Human laryngeal sensory receptor mapping illuminates the mechanisms of laryngeal adductor reflex control

Sinclair, Catherine F.; Téllez, María J.; Ulkatan, Sedat

doi:10.1002/lary.27248

Cited by 35 publications

(44 citation statements)

References 25 publications

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“…2,31 The second method of vagal CIONM as reported in this case series utilizes a physiologic laryngeal reflex (LAR-CIONM) to elicit a contractile response in laryngeal musculature. This technique requires an EMG endotracheal tube alone, with no placement of additional electrodes, and generates bilateral VF adduction triggered by laryngeal supraglottic mucosal stimulation via brainstem synapse 20 To date, LAR-CIONM has been successfully utilized in neck endocrine procedures, anterior cervical spine approaches, vagal schwannoma resections, and pediatric posterior fossa surgeries. 17,22,[25][26][27][31][32][33][34] The initial feasibility study of LAR-CIONM was published in 2018, and data from this article were used to establish LAR-CIONM warning criteria for nerve injury.…”

Section: Discussionmentioning

confidence: 99%

“…In 2016, a bilateral laryngeal reflex response was discovered in humans under total intravenous general anesthesia and used to create an alternative form of vagal CIONM, termed LAR-CIONM [16][17][18][19] The laryngeal adductor reflex (LAR) is triggered by supraglottic laryngeal mucosal stimulation. [20][21][22] Afferent neural impulses are carried by the internal superior laryngeal nerve (IBSLN) to the brainstem. After brainstem synapse, efferent impulses are carried via the vagus and RLN to the larynx, resulting in bilateral vocal fold (VF) adduction that can be recorded on ETT surface electrodes.…”

Section: Introductionmentioning

confidence: 99%

“…This IONM technique is distinct from CMAP-CIONM [9][10][11][12][13][14][15]23,24 in that it utilizes a brainstem reflex response instead of direct vagal stimulation to elicit laryngeal muscle contraction. [20][21][22][25][26][27][28][29] An initial feasibility study of LAR-CIONM with 134 nerves at risk demonstrated that LAR VF waveforms are distinct from CMAP waveforms, demonstrating that LAR-CIONM is highly sensitive to nerve traction or compression. Intraoperative decreases in LAR response amplitude during periods of nerve stress mirroring decreases in CMAP responses.…”

Section: Introductionmentioning

confidence: 99%

“…After brainstem synapse, efferent impulses are carried via the vagus and RLN to the larynx, resulting in bilateral vocal fold (VF) adduction that can be recorded on ETT surface electrodes. This IONM technique is distinct from CMAP‐CIONM 9–15,23,24 in that it utilizes a brainstem reflex response instead of direct vagal stimulation to elicit laryngeal muscle contraction 20–22,25–29 . An initial feasibility study of LAR‐CIONM with 134 nerves at risk demonstrated that LAR VF waveforms are distinct from CMAP waveforms, demonstrating that LAR‐CIONM is highly sensitive to nerve traction or compression.…”

Section: Introductionmentioning

confidence: 99%

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Continuous Laryngeal Adductor Reflex Versus Intermittent Nerve Monitoring in Neck Endocrine Surgery

Sinclair¹,

Téllez

Ulkatan

2020

The Laryngoscope

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Objective Intraoperative neuromonitoring (IONM) techniques aim to identify and potentially prevent nerve injury during surgeries. Prior studies into the efficacy of recurrent laryngeal nerve (RLN) IONM convey mixed results, with some claiming equivalence between IONM and no monitoring at all. The goal of the current study was to compare continuous RLN monitoring using the laryngeal adductor reflex (LAR) to intermittent RLN monitoring (intermittent IONM) to determine whether continuous monitoring reduces the incidence of intraoperative RLN injury during neck endocrine surgeries. Methods In this observational, historical case‐control study, a historical cohort of patients monitored with intermittent‐IONM (group 1, n = 130) were compared to prospectively collected data from consecutive nerves‐at‐risk monitored continuously with the LAR (LAR‐CIONM, group 2, n = 205), at a single center by a single surgeon. The test benefit ratio and relative risk reduction (RRR) for LAR‐CIONM over intermittent IONM were calculated. Results For group 1, nine nerves at risk exhibited intraoperative LOS with transient postoperative vocal fold (VF) hypomobility (n = 2) or immobility (VFI, n = 7). For group 2, two nerves at risk (0.98%) had sudden intraoperative LAR LOS following bipolar cautery, resulting in postoperative transient VFI (P = .004). In each group, there was one case of permanent postoperative VFI. The test benefit rate ratio for LAR‐CIONM demonstrated a dramatic effect at 5.23, with an RRR of 81.0%. Conclusion LAR‐CIONM significantly decreased rates of postoperative transient VF paralysis and paresis over intermittent IONM alone (P = .004). Surgeons should be aware of the benefits and limitations of intermittent IONM versus CIONM. Intermittent IONM, although useful in nerve mapping and intraoperative decision making, has minimal benefit for the prevention of nerve injury, whereas CIONM can potentially reduce nerve injury rates and improve patient outcomes. Level of Evidence 3 Laryngoscope, 131:230–236, 2021

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Continuous Laryngeal Adductor Reflex Versus Intermittent Nerve Monitoring in Neck Endocrine Surgery

Sinclair¹,

Téllez

Ulkatan

2020

The Laryngoscope

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“…The decision to touch the arytenoids was based on research suggesting that this area contains the highest density of mechanoreceptors compared to other laryngeal subsites, such as the epiglottis. 37…”

Section: Methodsmentioning

confidence: 99%

Inter- and Intra-Rater Reliability of Laryngeal Sensation Testing with the Touch Method During Flexible Endoscopic Evaluations of Swallowing

Borders

O'Dea

McNally

et al. 2020

Ann Otol Rhinol Laryngol

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Objectives: Sensation is an integral component of laryngeal control for breathing, swallowing, and vocalization. Laryngeal sensation is assessed by elicitation of the laryngeal adductor reflex (LAR), a brainstem-mediated adduction of the true vocal folds. During Flexible Endoscopic Evaluations of Swallowing (FEES), the touch method can be used to elicit the LAR to judge laryngeal sensation. Despite the prevalence of this method in clinical practice and research, prior studies have yet to examine inter- and intra-rater reliability. Methods: Four speech-language pathologists rated 125 randomized video clips for the presence, absence, or inability to rate the LAR. Fifty percent of video clips were re-randomized and re-rated 1 week later. Raters then created guidelines and participated in formal consensus training sessions on a separate set of videos. Ratings were repeated post-training. Results: Overall inter-rater reliability was fair (κ = 0.22) prior to training. Pre-training intra-rater reliability ranged from fair (κ = 0.35) to almost perfect (κ = 0.89). Inter-rater reliability significantly improved after training (κ = 0.42, P < .001), though agreement did not reach prespecified acceptable levels (κ ≥ 0.80). Post-training intra-rater reliability ranged from moderate (κ = 0.49) to almost perfect (κ = 0.85). Conclusion: Adequate inter-rater reliability was not achieved when rating isolated attempts to elicit the LAR. Acceptable within-rater reliability was observed in some raters 1 week after initial ratings, suggesting that ratings may remain consistent within raters over a short period of time. Limitations and considerations for future research using the touch method are discussed.

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Clarifying optimal outcome measures in intermittent and continuous laryngeal neuromonitoring

et al. 2021

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Background Intraoperative neuromonitoring (IONM) techniques have evolved over the past decade into intermittent IONM (I‐IONM) and continuous IONM (C‐IONM) modes of application. Despite many prior publications on both types of IONM, there remains uncertainty about what outcomes should be measured for each form of IONM. The primary objective of this paper is to define categories of benefit for I‐IONM/C‐IONM and to clarify and standardize their reporting outcomes. Methods Expert review consensus statement utilizing modified Delphi methodology. Results I‐IONM provides diagnosis, classification, and prevention of nerve injury through accurate and early nerve identification. C‐IONM provides real‐time information on nerve functional integrity and thus may prevent some types of nerve injury but cannot assist in nerve localization. Sudden mechanisms of nerve injury cannot be predicted or prevented by either technique. Conclusions I‐IONM and C‐IONM are complementary techniques. Future studies evaluating the utility of IONM should focus on outcomes that are appropriate to the type of IONM being utilized.

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Human laryngeal sensory receptor mapping illuminates the mechanisms of laryngeal adductor reflex control

Abstract: 4. Laryngoscope, E365-E370, 2018.

Cited by 35 publications

References 25 publications

Continuous Laryngeal Adductor Reflex Versus Intermittent Nerve Monitoring in Neck Endocrine Surgery

Continuous Laryngeal Adductor Reflex Versus Intermittent Nerve Monitoring in Neck Endocrine Surgery

Inter- and Intra-Rater Reliability of Laryngeal Sensation Testing with the Touch Method During Flexible Endoscopic Evaluations of Swallowing

Clarifying optimal outcome measures in intermittent and continuous laryngeal neuromonitoring

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