Vocal cord Paralysis Moderator: DR.AVS HANUMANTHA RAO Professor, ent,head&neck surgery Done by: DR. POLUNAIDU pg in ent 1/10/2012 www.nayyarENT.com

Introduction: It is a sign of disease and not a diagnosis. 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 It is a sign of disease and not a diagnosis. 1/10/2012 www.nayyarENT.com

To protect airway As organ of voice LARYNX HAS TWO MAJOR FUNCTIONS 1/10/2012 www.nayyarENT.com

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 1/10/2012 www.nayyarENT.com

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 1/10/2012 www.nayyarENT.com

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 1/10/2012 www.nayyarENT.com

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 1/10/2012 www.nayyarENT.com

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. 1/10/2012 www.nayyarENT.com

Anatomy of larynx Larynx 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) 1/10/2012 www.nayyarENT.com

Joints: Ligaments& membranes: Thyrohyoid membrane(extrinsic) Thyrohyoid ligament Cricothyroid membrane(extrinsic) Cricovocal membrane(internal) Cricotracheal membrane(extrinsic) Quadrangular membrane(internal) Anterior commissure tendon(broyle’s ligament) Hyoepiglottic ligament Cricothyroid ligament Joints: Cricothyroid cricoarytenoid 1/10/2012 www.nayyarENT.com

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 1/10/2012 www.nayyarENT.com

Adductors: 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. 1/10/2012 www.nayyarENT.com

Thyroarytenoideus externus - major adductor of vocal fold 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 1/10/2012 www.nayyarENT.com

Anatomy of the Larynx - Motion Adductors of the Vocal Folds: 1/10/2012 www.nayyarENT.com

Position of vocal cords A, median B,3.5 mm gap C,cadaveric(intermediate) D,full abduction(9.5mm) 1/10/2012 www.nayyarENT.com

Causes of vocal cord paralysis Malignant : This accounts for 25% of cases, one half being caused by carcinoma of lung 1/10/2012 www.nayyarENT.com

Causes of vocal cord paralysis Surgical/Traumatic: (20% cases) Thyroidectomy Pneumonectomy Penetrating neck or chest trauma. Post intubation Whiplash injuries Posterior fossa surgery 1/10/2012 www.nayyarENT.com

Causes of vocal cord paralysis Neurological (5-10%) Wallenberg syndrome (lateral medullary stroke) Syringomyelia Encephalitis Parkinsons, Poliomyelitis Multiple Sclerosis Myasthenia Gravis, Guillian-Barre Diabetes 1/10/2012 www.nayyarENT.com

Causes of vocal cord paralysis Inflammatory: Rheumatoid arthritis ,( really a "fixed" cord here) Infectious: Syphilis Tuberculosis Thyroiditis Viral 1/10/2012 www.nayyarENT.com

Causes of vocal cord paralysis Idiopathic (20-25%): Sarcoidosis, Lupus Polyarteritis nodosa Ortner's syndrome (left atrial hypertrophy). 1/10/2012 www.nayyarENT.com

Intracranial causes Distinctive features Other neurological signs and symptoms due to combined paralysis of soft palate, pharynx and larynx 1/10/2012 www.nayyarENT.com

Cranial Fracture base of skull Distinctive features 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 1/10/2012 www.nayyarENT.com

Neck Distinctive features Thyroidectomy Thyroid Tumours Post Cricoid Carcinoma Malignant Cervical Lymphnodes Distinctive features Superior and Recurrent Laryngeal nerves involved 1/10/2012 www.nayyarENT.com

Distinctive feature Chest Bronchogenic Carcinoma Cardiothoracic Surgery Aortic Aneurysm Mediastinal Lymphadenopathy Tracheal/Oesophageal surgery Distinctive feature Involvement of Left Recurrent Laryngeal Nerve 1/10/2012 www.nayyarENT.com

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 1/10/2012 www.nayyarENT.com

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 1/10/2012 www.nayyarENT.com

Evaluation – Physical Examination Complete 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 1/10/2012 www.nayyarENT.com

Evaluation - Videostroboscopy Demonstrates subtle mucosal motion abnormalities 1/10/2012 www.nayyarENT.com

Evaluation - Electromyography Assesses integrity of laryngeal nerves Differentiates denervation from mechanical obstruction of vocal cord movement Electrode placed in Thyroarytenoid and Cricothyroid 1/10/2012 www.nayyarENT.com

Evaluation - Electromyography Normal Joint Fixation Fibrillation Denervation Polyphasic Synkinesis Reinnervation 1/10/2012 www.nayyarENT.com

Evaluation - Imaging Chest X-ray MRI of Brain 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 1/10/2012 www.nayyarENT.com

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 1/10/2012 www.nayyarENT.com

Evaluation – Unilateral Paralysis Manual Compression Test 1/10/2012 www.nayyarENT.com

Evaluation – Unilateral Paralysis Assess extent of posterior glottic gap Consider consent for both anterior and posterior medialization procedures 1/10/2012 www.nayyarENT.com

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 1/10/2012 www.nayyarENT.com

Wegner and Grossman Theory “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)” 1/10/2012 www.nayyarENT.com

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. 1/10/2012 www.nayyarENT.com

Pictures of Vocal Fold Paralysis Unilateral left vocal fold paralysis (Superior N. Paralysis) Recurrent Laryngeal N. Paralysis 1/10/2012 www.nayyarENT.com

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. 1/10/2012 www.nayyarENT.com

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 1/10/2012 www.nayyarENT.com

Bilateral Recurrent Laryngeal Nerve Injury Usually 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 1/10/2012 www.nayyarENT.com

Management Bilateral 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 Inspiration Expiration 1/10/2012 www.nayyarENT.com

Management Bilateral Abductor Paralysis Tracheostomy Gold standard Most adults will require this Speaking valves aid in phonation Laser Cordectomy Laser Cordotomy Woodman Arytenoidectomy 1/10/2012 www.nayyarENT.com

Cordotomy 1/10/2012 www.nayyarENT.com

Management Bilateral Abductor Paralysis Vocal cord lateralisation through endoscopre Thyroplasty type 2 Nerve musle implant 1/10/2012 www.nayyarENT.com

Bilateral Abductor Paralysis Phrenic 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 1/10/2012 www.nayyarENT.com

Bilateral superior laryngeal nerve palsy 1. Uncommon 2. Inhalation of food & pharyngeal secretions giving rise to cough and choking fits 3. Voice is weak and husky 1/10/2012 www.nayyarENT.com

treatment 1.Tracheostomy with a cuffed tube and an oesophageal feeding tube 2.epiglottopexy 1/10/2012 www.nayyarENT.com

Unilateral combined paralysis Paralysis 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

2.Medialisation of cord(static procedures) management 1.Speech therapy 2.Medialisation of cord(static procedures) a, injection of teflon paste b, thyroplasty type 1 c, muscle or cartilage implant d, arthodesis of cricoarytenoid joint 1/10/2012 www.nayyarENT.com

Management – Unilateral Paralysis Vocal 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 1/10/2012 www.nayyarENT.com

Management – Unilateral Paralysis Vocal Cord Injection External landmarks – several mm anterior to oblique line horizontally, midpoint between thyroid notch and inferior thyroid border vertically 1/10/2012 www.nayyarENT.com

Management – Unilateral Paralysis Vocal Cord Injection 1/10/2012 www.nayyarENT.com

Management – Unilateral Paralysis Vocal Cord Injection - Materials Teflon Fat Collagen Autologous Collagen Homologous Micronized Alloderm (Cymetra) Heterologous Bovine Collagen (Zyderm Hyaluronic Acid Calcium Hydroxyapatite gel (Radiance FN) Polydimethylsiloxane gel (Bioplastique) 1/10/2012 www.nayyarENT.com

Management – Unilateral Paralysis Type I Thyroplasty 1/10/2012 www.nayyarENT.com

Medialization Laryngoplasty 1/10/2012 www.nayyarENT.com

Medialization Laryngoplasty 1/10/2012 www.nayyarENT.com

Management – Unilateral Paralysis 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

Arytenoid Adduction 1/10/2012 www.nayyarENT.com

Management – Unilateral Paralysis Arytenoid Adduction 1/10/2012 www.nayyarENT.com

Management – Unilateral Paralysis Arytenoid Adduction Complications Sutures too tight – may displace arytenoid complex anteriorly, adversely affecting voice Entry of piriform sinus 1/10/2012 www.nayyarENT.com

Management – Unilateral Paralysis Reinnervation(dynamic procedures) Results in synkynetic tone of vocal cord Ansa to Recurrent Laryngeal Nerve Ansa to Omohyoid to Thyroarytenoid 1/10/2012 www.nayyarENT.com

Management – Unilateral Paralysis Reinnervation(dynamic procedures) Hypoglossal to recurrent laryngeal nerve Crossed nerve grafts or wire conduction prostheses from one muscle to its paralyzed counterpart are being researched 1/10/2012 www.nayyarENT.com

Bilateral combined paralysis Rare condition Both cords in cadaveric position Total anaesthesia of larynx Aphonia & aspiration Inability to cough bronchopneumonia 1/10/2012 www.nayyarENT.com

Management – bilateral Paralysis Tracheostomy Epiglottopexy Vocal cord plication Total laryngectomy Divertion procedures 1/10/2012 www.nayyarENT.com

Tracheostomy: Emergency elective 1/10/2012 www.nayyarENT.com

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 1/10/2012 www.nayyarENT.com

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