title: Continuous laryngoscopic vocal cord monitoring for vascular malformation surgery in the medulla oblongata: technical note.
abstract: OBJECTIVE
  Resection of lesions located in the medulla oblongata may result in significant morbidity. The most lethal complications are swallowing disturbances, which can lead to aspiration pneumonia. To prevent this problem, the lower cranial nerves can be mapped with recording needles placed in the posterior pharyngeal wall and the tongue. However, mapping alone is not sufficient to preserve the lower cranial nerves and swallowing functions. To overcome this problem, we attempted to devise a method to intraoperatively monitor vocal cord movements with a laryngoscope. We used this method, in addition to other types of brainstem mapping, in three cases.
  
  
  METHODS
  Recording needles were inserted into the posterior pharyngeal wall and the tongue, to record the responses of Cranial Nerves IX and XII. A laryngoscope was inserted orally, for direct observation of vocal cord movements, and was maintained until the end of the operation. The floor of the fourth ventricle was stimulated with a monopolar stimulator. Somatosensory evoked potentials, auditory evoked potentials, and motor evoked potentials were simultaneously monitored.
  
  
  RESULTS
  We were able to confirm synchronized vocal cord adduction with stimulation of the expected vagal trigonum location and to monitor rhythmic vocal cord movements during spontaneous respiration. In all three cases, we removed the lesions without postoperative complications.
  
  
  CONCLUSIONS
  In addition to intraoperative vocal cord monitoring with a laryngoscope, we could safely determine the optimal location for the first incision in the floor of the fourth ventricle. Potentially lethal postoperative complications can be avoided with brainstem mapping and vocal cord monitoring.
authors.affiliation: Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan.
authors.forename: Yoshinori
authors.initials: Y
authors.lastname: Tamano
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Ujiie
authors.forename: Takakazu
authors.initials: T
authors.lastname: Kawamata
authors.forename: Tomokatsu
authors.initials: T
authors.lastname: Hori
mesh_terms: D001931:Brain Mapping / Q000379:methods; D020295:Brain Stem Neoplasms / Q000601:surgery*; D005260:Female; D020786:Hemangioma, Cavernous, Central Nervous System / Q000601:surgery*; D006801:Humans; D007828:Laryngoscopy; D008526:Medulla Oblongata / Q000503:physiopathology* / Q000601:surgery; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D014827:Vocal Cords / Q000503:physiopathology*