approach to a patient with vocal cord paralysis

APPROACH TO A PATIENT WITH VOCAL CORD PARALYSIS

EPIDEMIOLOGY• Acquired and congenital• Asymptomatic: 30-50%• Incidence increases with age.• left recurrent laryngeal nerve is more

frequently involved: lung ca, esophageal ca, aortic aneurysm, tuberculosis, sarcoidosis, lymphoma,

mediastinal Tm etc.• Surgical etiology more frequent than tumors.

Unilateral vocal fold palsy• Iatrogenic:

Nonthyroidthyroid

• Malignancy :LungNon lung

• Idiopathic• Neurogenic• Intubation• Trauma• Aortic/cardic• other

• 30.6%• 15.7%

• 6.6%• 6.9%• 17.6%• 7.9%• 4.4%• 2.2%• .6%• 12.6%

Bilateral vocal cord palsy

• Iatrogenic:ThyroidNon thyroid

• Malignancy• Intubation• Neurological• Trauma• others

• 55.5%• 48.6%• 6.9%• 9.7%• 8.3%• 6.9%• 1.4%• 8.4%

Vagus nerve

Causes of laryngeal palsy

• Supranuclear• Nuclear: vascular, neoplastic, motor, neuron

disease, polio and syringomyelia.• High vagal lesion: skull, jugular foramen or in

parapharyngeal space• Low vagal• Systemic causes• Idiopathic: 30%

Causes of combined palsy• Intracranial: Tumors of posterior fossa, basal

meningitis .

• Skull base: fracture, nasopharyngeal Tumors and glomus Tumors

• Neck: penetrating injury, parapharyngeal Tumors, metastatic nodes and lymphoma.

Causes of RLN paralysis

RIGHT(15%)• Neck trauma• Thyroid surgery• Ca cx esophagus• Cx LAP• Subclavian artery

aneurysm• Ca apex of lung• idiopathic

LEFT(75%)• Neck

Mediastinal • Bronchogenic Ca• Ca thoracic esophagus• Aortic aneurysm• Mediastinal LAP• Enlarged left

auricle(oatner’s syndrome)• idiopathic

Approach to patient with vocal cord palsy

Voice change

• Mode of onset

• Duration• Progressive, intermittent or constant.• Aggravating and relieving factors.• Effortful phonation• Vocal fatigue

acute

insidious

• H/o preceding URI, trauma, vocal abuse, surgery. Associated Throat symptoms

• Throat pain• Discomfort, dryness or soreness, frequent

clearing, burning sensation. Cough

• With or without sputum or blood• Diurnal variation• Aggravating factors : after meals or on lying

down.

• relieving factors

Breathing difficulty

• Duration• Mode of onset• Progressive• Noisy breathing• Chocking

Difficult swallowing• Duration

• Onset

• For liquids/solids

• Pain

• Progressive or non progressive

H/o:• trauma• Fever with evening rise• Weight loss• Decrease appetite• Swelling neck or other sites of body• Symptoms of hyper/hypothyroidism• Chest pain• Weakness & numbness

Past history• Trauma• Viral infection or URI• Previous surgery • Prolonged intubation• Drug intake• DM/ Tuberculosis/ HT• radiation

Family history• DM , HT, tuberculosis• Heart disease• Carcinoma• Neurogenic disorders

Personal history• Tobacco chewing• Smoking• Alcohol intake• Sleep habits

Professional history

EXAMINATIONGeneral physical examination.

• Build and nourishment• Vitals• Pallor, ictreus, anemia, clubbing, LAP,JVP• Cranial nerve examination.• Chest examination• CVS examination• GIT examination

LOCAL EXAMINATIONVoice evaluation(perceptual)

Quality: - normal( 50% Pt with u/l RLN or SLN palsy) - mild to moderately breathy( u/l SLN) - mod to severe breathy (u/l RLN) - hoarse

- mild to moderate or severe hypernasality - strained

• loudness: Soft

• Pitch• Reduced

• High ( paralytic falsetto )

• Pitch breaks

• Diplophonia ( u/l palsy)

• Weak cough

Quantitative analysis• Magneting tape recording• Performance assesment: MFT & range of speech

frequencies• Phonetogram: pitch vs. intensity• Spectogram: time, frequency and amplitude

• Aerodynamics analysis: phonatory airflow rate, subglottic air pressure & air volume.

Fourier’s spectral analysis:• Fundamental frequency: sustaining a single

tone at fundamental frequency.

• Shimmer: avg cycle to cycle difference in amplitude of sound

• Jitter: avg cycle to cycle difference in pitch of sound.

ENT examinationNose and PNS

Lips, vestibule, oral cavity and oropharynx

Palatopharyngeal gag reflex reduced or absent, inability to elevate soft palate.

Neck examination

Inspection: -laryngeal framework - swelling

Palpation: - laryngeal crepitus - swelling - lymph nodes

Indirect laryngoscopy• BOT, Vallecula, epiglottis, vocal

cord, arytenoids, pyriform fossa.

• Vocal cords: appearance, position at rest, in relation to each other, symmetry, glottic closure, movements in quite breathing and vocalization.

• ee sniff test : maximum adduction and abduction.

Features • U/L SLN palsy: during phonation.• Usually normal and difficult to appreciate• Floppy, lower level of paralysed cord.• Askew position of glottis• Short, bowed and bulky cords • hyperemia of hemilarynx ( loss of sympathetic

nerve supply)

• B/L SLN palsy: difficult to detect.• Epiglottis hangs over due to anterior tilt of larynx.• Cords are flaccid, bowed and hyperemic.• Guttmann’s test: frontal pressure on the thyroid

cartilage will normally lower voice pitch by counteracting cricothyroid, whereas lateral pressure has opposite effect.

• RLN palsy ( abductor palsy):• Cord is not mobile• Floppy• Flickers on phonation• Paralysed cord balloons out on phonation• Arytenoid crosses midline • B/L : cord in median position

- tends to limit activity- URTI precipitates laryngeal obstruction

Combined paralysis U/L: healthy cord not able to approximate paralysed cord

• Glottic incompetence.

Bilateral combined: • Cords lie in cadaveric position

• Aphonia & aspiration.

Adavntages: simple opd procedure, max information.

Disadvantages: brief duration, anterior glottic not seen, depth perception handicapped, ventricles , post cricoid, apex of pyriform sinus not seen and mucosal waves cannot be seen

• Vocal cord position: 6 positions not valid anymore

• Semon’s law • Wager & grossman hypothesis

• Modern theory: final position not static depends on – degree of muscle atrophy & fibrosis

- degree of reinnervation -Extent of synkinesis of musclesThree positions: abduction, adduction and

midline

Specific investigations of cord movement

• Rigid 70° video- telescopy.• Fiberoptic video laryngoscopy.

• Laryngostroboscopic: glottic closure pattern evaluation - mucosal wave in response - of pitch

and loudness- Lesion- Vocal fold opening and closing pattern- Supraglottic appearance- Symmetry of arytenoids

LARYNGEAL ELECTROMYOGRAPHY

Gold standard• Degree of paralysis & prognosis• Differiating from mechanical fixation of CA joint• Neurological diagnosis• Site of lesion• Synkinesis & dysfunction reinnervation• Intaoperative nerve monitoring• Therapeutic inspection• Biofeedback in speech & swallowing disorder.

INVESTIGATIONSVocal cord palsy is not a disease per se, it’s just a sign of underlying disease.

57% of cases can be diagnosed by taking proper history and detailed examination

Routine : CBC , RBS, SE, VDRL and LFT, barium swallow & thyroid scan.

low diagnostic yield ( usually not recommended)

Radiological chest xray:- secondaries, primary carcinoma,

apiration pneumonia, metastatic lymph nodes, aortic arch aneurysm and TB. (54% diagnostic yield)

No other detectable lesion: contrast CT ( skull base to aortic arch)

No mass lesion – idiopathic.Palatal & pharyngeal paralysis and other

neuropathies: gadolinium enhanched MRI skull base and neck.

If negative- HRCT temporal bone for bony mets

• Flexible or rigid esophagoscopy with biopsy.

Treatment Unilateral vocal fold palsy

Known permanent etiology/ unknown etiology > 9 months

Healthy pt, no aspiration

Healthy pt, with aspiration

sick pt, with or w/o aspiration

VOICE THERAPY PHONOSURGERY

Temporary or unknown etiology < 9 months

Healthy pt,no aspiration

Healthy pt,with aspiration & strong need of voice

sick pt, with or w/o aspiration

VOICE THERAPY TEMPORARY AUGMENTATION

after 9 months

DEFINITE PHONOSURGERY

• Educational information regarding phonation

• Vocal hygiene: voice rest, avoid shouting, talking loudly, clearing throat

- adequate hydration- steam inhalation - smoking cessation, reducing alcohol,- Diet and reflux reduction

VOICE THERAPY

• Vocal exercise : strengthening the muscle groups, improving glottic closure and efficiency.

• Reducing excessive tension in muscles around larynx, neck and shoulders.

• Advice on posture and breathing during speech• Laryngeal massage• General relaxation exercise• Psychological counseling.

Bilateral vocal cord paralysis• Tracheostomy

• Posterior transverse cordotomy( CO2 laser)

• Medial arytenoidectomy

• Total arytenoidectomy

• Endo-extralaryngeal suture.

• Laryngeal pacing.

In cases of contraindication• Epiglottopexy

• Vocal cord plication

• Total laryngectomy: cause is progressive, irreversible and speech is unservicable.

• Diversion procedures: intractable aspiration

PHONOSURGERYTYPES :• Microlaryngosurgery

• Laryngeal injection

• Laryngeal framework surgery

• Nerve pedicle rinnervation

• Laryngeal injection techniques:- for phonatory gap in u/l abductor or adductor palsy

• Teflon, fat, collagen, gelfoam, silicone etc

Laryngeal framework surgery

• THYROPLASTY: type 1( medial displacement)

• Arytenoid adduction: large posterior glottic gap.

• Laryngeal reinnervation: nerve muscle pedicle graft technique.

• Anterior belly of omohyoid with ansa hypoglossi and vessels.

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