今日の臨床サポート

喉頭麻痺

著者: 湯本英二 朝日野総合病院 耳鼻咽喉科

監修: 森山寛 東京慈恵会医科大学附属病院

著者校正/監修レビュー済:2020/01/17
参考ガイドライン:
日本音声言語医学会/日本喉頭科学会:音声障害診療ガイドライン2018年版
患者向け説明資料
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
湯本英二 : 特に申告事項無し[2021年]
監修:森山寛 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行って加筆修正した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 喉頭麻痺とは、内喉頭筋を支配する神経の障害によって、嗄声、嚥下障害、呼吸困難などの症状を来す病態をいう。
  1. 反回神経単独の障害だけでなく、上喉頭神経外枝の障害、内枝を含む上喉頭神経全体の障害、下位脳神経(舌咽神経や舌下神経)の障害を伴うことがある(混合性喉頭麻痺と呼ばれる)。
  1. 一側性麻痺は気息性嗄声と嚥下障害・誤嚥、咳が、両側性麻痺では吸気性呼吸困難(喘鳴) が主な症状である。
  1. 障害された神経の範囲が広いほど症状が高度になる。ある程度の神経再生が起こるので、発症後半年以上経過すると症状が変化する。
  1. 術後性麻痺が約半数を占める。頸部の術後(主に甲状腺)が最も多く、次いで、胸部術後(食道癌、心血管疾患)、挿管性麻痺の順に多い[1]
  1. 非術後性麻痺は胸部疾患(肺癌、食道癌)、頸部疾患(主に甲状腺癌)、頭部疾患の順に多い[1]
問診・診察のポイント  
  1. 症状とその出現時期、急激に発症?徐々に発症? 術後性麻痺のときは原疾患、行った手術、および原疾患の予後

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文献 

著者: Eiji Yumoto, Ryosei Minoda, Masamitsu Hyodo, Takahiko Yamagata
雑誌名: Auris Nasus Larynx. 2002 Jan;29(1):41-5.
Abstract/Text OBJECTIVE: Persistent hoarseness due to recurrent laryngeal nerve paralysis (RLNP) reduces the quality of life unless it is adequately treated. This study examined the indications for phonosurgical intervention in patients with RLNP.
MATERIALS AND METHODS: The medical records of the Ehime University Hospital, Ehime, Japan, from October 1976 until December 1997 were reviewed retrospectively to identify patients with RLNP. The data collected included age, gender, paralyzed side, and cause of paralysis.
RESULTS: Four hundred and sixty-six patients with RLNP were identified: 262 males and 204 females. Unilateral RLNP was present in 422 patients, while 44 presented with bilateral RLNP. The incidence was relatively high in the 7th and 8th decades, and was twice as high in male patients as in female patients. The 466 patients were divided into 2 groups: Group 1 included 225 patients seen before January 1987, and Group 2 included 241 patients seen after this date. The number of patients with postoperative RLNP was significantly higher in Group 2 (124 of 239 patients) than in Group 1 (65 of 227 patients) (P<0.05). Surgery for cardiovascular disease, esophageal cancer, and skull base and thyroid gland tumors contributed to this increased incidence of postoperative RLNP.
CONCLUSIONS: Patients with persistent unilateral RLNP require appropriate treatment for hoarseness, regardless of its cause. Since the incidence of RLNP related to surgery was significantly increased in Group 2, phonosurgery has become more important for improving the quality of life of these patients.

PMID 11772489  Auris Nasus Larynx. 2002 Jan;29(1):41-5.
著者: J A Sercarz, G S Berke, Y Ming, B R Gerratt, M Natividad
雑誌名: Ann Otol Rhinol Laryngol. 1992 Jul;101(7):567-77.
Abstract/Text Previous stroboscopic studies of human vocal cord paralysis have been infrequent and have lacked documentation of the site of lesion. In order to study human laryngeal paralysis, the recurrent and superior laryngeal nerves were infiltrated unilaterally with lidocaine hydrochloride in three human volunteers. Vagal paralysis was simulated by combined (superior and recurrent) infiltration in one volunteer. Additionally, 20 patients with untreated laryngeal paralysis were studied from the voice laboratory at UCLA. In addition to videostroboscopic analysis, photoglottography and electroglottography were performed and synchronized with the stroboscopic images. The most significant finding in stroboscopy of the paralyzed larynx was the asymmetry of traveling wave motion. The traveling wave on the normal vocal fold had a faster wave velocity that created a phase difference in the vibration of the two folds. The wave also traversed a greater distance along the vocal fold mucosa on the normal side. No patient or volunteer with untreated laryngeal paralysis had a symmetric traveling wave, either in superior or recurrent laryngeal nerve paralysis. Synchronization with glottography indicated that the differentiated electroglottographic waveform provides useful information about the timing of glottic opening and closure in states of asymmetric laryngeal vibration. Implications for future studies and for the diagnosis of laryngeal paralysis are discussed.

PMID 1626902  Ann Otol Rhinol Laryngol. 1992 Jul;101(7):567-77.
著者: Eiji Yumoto, Koji Nakano, Yukio Oyamada
雑誌名: Acta Otolaryngol. 2003 Jan;123(2):274-8.
Abstract/Text OBJECTIVE: We used multi-slice helical computerized tomography (MSHCT) to evaluate the 3D characteristics of the laryngeal structures in patients with unilateral vocal fold paralysis (UVFP) during phonation, and compared the results with those obtained using an aerodynamic vocal function test.
MATERIAL AND METHODS: The subjects were 37 patients with UVFP. The region over the larynx was scanned during quiet phonation and again during inspiration using MSHCT, and 3D endoscopic and coronal reconstruction images were produced. Maximum phonation time (MPT) and mean airflow rate (MFR) during phonation were measured.
RESULTS: During phonation, the affected fold was thinner than the healthy fold in 30 subjects and located at a higher position than the healthy fold in 21 subjects. Abduction or thinning of the affected fold during phonation (paradoxical movement) was seen in seven subjects. MFR was significantly greater when the affected fold was thinner than the healthy fold during phonation, and MPT was significantly shorter when the affected fold showed paradoxical movement. Over-adduction of the healthy fold during phonation was present in 15 subjects. There were no significant differences in MPT or MFR between subjects with and without over-adduction.
CONCLUSION: The combination of MSHCT endoscopic and coronal reconstruction images enables the 3D characteristics of the unilaterally paralyzed larynx to be visualized during phonation, and some of these characteristics are significantly correlated with vocal function in patients with UVFP.

PMID 12701757  Acta Otolaryngol. 2003 Jan;123(2):274-8.
著者: Eiji Yumoto, Yukio Oyamada, Koji Nakano, Yosiharu Nakayama, Yasuyuki Yamashita
雑誌名: Arch Otolaryngol Head Neck Surg. 2004 Aug;130(8):967-74. doi: 10.1001/archotol.130.8.967.
Abstract/Text OBJECTIVES: To evaluate the 3-dimensional (3-D) characteristics of the laryngeal lumen in patients with unilateral vocal fold immobility (UVFI) during phonation with the aid of multislice helical computed tomography (MSHCT).
DESIGN: A retrospective study.
SETTING: University hospital. Subjects Thirty-seven patients with UVFI.
INTERVENTIONS: Each subject was asked to sustain the vowel /a/ and then to inhale slowly. The region over the larynx was scanned using MSHCT during each maneuver for 5 seconds; 3-D endoscopic images and coronal multiplanar reconstruction images were produced and evaluated. Thirty-two subjects underwent videostroboscopy within 2 weeks of the MSHCT.
MAIN OUTCOME MEASURES: Presence of thinning and paradoxical movement of the affected vocal fold, overadduction of the healthy fold, and vertical positional difference between the vocal folds during phonation were assessed based on 3-D and multiplanar reconstruction images.
RESULTS: During phonation, the affected vocal fold was thinner in 31 subjects and was situated in a higher position in 21 subjects than the healthy fold. In 4 subjects, the affected vocal fold showed paradoxical movement and 3 other subjects had probable paradoxical movement. Overadduction of the healthy vocal fold occurred during phonation in 15 subjects. Videostroboscopy detected paradoxical movement in 2 of the 3 subjects with abduction of the affected vocal fold during phonation based on 3-D images, and overadduction in all 13 subjects examined.
CONCLUSIONS: The combination of 3-D endoscopy with coronal multiplanar reconstruction images enables description of the 3-D characteristics of the unilaterally immobile larynx and supplements videostroboscopic findings exemplified by differences in vertical position and thickness between the vocal folds.

PMID 15313868  Arch Otolaryngol Head Neck Surg. 2004 Aug;130(8):967-74・・・
著者: M R Amin, J A Koufman
雑誌名: Am J Otolaryngol. 2001 Jul-Aug;22(4):251-6. doi: 10.1053/ajot.2001.24823.
Abstract/Text PURPOSE: To describe a condition that occurs following an upper respiratory illness, which represents injury to various branches of the vagus nerve. Patients with this condition may present with breathy dysphonia, vocal fatigue, effortful phonation, odynophonia, cough, globus, and/or dysphagia, lasting long after resolution of the acute viral illness. The patterns of symptoms and findings in this condition are consistent with the hypothesis that viral infection causes or triggers vagal dysfunction. This so-called postviral vagal neuropathy (PVVN) appears to have similarities with other postviral neuropathic disorders, such as glossopharyngeal neuralgia and Bell's palsy.
MATERIALS AND METHODS: Five patients were identified with PVVN. Each patient's chart was reviewed, and elements of the history were recorded.
RESULTS: Each of the 5 patients showed different features of PVVN.
CONCLUSIONS: Respiratory infection can trigger or cause vocal fold paresis, laryngopharyngeal reflux, and neuropathic pain.

PMID 11464321  Am J Otolaryngol. 2001 Jul-Aug;22(4):251-6. doi: 10.105・・・
著者: Eiji Yumoto, Tetsuji Sanuki, Yutaka Toya, Narihiro Kodama, Yoshihiko Kumai
雑誌名: Arch Otolaryngol Head Neck Surg. 2010 Oct;136(10):965-9. doi: 10.1001/archoto.2010.155.
Abstract/Text OBJECTIVES: To describe a new technique of nerve-muscle pedicle (NMP) flap implantation combined with arytenoid adduction (AA) to treat dysphonia due to unilateral vocal fold paralysis and to examine postoperative vocal function.
STUDY DESIGN: Retrospective review of clinical records.
SETTING: Tertiary academic center.
PATIENTS: Twenty-two consecutive patients underwent NMP flap implantation with AA and were followed up short term over a period of 1 to 6 months (mean, 2.9 months) and long term over a period of 7 to 36 months (mean, 21.4 months).
INTERVENTIONS: An NMP flap was made using an ansa cervicalis branch and a piece of the sternohyoid muscle. A window was opened in the thyroid ala at the level of the vocal fold. Then, AA was performed and the NMP flap was securely implanted onto the thyroarytenoid muscle through the window under microscopic guidance.
MAIN OUTCOME MEASURES: The maximum phonation time, mean airflow rate, pitch range, and acoustic parameters (jitter, shimmer, and harmonics to noise ratio) were evaluated before surgery and twice after surgery.
RESULTS: All parameters improved significantly after surgery (P < .01). The measurements for maximum phonation time, mean airflow rate, and harmonics to noise ratio were within normal ranges after surgery. Furthermore, the maximum phonation time and jitter were significantly improved after long-term follow-up compared with early postoperative measurements (P < .01 and P < .05, respectively).
CONCLUSIONS: Precise harvest of an NMP flap and its placement directly onto the thyroarytenoid muscle combined with AA provided excellent vocal function. The NMP method may have played a certain role in the improvement of postoperative vocal function, although further study with electromyographic examination is required to clarify the innervation status of the thyroarytenoid muscle.

PMID 20956741  Arch Otolaryngol Head Neck Surg. 2010 Oct;136(10):965-9・・・
著者: Shun-Ichi Chitose, Kiminori Sato, Sachiyo Hamakawa, Hirohito Umeno, Tadashi Nakashima
雑誌名: Laryngoscope. 2011 Mar;121(3):567-70. doi: 10.1002/lary.21362. Epub 2011 Jan 19.
Abstract/Text
PMID 21344435  Laryngoscope. 2011 Mar;121(3):567-70. doi: 10.1002/lary・・・

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