vocal cord paralysis
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Vocal cord Paralysis
Moderator: DR.AVS HANUMANTHA RAO Professor, ent,head&neck surgery Done by: DR. POLUNAIDU pg in ent
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It is a sign of disease and not a diagnosis.
Introduction:
Paralysis is the term used to describe the
complete loss of voluntary motor
function(movement) due to neural or muscular disorder
Where as paresis is reduced, but incomplete abolition of voluntary
movement,
In clinical laryngology, nerve disorders are by far
more frequently found than muscle
disorder
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LARYNX HAS TWO MAJOR FUNCTIONS
To protect airway
As organ of voice
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The Vagus The vagus nerve has
three nuclei located within the medulla:
1. The nucleus
ambiguus
2. The dorsal
nucleus
3. The nucleus of the
tract of solitarius
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The nucleus ambiguus is the motor nucleus of the vagus nerve.
• The efferent fibers of the dorsal (parasympathetic) nucleus innervate the involuntary muscles of the bronchi, esophagus, heart, stomach, small intestine, and part of the large intestine.
The afferent fibers of the nucleus of the tract of solitarius carry sensory fibers from the pharynx, larynx, and esophagus
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As the vagus descends in jugular foramen, it widens to form superior ganglion, as it exits jugular foramen it widens again to form nodose ganglion
Here it gives off pharyngeal nerve to supply all striated muscles of soft palate & pharynx excepts tensor veli palatini & stylopharyngeus.
Superior laryngeal nerve exits the vagus at the inferior border of nodose ganglion & passes medial to internal & external carotids, then passes superomedial to superior thyroid, about 2cm from the nodose ganglion the nerve divides in to external & internal branches
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The superior laryngeal nerve branches into internal and external branches.
The internal superior laryngeal nerve penetrates the thyrohyoid membrane to supply sensation to the larynx above the glottis.
The external superior laryngeal nerve innervates the one muscle of the larynx not innervated by the recurrent laryngeal nerve, the cricothyroid muscle.
Nerve of galen is a small branch which arises from internal laryngeal to anastomose with the posterior branch of recurrent nerve to form ansa galeni
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The right vagus passes anterior to the subclavian artery and gives off the right recurrent laryngeal. This loops around the subclavian and ascends in the tracheo-esophageal groove, before it enters the larynx just behind the cricothyroid joint.
The left vagus does not give off its recurrent laryngeal nerve until it is in the thorax, where the left recurrent laryngeal nerve wraps around the aorta just posterior to the ligamentum arteriosum. It then ascends back toward the larynx in the TE groove.
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Anatomy of larynxLarynx is a midline structure, extending from root of tongue to trachea, it lies in front of c3 to c6. in children & females it lies at higher level.PARTS OF LARYNX- larynx consists of skeletal framework of cartilages connected by joints , ligaments& membranes ,cartilages are moved by no. of muscles .The cavity is lined by mucus membrane
Cartilages: 1, unpaired- epiglottis thyroid cricoid 2, paired- arytenoid cuneiform(c. of wrisberg) corniculate(c. of santorini)
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Ligaments& membranes:Thyrohyoid membrane(extrinsic)Thyrohyoid ligamentCricothyroid membrane(extrinsic)Cricovocal membrane(internal)Cricotracheal membrane(extrinsic)Quadrangular membrane(internal)Anterior commissure tendon(broyle’s ligament)Hyoepiglottic ligamentCricothyroid ligament
Joints:Cricothyroidcricoarytenoid
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The Laryngeal Musculature All The intrinsic muscles of the larynx are paired except transverse
interarytenoid. , all of which are innervated by the recurrent laryngeal nerve, except crico thyroid,
Muscles which change size and shape of inlet of larynx: aryepiglottic & oblique arytenoid
Muscles which move vocal cord: abductors: posterior cricoarytenoid - only abductor
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Lateral cricoarytenoid - - functions to close glottis by rotating arytenoids medially.
Transverse arytenoid - - only unpaired muscle of the larynx. Functions to approximate bodies of arytenoids closing posterior aspect of glottis.
Oblique arytenoid - - this muscle plus action of transverse arytenoid function to close laryngeal introitus during swallowing.
Adductors:
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Thyroarytenoid - - very broad muscle, usually divided into three parts: Thyroarytenoideus internus (vocalis) - adductor
and major tensor of free edge of vocal fold. Thyroarytenoideus externus - major adductor of
vocal fold Thyroepiglotticus - shortens vocal ligaments
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Anatomy of the Larynx - Motion Adductors of the Vocal Folds:
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Position of vocal cords
A, median
B,3.5 mm gap
C,cadaveric(intermediate)
D,full abduction(9.5mm)
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Causes of vocal cord paralysis
Malignant : This accounts for 25% of cases, one half being caused by carcinoma of lung
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Causes of vocal cord paralysisSurgical/Traumatic: (20% cases)• Thyroidectomy• Pneumonectomy• Penetrating neck or chest trauma.• Post intubation• Whiplash injuries• Posterior fossa surgery
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Causes of vocal cord paralysisNeurological (5-10%) • Wallenberg syndrome (lateral medullary stroke)• Syringomyelia• Encephalitis• Parkinsons, • Poliomyelitis• Multiple Sclerosis• Myasthenia Gravis, • Guillian-Barre• Diabetes
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Causes of vocal cord paralysisInflammatory:• Rheumatoid arthritis ,( really a "fixed" cord
here)
Infectious:• Syphilis• Tuberculosis• Thyroiditis• Viral
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Causes of vocal cord paralysisIdiopathic (20-25%):•Sarcoidosis, •Lupus•Polyarteritis nodosa•Ortner's syndrome (left atrial hypertrophy).
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Intracranial causes
Distinctive features
Other neurological signs and symptoms due to combined paralysis of soft palate, pharynx and larynx
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Cranial
Fracture base of skull
• Juglar foramen lesions (Glomus tumours, Naspharyngeal Carcinoma)
• Skull base osteomyelitis
Distinctive features
• Other cranial nerve palsies (IX,X,XI)
• Pharyngeal, superior and Recurrent Laryngeal nerve
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Neck
Thyroidectomy
Thyroid Tumours
Post Cricoid Carcinoma
Malignant Cervical Lymphnodes
Distinctive features
Superior and Recurrent Laryngeal nerves involved
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Chest
Bronchogenic Carcinoma
Cardiothoracic Surgery
Aortic Aneurysm
Mediastinal Lymphadenopathy
Tracheal/Oesophageal surgery
Distinctive feature
• Involvement of Left Recurrent Laryngeal Nerve
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Classification of laryngeal paralysis
Laryngeal paralysis may be unilateral or bilateral, and may involve:• Recurrent laryngeal nerve• Superior laryngeal nerve.• Both recurrent and superior laryngeal
nerves(combined or complete paralysis
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Evaluation – Patient History
Alcohol and Tobacco Usage Voice Abuse URI and Allergic Rhinitis Reflux oesophagitis Neurologic Disorders History of Trauma or Surgery Systemic Illness – Rheumatoid Duration – Affects Prognosis
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Evaluation – Physical ExaminationComplete Head and Neck Examination
Flexible Fiberoptic Laryngoscopy
90 degree Hopkins Rod-lens Telescope
Adequacy of Airway, Gross Aspiration
Assess Position of Cords
• Median, Paramedian, Lateral• Posterior Glottic Gap on Phonation
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Evaluation - Videostroboscopy
Demonstrates subtle mucosal motion abnormalities
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Evaluation - Electromyography
Assesses integrity of laryngeal nerves
Differentiates denervation from mechanical obstruction of vocal cord movement
Electrode placed in Thyroarytenoid and Cricothyroid
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Evaluation - ElectromyographyNormal• Joint Fixation
Fibrillation• Denervation
Polyphasic• Synkinesis• Reinnervation1/10/2012 www.nayyarENT.com 30
Evaluation - Imaging
Chest X-ray• Screen for intrathoracic lesions
MRI of Brain• Screen for CNS disorders
CT Skull Base to Mediastinum
Direct Laryngoscopy• Palpate arytenoids, especially when no L-EMG
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Evaluation – Unilateral Paralysis
Preoperative Evaluation• Speech Therapy• Assess patient’s vocal requirements• Do not perform irreversible
interventions in patients with possibility of functional return for 6-12 months
• Surgery often not necessary in paramedian positioning
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Evaluation – Unilateral ParalysisManual Compression Test
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Evaluation – Unilateral Paralysis
Assess extent of posterior glottic gap
Consider consent for both anterior and posterior medialization procedures
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Semon’s law:
Which states that in all progressive organic lesions , abductor fibers of the nerve , which are phylogenetically newer, are more susceptible and thus the first to be paralysed compared to adductor fibers
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“In the absence of cricoarytenoid joint fixation, an immobile vocal cord in paramedian position has total pure unilateral recurrent nerve paralysis, and an immobile vocal cord in lateral position has a combined paralysis of superior and recurrent nerves (the adductive action of cricothyroid muscle is lost)”
Wegner and Grossman Theory
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Unilateral Superior Laryngeal Nerve Injury Normal vocal fold position during quiet respiration.
Noticeable deviation of posterior commissure to paralyzed side during phonatory effort
At rest, the vocal fold on paralyzed side is slightly shortened and bowed, and may be depressed below level of normal side.
Isolated lesions of this nerve are rare, it is a part of combined paralysis.
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Pictures of Vocal Fold Paralysis
Recurrent Laryngeal N. Paralysis
Unilateral left vocal fold paralysis (Superior N. Paralysis)
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Unilateral Superior Laryngeal Nerve Injury
Loss of sensation to the supraglottic larynx can cause subtle symptoms such as frequent throat clearing, paroxysmal coughing, voice fatigue,Monotonous. vague foreign body sensations.
Loss of motor function to cricothyroid muscle can cause a slight voice change, which the patient usually interprets as hoarseness. Most common finding is diplophonia (with decreased range of pitch, most noticeable when trying to sing.
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Unilateral Recurrent Laryngeal Nerve Injury Nonfunction of the intrinsic muscles of the larynx on the affected side (loss of abduction with intact adduction by cricothyroid) cause the vocal cord to assume a paramedian position.
The voice is breathy but compensation occurs, though rarely back to normal.
The airway is adequate and may become compromised only with exertion.
Shallow pyriform fossa,arytenoid falls forward
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Bilateral Recurrent Laryngeal Nerve InjuryUsually result of damage to both
RLN by direct trauma.
Cords lie in paramedian position
Voice is good
Variable degree of stridor & dyspnoea
Worse on exertion or during an attack of acute laryngitis
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ManagementBilateral Abductor Paralysis
Patients exhibit lack of abduction during inspiration, but good phonation
Maintenance of airway is the primary goal
Airway preservation often damages an otherwise good voice
Expiration
Inspiration
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ManagementBilateral Abductor ParalysisTracheostomy• Gold standard• Most adults will require this• Speaking valves aid in phonation
Laser Cordectomy
Laser Cordotomy
Woodman Arytenoidectomy
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Cordotomy
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Vocal cord lateralisation through endoscopre
Thyroplasty type 2
Nerve musle implant
ManagementBilateral Abductor Paralysis
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Bilateral Abductor ParalysisPhrenic to Posterior Cricoarytenoid anastamosis• Allows abduction during inspiration• Preserves voice when successful
Electrical Pacing
• Timed to inspiration with electrode placed on posterior cricoarytenoid
• Long-term efficacy not yet shown
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1. Uncommon
2. Inhalation of food & pharyngeal secretions giving rise to cough and choking fits
3. Voice is weak and husky
Bilateral superior laryngeal nerve palsy
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treatment1.Tracheostomy with a cuffed tube and an oesophageal feeding tube2.epiglottopexy
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Unilateral combined paralysisParalysis of all muscles except interarytenoiod which also receives innervation from opposite side
Thyroid surgery is the most common cause
Also results in lesions of brain, jugular foramen or parapharyngeal space
Vocal cord lie in cadaveric position
Healthy cord unable to compensate results in glottic incompetence
This results in hoarseness & aspiration of liquids
Cough is ineffective due to air waste 1/10/2012 www.nayyarENT.com 49
management1.Speech therapy2.Medialisation of cord(static procedures) a, injection of teflon paste
b, thyroplasty type 1
c, muscle or cartilage implant
d, arthodesis of cricoarytenoid joint
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Management – Unilateral ParalysisVocal Cord Injection Adds fullness to the vocal cord to help it better appose the other side
Injection technique is similar regardless of material used
Injection into thyroarytenoid/vocalis
Injection can be done endoscopically or percutaneiously
Poor correction of posterior glottic gap
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Management – Unilateral ParalysisVocal Cord Injection
External landmarks – several mm anterior to oblique line horizontally, midpoint between thyroid notch and inferior thyroid border vertically
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Management – Unilateral ParalysisVocal Cord Injection
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Management – Unilateral ParalysisVocal Cord Injection - MaterialsTeflon
Fat
Collagen• Autologous Collagen• Homologous Micronized Alloderm (Cymetra)• Heterologous Bovine Collagen (Zyderm
Hyaluronic Acid
Calcium Hydroxyapatite gel (Radiance FN)
Polydimethylsiloxane gel (Bioplastique)
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Management – Unilateral ParalysisType I Thyroplasty
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Medialization Laryngoplasty
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Medialization Laryngoplasty
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Management – Unilateral ParalysisArytenoid Adduction
Arytenoid Adduction• First described by Ishiki with modifications
by Zeitels and others• Addresses posterior glottic gap by pulling
arytenoid into adducted position• Difficult to predict which patients will benefit
preoperatively.• Most advocate use in combination with
anterior medialization 1/10/2012 www.nayyarENT.com 58
Arytenoid Adduction
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Management – Unilateral ParalysisArytenoid Adduction
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Complications•Sutures too tight – may displace arytenoid complex anteriorly, adversely affecting voice
•Entry of piriform sinus
Management – Unilateral ParalysisArytenoid Adduction
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Management – Unilateral ParalysisReinnervation(dynamic procedures)
Results in synkynetic tone of vocal cord
Ansa to Recurrent Laryngeal Nerve
Ansa to Omohyoid to Thyroarytenoid
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Management – Unilateral ParalysisReinnervation(dynamic procedures)
Hypoglossal to recurrent laryngeal nerve
Crossed nerve grafts or wire conduction prostheses from one muscle to its paralyzed counterpart are being researched
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Bilateral combined paralysis
Rare condition
Both cords in cadaveric position
Total anaesthesia of larynx
Aphonia & aspiration
Inability to cough
bronchopneumonia
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Management – bilateral ParalysisTracheostomy
Epiglottopexy
Vocal cord plication
Total laryngectomy
Divertion procedures
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Tracheostomy:
Emergency
elective
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Conclusions – Key Points
Management – Unilateral Paralysis• Anterior and Posterior Glottic gap must be
addressed• Arytenoid adduction is irreversible• Continued improvement up to 1yr after Type I
thyroplasty
Management – Bilateral Paralysis• Preservation of airway is most important goal
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