Download Laryngeal Paralysis

Vocal cord Paralysis
Moderator: DR.AVS HANUMANTHA RAO
Professor, ent,head&neck surgery
Done by: DR. POLUNAIDU pg in ent
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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
It is a sign of disease and not a diagnosis.
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LARYNX HAS TWO MAJOR FUNCTIONS
To protect
airway
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As organ
of voice
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The Vagus
The vagus
nerve has
three nuclei
located within
the medulla:
1. The
nucleus
ambiguus
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2. The
dorsal
nucleus
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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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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 LARYNXlarynx 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 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
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The Laryngeal Musculature
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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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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.
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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 paralysis
Surgical/Traumatic: (20%
cases)
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Thyroidectomy
Pneumonectomy
Penetrating neck or chest trauma.
Post intubation
Whiplash injuries
Posterior fossa surgery
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Causes of vocal cord paralysis
Neurological (5-10%)
•
•
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•
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•
•
•
•
Wallenberg syndrome (lateral medullary stroke)
Syringomyelia
Encephalitis
Parkinsons,
Poliomyelitis
Multiple Sclerosis
Myasthenia Gravis,
Guillian-Barre
Diabetes
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Causes of vocal cord paralysis
Inflammatory:
• Rheumatoid arthritis ,( really a "fixed" cord
here)
Infectious:
•
•
•
•
Syphilis
Tuberculosis
Thyroiditis
Viral
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Causes of vocal cord paralysis
Idiopathic (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
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Distinctive
features
• Other cranial nerve
palsies (IX,X,XI)
• Pharyngeal,
superior and
Recurrent
Laryngeal nerve
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Neck
Thyroidectomy
Distinctive features
Thyroid Tumours
Post Cricoid
Carcinoma
Malignant Cervical
Lymphnodes
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Superior and
Recurrent
Laryngeal nerves
involved
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Chest
Bronchogenic Carcinoma
Cardiothoracic Surgery
Aortic Aneurysm
Mediastinal Lymphadenopathy
Tracheal/Oesophageal surgery
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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
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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 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
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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 - Electromyography
Normal
• Joint Fixation
Fibrillation
• Denervation
Polyphasic
• Synkinesis
• Reinnervation
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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 Paralysis
Manual 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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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)”
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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
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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 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
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Management
Bilateral Abductor Paralysis
Patients exhibit lack of
abduction during inspiration,
but good phonation
Maintenance of airway is the
primary goal
Inspiration
Airway preservation often
damages an otherwise good
voice
Expiration
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Management
Bilateral Abductor Paralysis
Tracheostomy
• 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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Management
Bilateral Abductor Paralysis
Vocal cord lateralisation through
endoscopre
Thyroplasty type 2
Nerve musle implant
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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
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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
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treatment
1.Tracheostomy with a cuffed
tube and an oesophageal
feeding tube
2.epiglottopexy
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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
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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
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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
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Management – Unilateral Paralysis
Vocal 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 Paralysis
Vocal Cord Injection
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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)
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Management – Unilateral Paralysis
Type I Thyroplasty
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Medialization Laryngoplasty
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Medialization Laryngoplasty
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Management – Unilateral Paralysis
Arytenoid 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
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Arytenoid Adduction
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Management – Unilateral Paralysis
Arytenoid Adduction
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Management – Unilateral Paralysis
Arytenoid Adduction
Complications
• Sutures too tight – may
displace arytenoid complex
anteriorly, adversely affecting
voice
• Entry of piriform sinus
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Management – Unilateral Paralysis
Reinnervation(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 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
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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 Paralysis
Tracheostomy
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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