Position of vocal cords from midline in healthy and diseased individuals.
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"8108",leadTitle:null,fullTitle:"Citrus - Research, Development and Biotechnology",title:"Citrus",subtitle:"Research, Development and Biotechnology",reviewType:"peer-reviewed",abstract:"Citrus is an extensively produced fruit crop and is cultivated predominantly in tropical and subtropical regions of the world. The Citrus genus consists of a variable number of species due to the admixture of wide morphological diversity, intra- and interspecific sexual compatibility, apomixis, and spontaneous mutations. Citrus fruits are highly nutritious and beneficial for health due to the presence of bioactive compounds that have antioxidant, antitumor, anti-inflammatory, and blood clot-inhibiting characteristics. This book describes the citrus plant and its nutrients, nutritional value, and nutraceutical applications, as well as related biotic and abiotic challenges in its cultivation. Chapters cover such topics as citrus genealogy, production, and crop management; milestones achieved in citrus improvement; importance of weather conditions in cropping systems; effects of changing climate on citrus; and much more.",isbn:"978-1-83968-724-2",printIsbn:"978-1-83968-723-5",pdfIsbn:"978-1-83968-725-9",doi:"10.5772/intechopen.77939",price:139,priceEur:155,priceUsd:179,slug:"citrus-research-development-and-biotechnology",numberOfPages:330,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"9b41d217f838ac9812215988333688ce",bookSignature:"Muhammad Sarwar Khan and Iqrar Ahmad Khan",publishedDate:"November 3rd 2021",coverURL:"https://cdn.intechopen.com/books/images_new/8108.jpg",numberOfDownloads:3745,numberOfWosCitations:0,numberOfCrossrefCitations:8,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:13,numberOfDimensionsCitationsByBook:0,hasAltmetrics:1,numberOfTotalCitations:21,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 7th 2020",dateEndSecondStepPublish:"October 5th 2020",dateEndThirdStepPublish:"December 4th 2020",dateEndFourthStepPublish:"February 22nd 2021",dateEndFifthStepPublish:"April 23rd 2021",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"212511",title:"Prof.",name:"Muhammad Sarwar",middleName:null,surname:"Khan",slug:"muhammad-sarwar-khan",fullName:"Muhammad Sarwar Khan",profilePictureURL:"https://mts.intechopen.com/storage/users/212511/images/system/212511.jpg",biography:"Muhammad Sarwar Khan is a distinguished Plant Molecular Biologist who started his career as a Bachelor and Master student in horticulture. He earned his Ph.D. from the University of Cambridge, UK. Dr. Khan was awarded a prestigious fellowship to research at the Waksman Institute of Microbiology, Rutgers, The State University of New Jersey, by the Rockefeller Foundation. He has served as the founding Head of the Biotech Interdisciplinary Division at the NIBGE and is currently serving as the Director of the Center of Agricultural Biochemistry and Biotechnology (CABB), University of Agriculture, Faisalabad, Pakistan. Dr. Khan has supervised more than 100 Ph.D. candidates, MPhil students, and researchers. He has published several papers in high-impact journals, including Nature and Nature Biotechnology, and is the author of several book chapters and books. Dr. Khan has received several prestigious awards, including the President’s Medal for Technology, a Gold Medal in Agriculture from the Pakistan Academy of Sciences, a Performance Gold Medal, the Biotechnologist Award by the National Commission of Biotechnology, and the Best University Teacher Award by the Higher Education Commission of Pakistan. He is a fellow of the Cambridge Commonwealth Society, the Cambridge Philosophical Society, the Rockefeller Foundation, and the Cochran Foundation. He is also a member of the Pakistan Botanical Society and the International Association for Plant Biotechnology.",institutionString:"University of Agriculture Faisalabad",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"7",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"University of Agriculture Faisalabad",institutionURL:null,country:{name:"Pakistan"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"341509",title:"Dr.",name:"Iqrar Ahmad",middleName:null,surname:"Khan",slug:"iqrar-ahmad-khan",fullName:"Iqrar Ahmad Khan",profilePictureURL:"https://mts.intechopen.com/storage/users/341509/images/system/341509.png",biography:"Iqrar Ahmad Khan is a horticulturist/botanist by profession. Dr. Khan has a distinguished career spanning more than forty years. He is a graduate of the University of Agriculture, Faisalabad, Pakistan, and the University of California, Riverside, USA. He has supervised more than seventy graduate students including fourteen PhDs. His students and research associates have achieved significant positions in academia and industry. He has undertaken forty-four research projects and published 375 articles and books. He served as vice-chancellor of two universities for more than nine years and founded five new universities and district campuses (2008–2017). He has also established several national and international research centers and institutes, including a Chinese Confucius Institute and a Bio-Energy Institute. He was COP/Director US-Pak Center of Advanced Studies (2017–2019) and Ela Bhatt Professor at the University of Kassel, Germany (2020). His research on wheat, potato, citrus, mango, and dates has benefitted the industry and significantly improved the life and livelihood of farmers and rural communities. He is a Distinguished National Professor and a Fellow of the Pakistan Academy of Sciences. He was awarded Sitara-e-Imtiaz for his services by the President of Pakistan and Ordre des Palmes Academiques by the French Government for his international contribution to education.",institutionString:"University of Agriculture Faisalabad",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Agriculture Faisalabad",institutionURL:null,country:{name:"Pakistan"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"342",title:"Pomology",slug:"pomology"}],chapters:[{id:"77835",title:"Introductory Chapter: Citrus for a Healthy Life",doi:"10.5772/intechopen.99355",slug:"introductory-chapter-citrus-for-a-healthy-life",totalDownloads:110,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:null,signatures:"Muhammad Sarwar Khan",downloadPdfUrl:"/chapter/pdf-download/77835",previewPdfUrl:"/chapter/pdf-preview/77835",authors:[{id:"212511",title:"Prof.",name:"Muhammad Sarwar",surname:"Khan",slug:"muhammad-sarwar-khan",fullName:"Muhammad Sarwar Khan"}],corrections:null},{id:"75484",title:"Horticultural Classification of Citrus Cultivars",doi:"10.5772/intechopen.96243",slug:"horticultural-classification-of-citrus-cultivars",totalDownloads:476,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"Globally, citrus fruits are grown over an area of 11.42 million ha with 179.0 million tons production. China with 82.7 m tons production is the major producer of citrus fruits followed by Brazil (18.14 m tons) and India (10.53 m tons) (FAOSTAT, 2019). All commercially used scion and rootstock cultivars belong to the genus Citrus, except kumquats, Fortunella spp., and Poncirus trifoliata, which are used as rootstock only all over the world. Worldwide citrus cultivars divided into four, reasonably-well-defined horticultural groups: the Sweet oranges, the mandarins, the grapefruits and the pummelos and the common acid members. The true or ‘biological’ citrus, including species of Citrus (C. reticulata, C. maxima and C. medica), share certain characteristics, however, these are clearly differentiated according to the morpho- taxonomic traits. Hundreds of different citrus cultivars are available. Many varieties were chance finds from natural populations, and not the product of intentional breeding efforts. Other varieties in common use have originated from planned citrus hybridization and breeding efforts from worldwide. Most of the readers will be well acquainted with the cultivated types of Citrus scion and rootstocks. This chapter provides ripening season information for worldwide, farmers/gardeners have had success with citrus in many different regions of world where tropical/subtropical climatic conditions occur.",signatures:"Jagveer Singh, Vishal Sharma, Kuldeep Pandey, Shahnawaz Ahmed, Manveen Kaur and Gurupkar Singh Sidhu",downloadPdfUrl:"/chapter/pdf-download/75484",previewPdfUrl:"/chapter/pdf-preview/75484",authors:[{id:"219337",title:"Dr.",name:"Jagveer",surname:"Singh",slug:"jagveer-singh",fullName:"Jagveer Singh"},{id:"333389",title:"Dr.",name:"Gurupkar Singh",surname:"Sidhu",slug:"gurupkar-singh-sidhu",fullName:"Gurupkar Singh Sidhu"},{id:"333391",title:"MSc.",name:"Kuldeep",surname:"Pandey",slug:"kuldeep-pandey",fullName:"Kuldeep Pandey"},{id:"344842",title:"Dr.",name:"Shahnawaz",surname:"Ahmed",slug:"shahnawaz-ahmed",fullName:"Shahnawaz Ahmed"},{id:"344843",title:"Dr.",name:"Vishal",surname:"Sharma",slug:"vishal-sharma",fullName:"Vishal Sharma"},{id:"344844",title:"Dr.",name:"Manveen",surname:"Kaur",slug:"manveen-kaur",fullName:"Manveen Kaur"}],corrections:null},{id:"78756",title:"Citrus Biotechnology: Current Innovations and Future Prospects",doi:"10.5772/intechopen.100258",slug:"citrus-biotechnology-current-innovations-and-future-prospects",totalDownloads:218,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"Citrus is a valuable fruit crop worldwide. It not only provides essential minerals and vitamins but is also of great commercial importance. Conventional research has contributed a lot to the improvement of this fruit plant. Numerous improved varieties have been developed through conventional breeding, mutational breeding, polyploidization and tissue culture yet pathogens continue to emerge at a consistent pace over a wide range of citrus species. Citriculture is vulnerable to various biotic and abiotic stresses which are quite difficult to be controlled through conventional research. Biotechnological intervention including transgenesis, genome editing, and OMICS offers several innovative options to resolve existing issues in this fruit crop. Genetic transformation has been established in many citrus species and transgenic plants have been developed having the ability to tolerate bacterial, viral, and fungal pathogens. Genome editing has also been worked out to develop disease-resistant plants. Likewise, advancement in OMICS has helped to improve citrus fruit through the knowledge of genomics, transcriptomics, proteomics, metabolomics, interactomics, and phenomics. This chapter highlights not only the milestones achieved through conventional research but also briefs about the achievements attained through advanced molecular biology research.",signatures:"Ghulam Mustafa, Muhammad Usman, Faiz Ahmad Joyia and Muhammad Sarwar Khan",downloadPdfUrl:"/chapter/pdf-download/78756",previewPdfUrl:"/chapter/pdf-preview/78756",authors:[{id:"212511",title:"Prof.",name:"Muhammad Sarwar",surname:"Khan",slug:"muhammad-sarwar-khan",fullName:"Muhammad Sarwar Khan"},{id:"436261",title:"Dr.",name:"Ghulam",surname:"Mustafa",slug:"ghulam-mustafa",fullName:"Ghulam Mustafa"},{id:"436262",title:"Dr.",name:"Muhammad",surname:"Usman",slug:"muhammad-usman",fullName:"Muhammad Usman"},{id:"436263",title:"Dr.",name:"Faiz Ahmad",surname:"Joyia",slug:"faiz-ahmad-joyia",fullName:"Faiz Ahmad Joyia"}],corrections:null},{id:"75845",title:"Integrated Management Approach to Citrus Fungal Diseases by Optimizing Cocoa-Based Agroforests Structural Characteristics",doi:"10.5772/intechopen.95571",slug:"integrated-management-approach-to-citrus-fungal-diseases-by-optimizing-cocoa-based-agroforests-struc",totalDownloads:183,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The health and productivity of citrus are generally jeopardized by a host of diseases, for which the environmental conditions of the cropping system are critical drivers. Several studies conducted on various diseases of perennial crops have shown the involvement of the structural futures of the cocoa-based agroforestry system (CBAFS) in the spread of pathogens and the epidemics development. This chapter highlights the effect of the CBAFS’s structural characteristics on the intensity of three citrus diseases in the humid forest zones of Cameroon. The involvement of CBAFS structural characteristics in diseases regulation is demonstrated. In particular, the spatial structure of citrus in agroforests shows an effect on the spread of diseases. Moreover, distribution of citrus in the CBAFS, with minimum spacing of 12 m between citrus trees, limits the damage caused by Pseudocercospora leaf and fruit spot disease (PLFSD) and citrus diseases caused by Phytophthora (CDP). Dense shading helps to minimize the intensity of diseases such as CDP and PLFSD and Citrus scab disease. This work may make it possible to contribute to the development of an integrated management tool for citrus diseases in an associated crop context.",signatures:"Ndo Eunice Golda Danièle and Akoutou Mvondo Etienne",downloadPdfUrl:"/chapter/pdf-download/75845",previewPdfUrl:"/chapter/pdf-preview/75845",authors:[{id:"250588",title:"Dr.",name:"Ndo",surname:"Eunice Golda Danièle",slug:"ndo-eunice-golda-daniele",fullName:"Ndo Eunice Golda Danièle"},{id:"332054",title:"Ph.D. Student",name:"Akoutou Mvondo",surname:"Etienne",slug:"akoutou-mvondo-etienne",fullName:"Akoutou Mvondo Etienne"}],corrections:null},{id:"74957",title:"A Current Overview of Two Viroids Prevailing in Citrus Orchards: Citrus Exocortis Viroid and Hop Stunt Viroid",doi:"10.5772/intechopen.95914",slug:"a-current-overview-of-two-viroids-prevailing-in-citrus-orchards-citrus-exocortis-viroid-and-hop-stun",totalDownloads:281,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Citrus exocortis viroid (CEVd) and hop stunt viroid (HSVd) are the main viroids circulating in all citrus-growing areas worldwide, and causing two well-known diseases on citrus trees; exocortis and cachexia, respectively. These viroids are small, covalently closed single-stranded RNA, allocated to the Pospiviroidae family. CEVd is the first viroid being described on citrus trees in 1948 in California. It is considered the largest citrus viroid at 371 nucleotides. It causes bark scaling disorder on the rootstock of citrus trees grafted on trifoliate orange and its hybrids and can cause dwarfing of trees grown on these rootstocks. HSVd was first observed in 1945 in Florida. It consists of 299 nucleotides. Stunting, chlorosis, bark gumming, stem pitting, decline, and depressions in the wood are the main symptoms of HSVd in mandarin and its hybrids. The introduction and propagation of infected budwoods are the main causes of viroids spread in citrus orchards. These agents are mechanically sap-transmissible and spread by contaminated tools. Neither seed transmission nor vectors have been reported for both viroids. Root transmission, though possible, would be overshadowed by mechanical transmission. Rapid and sensitive molecular-based detection methods specific to both viroids are available. Both diseases are controlled by using viroids-free budwoods for new plantations, launching budwood certification programs, and establishing a quarantine system for new citrus varieties introduction. The most important achievements in CEVd and HSVd researches are outlined in this chapter. This would help to provide a clearer understanding of the diseases they cause and contribute to the development of better control strategies.",signatures:"Zineb Belabess, Nabil Radouane, Tourya Sagouti, Abdessalem Tahiri and Rachid Lahlali",downloadPdfUrl:"/chapter/pdf-download/74957",previewPdfUrl:"/chapter/pdf-preview/74957",authors:[{id:"193409",title:"Dr.",name:"Rachid",surname:"Lahlali",slug:"rachid-lahlali",fullName:"Rachid Lahlali"},{id:"335465",title:"Dr.",name:"Zineb",surname:"Belabess",slug:"zineb-belabess",fullName:"Zineb Belabess"},{id:"335466",title:"Dr.",name:"Tourya",surname:"Sagouti",slug:"tourya-sagouti",fullName:"Tourya Sagouti"},{id:"335468",title:"Mr.",name:"Nabil",surname:"Radouane",slug:"nabil-radouane",fullName:"Nabil Radouane"},{id:"335470",title:"Prof.",name:"Abdessalem",surname:"Tahiri",slug:"abdessalem-tahiri",fullName:"Abdessalem Tahiri"}],corrections:null},{id:"75243",title:"Indexing Virus and Virus-Like Diseases of Citrus",doi:"10.5772/intechopen.95897",slug:"indexing-virus-and-virus-like-diseases-of-citrus",totalDownloads:262,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Citrus is a highly nutritive and prized fruit crop around the world. It contributes a substantial share in local consumption and exports of a nation to earn a handsome foreign exchange. The production of citrus is under the threat of citrus decline. Different factors are responsible for the citrus decline but virus and virus-like diseases have the major role in this decline. Virus and virus-like diseases alone or in association with other biotic and abiotic factors exist in the citrus orchards. Therefore, indexing of diseases caused by virus and virus-like pathogens is the key factor to manage these citrus diseases. Proper facilities and skilled personnel are the pre-requisite for the diseases indexing procedures. Biological, serological and molecular indexing is sensitive, reliable and durable strategy for managing different citrus virus and virus-like diseases under different conditions. Moreover, indexing of viruses and virus-like pathogens are very important for the production of disease free citrus nurseries. This chapter gives a brief review for the commonly used biological, serological and molecular assays for the detection of citrus virus and virus-like pathogens.",signatures:"Yasir Iftikhar, Muhammad Zeeshan Majeed, Ganesan Vadamalai and Ashara Sajid",downloadPdfUrl:"/chapter/pdf-download/75243",previewPdfUrl:"/chapter/pdf-preview/75243",authors:[{id:"260766",title:"Dr.",name:"Muhammad Zeeshan",surname:"Majeed",slug:"muhammad-zeeshan-majeed",fullName:"Muhammad Zeeshan Majeed"},{id:"333703",title:"Assistant Prof.",name:"Yasir",surname:"Iftikhar",slug:"yasir-iftikhar",fullName:"Yasir Iftikhar"},{id:"345159",title:"Dr.",name:"Ganesan",surname:"Vadamalai",slug:"ganesan-vadamalai",fullName:"Ganesan Vadamalai"},{id:"345160",title:"Mrs.",name:"Ashara",surname:"Sajid",slug:"ashara-sajid",fullName:"Ashara Sajid"}],corrections:null},{id:"76572",title:"Xanthomonas citri ssp. citri Pathogenicity, a Review",doi:"10.5772/intechopen.97776",slug:"-em-xanthomonas-citri-em-ssp-em-citri-em-pathogenicity-a-review",totalDownloads:186,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"The infectious process of plant by bacteria is not a simple, isolated and fortuitous event. Instead, it requires a vast collection of molecular and cell singularities present in bacteria in order to reach target tissues and ensure successful cell thriving. The bacterium Xanthomonas citri ssp. citri is the etiological agent of citrus canker, this disease affects almost all types of commercial citrus crops. In this chapter we review the main structural and functional bacterial features at phenotypical and genotypical level that are responsible for the symptomatology and disease spread in a susceptible host. Biological features such as: bacterial attachment, antagonism, effector production, quorum sensing regulation and genetic plasticity are the main topics of this review.",signatures:"Juan Carlos Caicedo and Sonia Villamizar",downloadPdfUrl:"/chapter/pdf-download/76572",previewPdfUrl:"/chapter/pdf-preview/76572",authors:[{id:"192846",title:"Ph.D.",name:"Juan Carlos",surname:"Caicedo",slug:"juan-carlos-caicedo",fullName:"Juan Carlos Caicedo"},{id:"195946",title:"Dr.",name:"Sonia",surname:"Villamizar",slug:"sonia-villamizar",fullName:"Sonia Villamizar"}],corrections:null},{id:"74767",title:"Climate Change and Citrus",doi:"10.5772/intechopen.95488",slug:"climate-change-and-citrus",totalDownloads:638,totalCrossrefCites:1,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Climate change is the change in the statistical distribution of weather patterns that lasts for an extended period. Climate change and agriculture are interrelated processes and affect in many ways. Citrus fruits are one of the largest fruit crops in the world. Yield loss at a drastic level due to abiotic stress annually in which temperature and water stress are the main environmental factors. These factors cause biochemical, anatomical, physiological, and genetic changes in plant structure and lead to defective growth, development, and reproduction, which ultimately cause a reduction in the economic yield of the crop. An increase in temperature and water stress at critical phenological stages of citrus results in reduced tree fruit set, decrease in fruit growth and size, increase in fruit acidity, low tree yield, reduced fruit peel thickness, and pre-harvest fruit drop. Stomatal conductance and net carbon dioxide assimilation in citrus leaves can be reduced by super optimal leaf temperature. Water deficit reduces the transpiration rate, stomatal conductance by stomatal closure associated with ABA content and causes an abrupt decrease in photosynthesis and CO2 assimilation in citrus which reduce trees overall growth and production. Interventions in agronomic practices, breeding strategies, and biotechnological approaches can mitigate climate change effects on citrus. The groundwork against climate change is compulsory for better global livelihood and food security.",signatures:"Waqar Shafqat, Summar A. Naqvi, Rizwana Maqbool, Muhammad Salman Haider, Muhammad Jafar Jaskani and Iqrar A. Khan",downloadPdfUrl:"/chapter/pdf-download/74767",previewPdfUrl:"/chapter/pdf-preview/74767",authors:[{id:"341509",title:"Dr.",name:"Iqrar Ahmad",surname:"Khan",slug:"iqrar-ahmad-khan",fullName:"Iqrar Ahmad Khan"},{id:"331824",title:"Prof.",name:"Muhammad",surname:"Jaskani",slug:"muhammad-jaskani",fullName:"Muhammad Jaskani"},{id:"341502",title:"Dr.",name:"Summar",surname:"Naqvi",slug:"summar-naqvi",fullName:"Summar Naqvi"},{id:"341505",title:"Dr.",name:"Rizwana",surname:"Maqbool",slug:"rizwana-maqbool",fullName:"Rizwana Maqbool"},{id:"341507",title:"Dr.",name:"Muhammad",surname:"Haider",slug:"muhammad-haider",fullName:"Muhammad Haider"},{id:"341511",title:"Dr.",name:"Waqar",surname:"Shafqat",slug:"waqar-shafqat",fullName:"Waqar Shafqat"}],corrections:null},{id:"74981",title:"Citrus Fruits: Nutritive Value and Value-Added Products",doi:"10.5772/intechopen.95881",slug:"citrus-fruits-nutritive-value-and-value-added-products",totalDownloads:152,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Citrus fruits are essential sources of food and energy and play a critical role in supplementing healthy diets. Citrus fruits contain mostly carbohydrates such as sucrose, glucose, and fructose and are good dietary fiber sources, which help prevent gastrointestinal disease and promote high circulating cholesterol. Besides, citrus fruits are also significant sources of vitamin C and various bioactive compounds. It is suggested that these components are of vital importance in improving human health due to their antioxidant properties and being converted to vitamin A. However, citrus fruit is still being used for different purposes like juice, jam, jelly, squash, pies, cake, candies, marmalades, etc. Most citrus waste materials are currently used as animal feed. Innovations are occurring in the conversion of citrus by-products into valuable commodities with the development of innovative technologies. This chapter has put up primary and secondary research findings of citrus fruits, especially lemon and pomelo, their chemical properties, composition, and their use in health and cosmetic needs.",signatures:"Abu Saeid and Maruf Ahmed",downloadPdfUrl:"/chapter/pdf-download/74981",previewPdfUrl:"/chapter/pdf-preview/74981",authors:[{id:"262702",title:"Prof.",name:"Maruf",surname:"Ahmed",slug:"maruf-ahmed",fullName:"Maruf Ahmed"},{id:"262706",title:"Mr.",name:"Abu",surname:"Saeid",slug:"abu-saeid",fullName:"Abu Saeid"}],corrections:null},{id:"75024",title:"Citrus Essential Oils: A Suite of Insecticidal Compounds",doi:"10.5772/intechopen.95887",slug:"citrus-essential-oils-a-suite-of-insecticidal-compounds",totalDownloads:325,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Citrus essential oils (CEOs) and their constituent compounds are being reported to have multifarious activities. In this chapter an attempt is made to discuss the insecticidal activities, as well as CEO profile of different vegetative part of Citrus species and biocidal potentiality of their constituent compounds against diverse insect pests. It is observed that in most of the CEO constituent profile, limonene is the major constituent compound. Other important constituents present in different percentages in different CEOs are β-citronellal, linalool, pinene, β- caryophyllene, β-myrcene, terpinene, citral etc. These plant EO constituents are reported to have insecticidal effects against diverse insect species. Taking the four peel EOs of Citrus limon, Citrus paradisi, Citrus medica, Citrus maxima commonly grown in North Eastern part of India, study on their insecticidal effects against Dolichoderus affinis (Hymenoptera: Formicidae) was made and result is presented showing higher fumigant toxicity of C. medica and C. limon oil against the ant sp. With the increasing awareness for using safe insecticidal products among consumers, the citrus EOs with their attracting terpene compounds having good insecticidal potency bear all attributes to be used as commercial green pesticides in coming days both in indoor and outdoor management of insect pests.",signatures:"Bulbuli Khanikor, Kamal Adhikari and Bikash Rabha",downloadPdfUrl:"/chapter/pdf-download/75024",previewPdfUrl:"/chapter/pdf-preview/75024",authors:[{id:"147060",title:"MSc.",name:"Bulbuli",surname:"Khanikor",slug:"bulbuli-khanikor",fullName:"Bulbuli Khanikor"},{id:"334559",title:"Mr.",name:"Kamal",surname:"Adhikari",slug:"kamal-adhikari",fullName:"Kamal Adhikari"},{id:"334560",title:"Mr.",name:"Bikash",surname:"Rabha",slug:"bikash-rabha",fullName:"Bikash Rabha"}],corrections:null},{id:"75482",title:"The Orange Peel: An Outstanding Source of Chemical Resources",doi:"10.5772/intechopen.96298",slug:"the-orange-peel-an-outstanding-source-of-chemical-resources",totalDownloads:192,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"Citrus sinensis (L.) Osbeck is a very common cultivar belonging to the Rutaceae family. It is largely diffused in several areas of the world characterized by mild to warm climate conditions. Its abundant worldwide production (up to 107 Tons. per year) and consumption both as the edible part of the fruit and as several types of derivative products imply the production of a huge amount of waste, such as the fruit pomace. Several ways of recycling this material have been developed in recent years: employment as fertilizer, fodder ingredient, and even cloth material. However, the chemical added value of Citrus sinensis peel has been underestimated despite the diversified and significant content of useful chemicals, such as polyphenols, polymethoxylated phenols, glycosylated flavonoids, volatile and non-volatile terpenoids, pectins, enzymes, etc. This work aims to highlight the outstanding chemical potential of Citrus sinensis peel.",signatures:"Gianfranco Fontana",downloadPdfUrl:"/chapter/pdf-download/75482",previewPdfUrl:"/chapter/pdf-preview/75482",authors:[{id:"332243",title:"Assistant Prof.",name:"gianfranco",surname:"fontana",slug:"gianfranco-fontana",fullName:"gianfranco fontana"}],corrections:null},{id:"74926",title:"Physiological Functions Mediated by Yuzu (Citrus junos) Seed-Derived Nutrients",doi:"10.5772/intechopen.95534",slug:"physiological-functions-mediated-by-yuzu-em-citrus-junos-em-seed-derived-nutrients",totalDownloads:219,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"This section is focused on the physiological functions of yuzu (Citrus junos) to improve health. The modern lifestyle involves number of modern lifestyles involve various factors that may increase the production of active oxygen species. Nutritional supplements and medicines are commonly utilized to maintain health. Yuzu seeds contain >100-fold the limonoid content of grapefruit seeds and are rich in polyamines (PAs), including putrescine, spermidine, and spermine. Limonoid components mediate the antioxidant properties of citrus. Limonoids and PAs convey various bioactivities. PAs are closely associated with maintaining the function of the intestinal mucosal barrier, which might be involved in the metabolic processes of indigenous intestinal bacteria and in the health of the host. After ingestion, food is digested and absorbed in the intestinal tract, which is also responsible for immune responses against food antigens and intestinal bacteria. Detailed investigations of the physiological functions of extracted yuzu seed extracts may help to develop new treatment strategies against diseases associated with inflammatory responses.",signatures:"Mayumi Minamisawa",downloadPdfUrl:"/chapter/pdf-download/74926",previewPdfUrl:"/chapter/pdf-preview/74926",authors:[{id:"334893",title:"Associate Prof.",name:"Mayumi",surname:"Minamisawa",slug:"mayumi-minamisawa",fullName:"Mayumi Minamisawa"}],corrections:null},{id:"75090",title:"Nondestructive Assessment of Citrus Fruit Quality and Ripening by Visible–Near Infrared Reflectance Spectroscopy",doi:"10.5772/intechopen.95970",slug:"nondestructive-assessment-of-citrus-fruit-quality-and-ripening-by-visible-near-infrared-reflectance-",totalDownloads:277,totalCrossrefCites:3,totalDimensionsCites:4,hasAltmetrics:0,abstract:"As non-climacteric, citrus fruit are only harvested at their optimal edible ripening stage. The usual approach followed by producers and packinghouses to establish the internal quality and ripening of citrus fruit is to collect fruit sets throughout ripening and use them to determine the quality attributes (QA) by standard and, in many cases, destructive and time-consuming methods. However, due to the large variability within and between orchards, the number of measured fruits is seldom statistically representative of the batch, resulting in a fallible assessment of their internal QA (IQA) and a weak traceability in the citrus supply chain. Visible/near-infrared reflectance spectroscopy (Vis–NIRS) is a nondestructive method that addresses this problem, and has proved to predict many IQA of a wide number of fruit including citrus. Yet, its application on a daily basis is not straightforward, and there are still several questions to address by researchers in order to implement it routinely in the crop supply chain. This chapter reviews the application of Vis–NIRS in the assessment of the quality and ripening of citrus fruit, and makes a critical evaluation on the technique’s limiting issues that need further attention by researchers.",signatures:"Ana M. Cavaco, Dário Passos, Rosa M. Pires, Maria D. Antunes and Rui Guerra",downloadPdfUrl:"/chapter/pdf-download/75090",previewPdfUrl:"/chapter/pdf-preview/75090",authors:[{id:"332644",title:"Dr.",name:"Ana Margarida",surname:"Cavaco",slug:"ana-margarida-cavaco",fullName:"Ana Margarida Cavaco"},{id:"332662",title:"Prof.",name:"Rui",surname:"Guerra",slug:"rui-guerra",fullName:"Rui Guerra"},{id:"336109",title:"M.Sc.",name:"Rosa",surname:"Pires",slug:"rosa-pires",fullName:"Rosa Pires"},{id:"337423",title:"Dr.",name:"Dário",surname:"Passos",slug:"dario-passos",fullName:"Dário Passos"},{id:"345865",title:"Prof.",name:"Maria Dulce",surname:"Antunes",slug:"maria-dulce-antunes",fullName:"Maria Dulce Antunes"}],corrections:null},{id:"76078",title:"Electrochemical Applications for the Antioxidant Sensing in Food Samples Such as Citrus and Its Derivatives, Soft Drinks, Supplementary Food and Nutrients",doi:"10.5772/intechopen.96873",slug:"electrochemical-applications-for-the-antioxidant-sensing-in-food-samples-such-as-citrus-and-its-deri",totalDownloads:228,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Although there are many definitions of antioxidants, the most general description; antioxidants are carried a phenolic function in their structure and prevent the formation of free radicals or intercept from damage to the cell by scavenging existing radicals. Moreover, they are one of the most effective substances that contain essential nutrients for healthy individuals. The importance of these antioxidants, which have an incredible effect on the body and increase the body’s resistance, is increasing day by day for healthy individuals. Numerous studies have been carried out for antioxidants with excellent properties and however new, reliable, selective, sensitive and green analytical methods are sought for their determination at trace levels in food samples. Along with the latest developments, electrochemical methods are of great interest in the world of science because they are fast, reliable, sensitive and environmentally friendly. Electrochemical methods have been frequently applied to analyze antioxidant capacity in many nutrients samples found in different forms such as solid, liquid without any pretreatment applications in the last decade. Furthermore, these methods are preferred because of the short analysis time, the ability to lower detection limits, reduction in a solvent, high sensitivity, portability, low sample consumption, wide working range, and more economical than existing other traditional analytical methods. The antioxidant sensing applications by modern electrochemical methods such as cyclic, square wave, differential pulse, and combined with stripping voltammetric techniques were used to deduce antioxidant capacity (AC) in critical nutrients. Moreover, this chapter includes a description of the classification of electrochemical methods according to the working electrode type, dynamic working range, limit of determination (LOD), limit of quantification (LOQ), sample type, and using standard analyte and so forth for each voltammetric methods. While many articles applied for the determination of antioxidant sensing by electrochemistry have gained momentum in the last two decades, we focused on the studies conducted over the last 4 years in this chapter.",signatures:"Ersin Demir, Hülya Silah and Nida Aydogdu",downloadPdfUrl:"/chapter/pdf-download/76078",previewPdfUrl:"/chapter/pdf-preview/76078",authors:[{id:"331627",title:"Assistant Prof.",name:"Ersin",surname:"Demir",slug:"ersin-demir",fullName:"Ersin Demir"},{id:"356826",title:"Dr.",name:"Hülya",surname:"Silah",slug:"hulya-silah",fullName:"Hülya Silah"},{id:"356827",title:"Dr.",name:"Nida",surname:"Aydogdu",slug:"nida-aydogdu",fullName:"Nida Aydogdu"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"6976",title:"Transgenic Crops",subtitle:"Emerging Trends and Future 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Larynx plays role in phonation, respiration, airway protection, prevention of aspiration, and swallowing. The extrinsic muscles are associated with swallowing, while the prime function of intrinsic muscles is respiration and phonation.
Vocal cord refers to the immobility of vocal cord. It can be unilateral or bilateral. Both can be due to diseases affecting the vocal cord itself such as tumor or scarring; or due to paralysis of recurrent laryngeal nerve or superior laryngeal nerve.
The most common causes include laryngeal or extralaryngeal cancers, iatrogenic trauma during neck, thyroid gland, or chest surgery, and various neurogenic conditions (e.g., amyotrophic lateral sclerosis and closed head injury) [1, 2, 3, 4].
Vocal cord paralysis is most commonly unilateral. The affected vocal cords do not adduct or abduct properly causing voice disorder. Along with that there might be difficulty in swallowing. As for bilateral paralysis, breathing difficulty, choking, and aspiration are there along with voice change. The incidence of the bilateral vocal cords paralysis comprises around one-third of all vocal cord paralysis cases [2].
It requires interprofessional team of otolaryngologists, radiologists, and speech therapists in the evaluation and management of vocal cord paralysis.
Five positions of vocal cords are described traditionally (Table 1; Figure 1). The position of the vocal cords may not correlate with the severity and site of the lesion and, thus, is not a reliable indicator. As re-innervation occurs the position of the vocal cord often changes.
Position of vocal cords | Location of the cord from midline | Healthy | Diseased |
---|---|---|---|
Median | Midline | Phonation | RLN paralysis |
Paramedian | 1.5 mm | Strong whisper | RLN paralysis |
Intermediate(cadaveric) | 3 mm, this is the neutral position of vocal cords. | Paralysis of both RLN & SLN | |
Gentle abduction | 7 mm | Quite respiration | Paralysis of adductors |
Full abduction | 9 mm | Deep respiration | — |
Position of vocal cords from midline in healthy and diseased individuals.
Diagram showing different positions of vocal cords (FA—full abduction, SA—slight abduction, C—cadaveric, PM—paramedian, M—median).
Causes of vocal cord paralysis include
Supranuclear-stroke, tumor, meningitis, or head injury. Diffuse emboli in cerebral cortex may cause sustained abduction(aphonia) or inappropriate adduction(inspiratory stridor).
Nuclear-lesions of Nucleus ambigus in medulla, usually associated with other lower cranial N. paralysis, stroke, tumors, motor neuron disease, poliomyelitis, syringobulbia.
High vagal lesions—Intracranial: Tumors of posterior fossa, Basal meningitis(tubercular).
Jugular foramen (skull base): Fractures, nasopharyngeal cancer, Glomus tumor, skull base osteomyeltis.
Parapharyngeal space: Penetrating injury, parapharyngeal tumor, metastatic nodes, lymphoma.
Low vagal lesions or RLN: Most common cause, referTable 2.
Systemic causes: Diabetes mellitus, diphtheria, typhoid, lead poisoning, amyotrophic lateral sclerosis (ALS), Guillain-Barre syndrome(GBS).
Idiopathic—In around 30% of cases.
Right | Left | Both |
---|---|---|
Neck trauma | 1. Neck Accidental trauma | |
Benign or malignant thyroid disease | Benign or malignant thyroid disease | |
Thyroid surgery | Thyroid surgery | |
Carcinoma cervical esophagus | Carcinoma cervical esophagus | Thyroid surgery |
Cervical lymphadenopathy | Cervical lymphadenopathy | Carcinoma thyroid |
Subclavian artery aneurysm | 2. Mediastinum | Carcinoma cervical esophagus |
Carcinoma apex right lung | Bronchogenic carcinoma | Cervical lymphadenopathy |
Tuberculosis of cervical pleura | Carcinoma thoracic esophagus | |
Idiopathic | Aortic aneurysm | |
Mediastinal lymphadenopathy | ||
Enlarged left auricle | ||
Intrathoracic surgery | ||
Idiopathic |
Causes of recurrent laryngeal nerve paralysis (low vagal trunk or RLN).
Studies on comparison of patient demographics show no statistically significant difference in age, gender, or duration of symptoms. About one-third of UVCP cases are neoplastic in origin, one-third are post traumatic and one-third are idiopathic. Viral neuronitis probably accounts for most idiopathic cases. Paralysis of the left vocal cord is reported to be 1.4–2.5 times more than right [5].
RLN damage is the most common cause of vocal cord paralysis. Combined paralysis of RLN and SLN is also possible and is seen post-thyroidectomy surgeries due to iatrogenic trauma.
To understand the pathophysiology of vocal cord paralysis, it is of importance to know the origin and course of vagus nerve and its branches as they give rise to laryngeal sensory and motor supply.
Vagus nerve has two nuclei—nucleus ambiguous and dorsal nucleus of vagus. Nucleus ambiguous is situated in medulla and gives origin to motor efferent fibers to soft palate, pharynx, and larynx. Dorsal nucleus of vagus is an autonomic nucleus, which gives general efferent visceral fibers that supply smooth muscles and glands of trachea and bronchi, heart, and abdominal viscera.
The superior laryngeal nerve arises from inferior ganglion of vagus and descends behind internal carotid artery, and at the level of greater cornua of hyoid, it divides into internal and external branches. The internal branch travels medially along superior laryngeal branch of superior thyroid artery and pierces the thyrohyoid membrane about 1 cm anterior to greater cornu and about 1 cm above ala of thyroid cartilage. The nerve then runs submucosally in the lateral wall of pyriform fossa. It provides sensory innervation to the mucosa above the true vocal cords. The external branch runs along the posterior aspect of superior thyroid artery and proceeds inferiorly along oblique line of thyroid. As it reaches inferior constrictor muscle, it sends a branch and then passes deep to sternothyroid muscle to reach the cricothyroid muscle. It innervates the cricothyroid muscle (essential in changing the pitch of the voice). Isolated superior laryngeal nerve lesions are rare and it is usually part of combined paralysis. It results in loss of sensation above the level of true vocal cords and a husky voice.
On the right side, RLN arises from vagus in front of subclavian artery in lower part of neck, and it traversus below the subclavian artery after emerging from vagus nerve. RLN is derived from sixth arch and is displaced by arteries of previous arch, which necessitates change in direction and course of recurrent laryngeal nerve. The right recurrent laryngeal nerve stays lateral to the trachea-esophageal groove in the fat plane and comes closure to the groove as it crosses inferior thyroid artery. The left RLN has longer course and from its origin at the anterior surface of arch of aorta to the interspace between origin of left common carotid artery and subclavian artery. The nerve loops around arch of aorta distal to ligamentum arteriosum and then enters the neck, and lies deeper in the trachea-esophageal groove. Rest of the course is in similar on both sides, as RLN reaches the suspensory ligament of thyroid gland and lies on either medial or lateral from within. Then, it divides to supply the intrinsic muscles of larynx. Left RLN is more prone for injury as it has a longer course and injury most commonly occurs in the region of trachea-esophageal groove during thyroid or any other neck surgery.
There are two theories to explain the position of vocal cord in cases of cord paralysis. Semon’s law states that in the sequence of position of the vocal cords in slowly progressive organic central lesions, motor nerve fibers supplying the abductors of vocal cords become involved much earlier than adductors. Wegner and Grossman hypothesis explains the median and paramedian position of cords after RLN palsy, on the basis that cricothyroid muscle that receives supply from superior laryngeal nerve takes over & it has adductor and tensor function.
Patients with unilateral cord paralysis present with a sudden onset of change in voice, that is, dysphonia and/or transient aphonia. In addition to dysphonia, a significant proportion of patients present with swallowing difficulties, weak cough reflex, and regurgitation. Poor exercise tolerance with shortness of breath on minimal exertion is observed in many patients with UVCP in spite of normal lung function.
It is important to obtain elaborate history including the symptoms and signs pertaining to head and neck cancer. History of pain during swallowing, hemoptysis, neck nodes, referred ear pain, and significant weight loss should be asked. Past medical history including heart or lung disease, smoking, tobacco chewing, and alcohol consumption status are all important indicators of potential malignant disease. Clinical evaluation of the patient should include a complete otolaryngological examination, with particular attention to inspection and palpation of the neck. Flexible nasal endoscopy of the oropharynx and glottis helps forming the diagnosis. Assessment of voice quality can be graded with GRBAS scale (Grade, Roughness, Breathlessness, Aesthenia, Strain) [6], which has frequently shown the voice to be worse in such patients.
Flexible laryngoscopy of the glottis is the most useful method of evaluating appearance and movement of vocal cords. It is easily performed in the outpatient setting and can be combined with videostroboscopy to obtain a detailed overview of vocal cord movements (Figure 2).
Videolaryngoscopy showing left vocal cord paralysis post left hemithyroidectomy (a)abduction (b) adduction.
Videostrobscopy uses the same equipment as videolaryngoscopy combined with a microphone and flashing strobe light. During speech production, our vocal cords move at a very high speed, too fast to be perceived by naked human eyes. Stroboscopy is used to “slow down” the movement to study the detailed vocal cord movements such as amplitude, mucosal wave, vibratory pattern. It is a gold standard test in cases of voice disorders (Figure 3).
Videostroboscopy pictures showing right vocal cord paralysis.
A
Neck and laryngeal ultrasound can be used to assess vocal cord movement and investigate surrounding pathologies. However, ultrasound does not yield the same anatomical definition as CT requires an experienced ultrasonographer and is less reliable in obese patients.
Routine serological testing only aids in the diagnosis of a particular etiology. There is no strong evidence of them in helping form a diagnosis. Serum tests can be used in suspected inflammatory or infectious UVCP, with common tests including rheumatoid factor, antinuclear antibodies, serum ACE, lyme titer, and erythrocyte sedimentation rate (ESR).
Laryngeal electromyography can be used as a prognostic tool. It is an office-based procedure. A percutaneous EMG needle is inserted through the anterior part of neck to the muscles of the larynx and their electrophysiological evaluation is done. Although growing in popularity, the test is not widely available.
Patients with UVCP are initially treated with speech therapy. A “watchful waiting” period of 6 to 9 months is observed for spontaneous motion recovery by the opposite healthy vocal cord, as there is no definitive guidelines on how long a clinician should wait before surgical intervention.
The aim of surgery in cases of unilateral cord paralysis is cord medialization. The different surgical options are as follows:
Around one-third of patients of UVCP will experience motion recovery, due to the compensatory action of the opposite vocal cord [10]. Laryngeal electromyography is an useful tool to track prognosis in patients with persistent dysphonia [11].
The adverse effect on voice and swallowing can have a significant detrimental impact on the patient’s quality of life. Incomplete closure of the glottis can also lead to a risk of aspiration, and despite being rare, this can lead to life-threatening aspiration pneumonia. In particular, patients who rely on their voice for a living (teachers, singers, secretaries) may suffer significant psychological and financial difficulty as a result of UVCP.
The interprofessional team approach is better in diagnosing and managing cases of UVCP. Otolaryngologists can diagnose it with elaborate history, clinical examination, and flexible video laryngoscopy. Radiologists can aid in diagnosis through the study of the course of nerve involved or mediastinal lesion through CT /MRI imaging. Management can be done with speech therapy with the support of speech and language therapists and surgical treatment for those patients by otolaryngologists who do not respond to initial therapy.
The most common presentation of bilateral vocal cord paralysis is stridor [12]. These patients typically present with respiratory distress. In addition to considerable airway obstruction, bilateral vocal cord paralysis presents with symptoms common in unilateral vocal cord immobility such as ineffective cough, aspiration, recurrent pneumonia, reactive airway disease, and feeding difficulties [13, 14]. Voice and cry may be fairly normal in children with bilateral vocal cord paralysis [15].
As bilateral vocal cord paralysis occurs most commonly after iatrogenic trauma to recurrent laryngeal nerve, there is history of recent thyroid surgery in these patients. The incidence of the bilateral vocal cords paralysis comprises around one-third of all vocal cord paralysis cases. Bilateral cord paralysis is slightly more common in females, and it is attributed to the fact that thyroid diseases are more common in them as compared to males. Idiopathic bilateral paralysis cases show no gender preponderance and incidence is equal in both males and females.
RLN damage is the most common cause of bilateral vocal cord paralysis. Combined paralysis of RLN and SLN is also possible and is seen post-thyroidectomy surgeries due to iatrogenic trauma.
Bilateral vocal cord paralysis can be caused by injury to the vagus nerve near its origin or anywhere along its course or injury to its branches RLN and SLN through neck, thorax, and abdomen. Injury to the RLN is most common, classically leaving the vocal cords in a median position in case of bilateral vocal cord paralysis. Injury to the SLN will lower the pitch of the voice and can lead to a bowing deformity of the vocal cords due to a loss of tone from the dennervated cricothyroid muscles. A high vagal injury can leave the cord in a nearly fully abducted position.
A bilateral vocal cord paralysis patient most commonly presents with breathing difficulties such as stridor, increased work of breathing, and aspiration. It can be life-threatening and immediate measures that have to be taken to secure the airway. Voice in bilateral paralysis is usually of good quality but of limited intensity, changed pitch, and with voice fatigue. Any recent history of URI, any neck or mediastinal surgery or trauma, malignancy, radiation therapy, and a thorough past medical history should be obtained. A thorough physical examination is done, with an emphasis on the head and neck and lung examination.
Clinical diagnosis can be made based on flexible fiber-optic laryngoscopy, where the vocal cord position can be noted and are observed to be immobile. If the diagnosis is still uncertain, video stroboscopy and bronchoscopy can provide additional information about motion wave of the vocal cord vibrations and rule out subglottic and tracheal pathology, such as subglottic stenosis or tracheomalacia.
The investigations that aid in diagnosis are as follows:
Videolaryngoscopy pictures showing bilateral vocal cord paralysis.
In bilateral cord paralysis, patient adequate airway must be re-established. Common surgical options for management include tracheostomy, arytenoidectomy, and cordotomy. Laryngeal re-innervation techniques and botulinum toxin (Botox) injections into the vocal fold adductors have also been used with varying success rates. More recently, there has been research on neuromodulation, laryngeal pacing, gene therapy, and stem cell therapy. These newer approaches have the potential to recover the vocal cord movement without any anatomical destruction. However, clinical data are limited for these new treatment options, and more interventional studies are needed. These areas of research are expected to provide dramatic improvements in the treatment of bilateral cord paralysis in future.
Botulinum toxin injection to adductor muscles provides transient improvement in symptoms for approximately three to 6 months at a time, requiring repeated injections for longer-lasting relief.
Reinnervation techniques are technically challenging and require experienced surgeons in its use for the procedure to be a success. The goal here is to establish vocal cord abduction through the restoration of the activity of the posterior cricoarytenoid (PCA) muscle. While it enables the return of spontaneous vocal cord abduction, it does not affect adduction. Gene therapy and stem cell therapy are in preclinical stage but hold promising for treatment in future.
In adults, spontaneous recovery of idiopathic vocal cord paralysis can occur as early as 12 months following the onset. It is expected in 55% of patients, but full recovery can be very protracted. The prognosis for complete spontaneous recovery is far worse in bilateral vocal cord paralysis than unilateral. Recovery depends upon the underlying etiology.
Bilateral cord paralysis can lead to the following complications: Stridor, airway obstruction, dyspnea, poor cough reflex, aspiration, bronchopneumonia due to aspiration, difficulty in swallowing, feeding difficulties, and failure to thrive in children & voice fatigue. In addition to this, in the long-run arytenoid granuloma formation and chondritis may occur.
Bilateral vocal cord paralysis is a challenging and troublesome entity. Tracheostomy, cordotomy, and arytenoidectomy all have been applied with positive outcomes in bilateral cord paralysis cases. Management should be individualized based on the patient’s clinical presentation and the surgeon’s expertise.
Vocal cord fixation is immobility of vocal cords due to scarring or due to mass effect, involvement of muscles, and joints or the nerve as in case of malignancy. Cord fixation can also be due to rheumatoid arthritis. There may be obvious swelling around cricoarytenoid joint, cord is immobile and fixed, its position does not correspond to any of the described anatomical positions of vocal cords, and aryepiglottic folds are normal. There is no change in position on applying pressure passively on arytenoids, which is in contrast to vocal cord paralysis. Also, in cases of fixation there is absence of any neurological symptoms and signs. In cases of vocal cord paralysis, aryepiglottic folds are paralyzed and pushed aside, cord is fixed to median or paramedian position, but there is no fixation of the joint and it is mobile on manipulating passively. Also, cord paralysis is purely a neurological condition in contrast to cord fixation.
Vocal cord paralysis presents more commonly as stridor in neonates and children. It can be unilateral or bilateral in children, unilateral being more common. Vocal cord paralysis is the second most common cause of stridor in pediatric population following laryngomalacia and accounts for 10% of all congenital anomalies of larynx. Murty et al. estimate the incidence of bilateral vocal cord paralysis to be 0.75 cases per million births per year. Congenital vocal cord paralysis should be part of the differential diagnosis for an infant with respiratory distress. In up to 48–62% of neonates and children with bilateral vocal cord paralysis, spontaneous recovery of vocal cord function can occur, but the prognosis rests with the overall health of the child and any concomitant medical problems [19].
Birth trauma due to vertex or breech delivery and the use of forceps can also lead to RLN injury, though less commonly a bilateral injury [20]. In infants, cardiovascular surgery, including patent ductus arteriosus ligation, and repair of a tracheoesophageal fistula are the common causes of bilateral vocal cord paralysis [21]. Table 3 summarizes causes of congenital vocal cord paralysis.
Unilateral | Bilateral |
---|---|
More common | Causes |
Causes | Hydrocephalus |
Birth trauma | Arnold-chiari malformation |
Congenital anomaly of | Intracerebral hemmorrhage |
Great vessels of heart | Myelomeningocele |
Cerebral agenesis |
Causes of congenital vocal cord paralysis.
A detailed family and perinatal histories, including prolonged or protracted or forceps-assisted delivery, concurrent congenital conditions and length of any NICU stay, should be inquired. Presenting symptoms in children include stridor, a weak cry, feeding difficulties, failure to thrive, and aspiration. Neonates and children with bilateral cord paralysis are likely to exhibit severe manifestation such as cyanosis and apnea. Bilateral cases usually have good voice because vocal cords are in median or paramedian position with abductor paralysis but can have marked inspiratory stridor and accessory muscles of respiration working.
Diagnosis can be made by awake fiber-optic laryngoscopy and careful evaluation of the larynx by an experienced pediatric otolaryngologist. Laryngomalacia should be considered as differential diagnosis and ruled out during laryngoscopy, which is far more common than bilateral vocal cord paralysis but can have similar presenting symptoms.
If the diagnosis is still uncertain, direct laryngoscopy and bronchoscopy can be performed under general anesthesia. This is done with the patient spontaneously breathing so the motion of the vocal cords can be assessed intraoperatively. This also allows lower airway examination to rule out concurrent or alternate pathology such as subglottic stenosis and trachea- or bronchomalacia.
Before surgical treatment is considered, parents are advised to position the child so that he or she is sitting up and to thicken the food in order to manage feeding difficulties and milk regurgitation. If gastroesophageal reflux is suspected, then this should also be treated. In addition, all children with vocal cord paralysis should be seen by a speech pathologist. Greater than 50% of children will undergo spontaneous symptom resolution in the first 12 months of life, though the prognosis is much more guarded for bilateral vocal cord paralysis cases when compared with unilateral [22].
There are no definite guidelines on when to perform surgery and the decision is difficult since in children spontaneous recovery may occur anytime over the years. It should be guided according to the individual case. In general, for cases of bilateral palsy destructive procedures such as cordotomy or arytenoidectomy are advised to be deferred till adolescence.
Tracheostomy is needed and should be performed to improve the airway in bilateral vord paralysis cases, even if spontaneous recovery is expected. Patient can be decanulated once vocal cord recovery occurs.
An integrated diagnostic and treatment program is necessary for patients with vocal cord paralysis. Otolaryngologists, speech therapist, and radiologists all play important role in evaluation and management. Treatment strategies should be individualized based on the patient’s clinical presentation and the surgeon’s expertise.
I would like to express my gratitude to the faculty members of the department and the management for giving their valuable suggestions and inputs. Special mention and thanks to Dr. Hukam singh and Dr. Avinash goswami for their encouragement and support in making this chapter possible.
The author declares no conflict of interest.
recurrent laryngeal nerve
superior laryngeal nerve
unilateral vocal cord paralysis
computer tomographic imaging
magnetic resonance imaging
electromyography
amyotropic lateral sclerosis
Guillain-Barre syndrome
Grade, Roughness, Breathlessness, Aesthenia, Strain
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Although POP can occur in younger women, it is commonly seen in aging population with a prevalence of 45–50%. Older terms describing pelvic organ prolapse (e.g., cystocele, urethrocele, rectocele) have been replaced because they do not provide complete information regarding the structures on the other side of the vaginal bulge, especially in women who have had previous pelvic organ prolapse surgery. Therefore, a thorough history and performing a careful physical examination with dignity and care, using some basic tools that aid in the accurate evaluation of anatomical and functional defects, should be conducted. 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