustici

Spectrograma

Parametrii

Pitch
Jitter
Shimmer
HNR
Open/Close
Quotient

Electroglotografie

Cele mai lungi cuvinte din limba romn:


ELECTROGLOTOSPECTROGRAFIE (25 de caractere)
DICLORDIFENILTRICLORMETILMETAN (termen medical 30 de litere)
GASTROPILORODUODENOJEJUNOSTOMIE (31 de litere)
ENCEFALOMIELOPOLIRADICULONEVRITA (32 de litere)
DIFOSFOPIRIDINNUCLEOTIDPIROFOSFATAZA (36 de
litere)
PNEUMONOULTRAMICROSCOPICSILICOVOLCANICONIO
ZA (44 de litere)

Teste aerodinamice

timpul maxim de fonaie


coeficientul fonator
testul S/Z
presiunea declansatoare
debitul aerian fonator
presiunea subglotic

Imagistic
CT
vagul distal
de la osul hioid pn n mediastin
baza craniului cu fereastr osoas

MRI
vagul proximal
secvene - T1W, T2W, contrastenhanced T1W FS
seciuni axiale i coronale
de la bulb pn la hioid

Radiografie toracic

Electromiografie laringian

Afeciuni neurolaringologice
paralizie
Progressive
vocal
lateral
spastic
disartrie
sclerosis
Babinsky
Pseudobulbar
+
palsy
voce
Parkinsons
tensionat
disease
fragmentri
Spasmodic dysphonia
de frecven
tremor
Laryngeal tremor

voce
hipernazal
Amyotrophic
slab,
lateralsuflat
sclerosis
(Lou Gehrig)

paralizie
Progressive
vocal flasc
insuficien
bulbar palsyglotic
hipernazalizare
Sdr Wallenberg

hipo- Peripheral
sau imobilitate
distrofie
paralysis

ataxie
disartrie
tremor
Myoclonus
oboseal
Myasthenia
la
sarcini
gravis
repetitive

NX
N LS

N LI

hipomibilitate
Toxic/metabolic
flaciditate
myopathies
Polymyositis,
dermatomyositis
Muscular dystrophies

Paralizii periferice

Leziuni vagale proximale

Paralizii unilaterale recurent

pierderea registrului nalt


hipoestezie supraglotic - aspiraie

Fenomene de reinervare

voce suflat
diplofonie
aspiraie
secionare parial-stridor inspirator sau
chiar asfixie

Paralizii unilaterale laringeu superior

Hipotonia palatului moale


Devierea uvulei
Disfagie

dup 4 luni
synkinezii
vocea de benzi ventriculare

Tratament

reinervare
thyroplastie de medializare
pacemaker laringian
terapie genic

Thyroplastia de madializare

Cartilaj
Colagen
esut adipos
Gel

Boala Parkinson/ Tremorul esenial

degenerescena celulelor secretoare


de dopamin din sistemul
extrapiramidal
70% dintre bolnavi prezint
manifestri vocale:
tremor n repaus
lipsa reflexelor posturale
voce monoton
pauze de respiraie neadecvate
rigiditate
tratament:
terapie vocal
augmentare cu colagen

nu are substrat neuropatologic specific

nu apare n repaus
apare la meninerea unei posturi
oscilaii ale intensitii i
frecvenei fundamentale
sunt implicai i muchii extrinseci

tratament:
administrare de propanolol
injectare de toxin botulinic

Disfonia spasmodic
distonie focal contracii
involuntare
tipuri:
AbdSD m cricoaritenoidinan
posterior
voce suflat, intermitent

AddSD(80%) m tiroaritenoidinan
voce presat, tensionat, cu pauze

mixt (rar)

n strigt, plns, rs, cntat, cscat


sau oapt, vocea e normal
tratament:
injectare de toxin botulinic
denervare-reinervare selectiv

disfuncia sistemelor
laringiene de feedback
cantitate redus de
mielin n genunchiul
capsulei albe interne
acumulri minerale n:
putamen
globus pallidus

diffusion tensor imaging (DTI)

Concluzii

schimbrile n
voce pot fi semne
premergtoare
unor afeciuni
neurologice

tehnologia
actual permite
ameliorarea
simptomelor
vocale sle bolilor
neurologice
buna cunoatere a
neuroanatomiei
laringiene este
esenial

colaborarea
dintre ORL-ist
i neurolog
este foarte
important

Bibliografie

R. Murean, M. Chiril, Reabilitarea i igiena vocii, Alma Mater, 2010


Cummings Otolaryngology - Head and Neck Surgery, 5th edition: Expert Consult Online and Print By Paul
W. Flint, MD, Bruce H. Haughey, MBChB, MS, FACS, FRACS, Valerie J. Lund, CBE, MS, FRCS, FRCSEd,
John K. Niparko, MD, Mark A. Richardson, MD, K. Thomas Robbins, MD, FACS and J. Regan Thomas, MD,
FACS
C. Sarafoleanu, Esenialul n laringologie
Nnez-Batalla F, et al. Neurolaringologa. Acta Otorrinolaringol Esp. 2012;63:132---40
Adam D. Rubin, Neurolaryngologic Evaluation of the Performer, Otolaryngol Clin N Am 40 (2007) 971
989
Ludlow et al., Research Priorities in Spasmodic Dysphonia, Otolaryngol Head Neck Surg. 2008 October ;
139(4): 495505. doi:10.1016/j.otohns.2008.05.624
Kristina Simonyan,1 Fernanda Tovar-Moll,2 John Ostuni,3 Mark Hallett,4 Victor F. Kalasinsky,5 Michael
R. Lewin-Smith,5 Elisabeth J. Rushing,6 Alexander O.Vortmeyer7 and Christy, Focal white matter
changes in spasmodic dysphonia:a combined diffusion tensor imaging and neuropathological study,
Brain (2008), 131, 447^459
Pedro Gmez Vilda, Mara Victoria Rodellar Biarge, Victor Nieto Lluis, Cristina Muoz-Mulas, Luis Miguel
Mazaira-Fernndez, Carlos Ramrez-Calvo, Mario Fernndez-Fernndez, Elvira Toribio-Daz:
Neurological Disease Detection and Monitoring from Voice Production. NOLISP 2011: 1-8
Kristina Simonyan and Christy L. Ludlow, Abnormal Activation of the Primary Somatosensory Cortex in
Spasmodic Dysphonia: An fMRI Study, Cerebral Cortex November 2010;20:27492759
Blitzer et al., Invited Article: Recommendations of the Neurolaryngology Study Group on Laryngeal
Electromyography, Otolaryngol Head Neck Surg. 2009 June ; 140(6): 782793.
doi:10.1016/j.otohns.2009.01.026
Sara C. Scheid, MD, Daniel P. Nadeau, MD, Oren Friedman, MD, and Robert T. Sataloff, MD, Anatomy of
the Thyroarytenoid Branch of the Recurrent Laryngeal Nerve, Journal of Voice, Vol. 18, No. 3, pp. 279
284
HSUEH-HSIN Huang, Vagus nerve paralysis due to skull base fracture
CHENG KANG ONG, , Vincent Fook Hin Chong, The glossopharyngeal, vagus and spinal accessory nerves
European Journal of Radiology,Volume 74, Issue 2, May 2010, 359367
ROHEN J.; Color Atlas of Anatomy: A Photographic Study of the Human Body

Voice is a kind of sound characteristic of what has soul in it.


Aristotle, On the soul, II, 8, (trans. J. A. Smith)