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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Anatomy of the Larynx - Motion
Adductors of the Vocal Folds:
1/10/2012

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

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

17. 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

18. 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

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

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

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

22. 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

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

24. 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

25. 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

26. 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

27. 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

28. Evaluation - Videostroboscopy
Demonstrates subtle mucosal motion abnormalities
1/10/2012

29. 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

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

31. 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

32. 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

33. Evaluation – Unilateral Paralysis
Manual Compression Test
1/10/2012

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

35. 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

36. 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

37. 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

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

39. 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

40. 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

41. 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

42. 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

43. 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

44. Cordotomy
1/10/2012

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

46. 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

47. 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

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

49. 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

50. 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

51. 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

52. 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

53. Management – Unilateral Paralysis Vocal Cord Injection
1/10/2012

54. 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

55. Management – Unilateral Paralysis Type I Thyroplasty
1/10/2012

56. Medialization Laryngoplasty
1/10/2012

57. Medialization Laryngoplasty
1/10/2012

58. 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

59. Arytenoid Adduction
1/10/2012

60. Management – Unilateral Paralysis Arytenoid Adduction
1/10/2012

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

62. 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

63. 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

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

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

66. Tracheostomy:
Emergency
elective
1/10/2012

67. 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

68. For more ENT topics, please visit www.nayyarENT.com
To upload your presentations, kindly them to
1/10/2012