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VOCAL CORD PALSY

DEPT OF ENT, HEAD AND NECK SURGERY

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VOCAL CORD PALSY

  • WHAT IS VOCAL CORD PALSY ?
  • NERVE SUPPLY AND MOVEMENT OF LARYNX
  • FUNCTION OF LARYNX
  • TYPES OF VOCAL CORD PALSY
  • CLINICAL FEATURES
  • MANAGEMENT OF V.C. PALSY

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CRANIAL NERVES

IV Trochlear

III Oculomotor

VII Facial

VI Abducens

V Trigeminal

CEREBRAL

HEMISPHERE

MIDBRAIN

PONS

MEDULLA

II Optic

I Olfactory

VIII Acoustic

XII Hypoglossal

XI Accessory

X Vagus

IX Glossopharyngeal

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NERVE SUPPLY

  • SUPERIOR LARYNGEAL NERVE
    • SUPRA-GLOTTIC AFFERENT (INT.)
    • CRICOTHYROID MUSCLES (EXT.)
  • RECURRENT LARYNGEAL NERVE
    • MOTOR TO ALL INTRINSIC MUSCLES
    • SENSORY TO INFRA-GLOTTIC AREA

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Anatomy of Larynx - Nerves

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Anatomy of Larynx - Nerves

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ANATOMY OF LARYNX

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ANATOMY - MUSCLES

  • ADDUCTORS
    • THYROARYTENOID
    • LATERAL CRICOARYTENOID
    • INTERARYTENOID
    • CRICOTHYROID
  • ABDUCTORS
    • POSTERIOR CRICOARYTENOID

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  • THYROARYTENOID
    • TENSE
    • ADDUCTS
    • RECC LARYNGEAL NERVE
  • LATERAL CRICOARYTHENOID
  • INTERARYTHENOID
    • ADDUCTS
    • RECC LARYNGEAL NERVE

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CRICOTHYROID

  • ADDUCTS
  • TENSE
  • SUPERIOR LARYNGEAL NERVE

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POSTERIOR CRICOARYTHENOID

  • ONLY ABDUCTOR
  • RECCURANT LARYNGEAL NERVE

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FUNCTION OF LARYNX

  • AIRWAY PROTECTION
  • PHONATION
  • RESPIRATION
  • FIXATION OF CHEST

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Respiration

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VOCAL CORD PALSY- TYPES

  • RECURRENT LARYNGEAL NERVE PALSY
  • SUPERIOR LARYNGEAL NERVE PALSY
  • COMBINED PALSY
    • CAN BE
      • UNILATERAL
      • BILATERAL

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  • ABDUCTOR PALSY
  • ADDUCTOR PALSY
  • UNILATERAL
  • BILATERAL

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Semon’s law

  • It states that abductor fibres & adductor fibres lie in separate bundles and
  • Abductor fibres are phylogenetically newer fibres &
  • Hence these are more vulnerable to damage
  • Moreover, the adductors have a protective action for the larynx to prevent the entry of foreign bodies & hence these are stronger than abductors
  • Reversal phenomenon occurs in recovery

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Semon’s law …progression

  • Stage 1: only abductor fibers are affected and the vocal cords approximate in the midline and adduction is still possible

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  • Stage 2: additional contracture of adductors occurs so that vocal cords are immobilized in the median position

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  • Stage 3: adductors become paralysed and the vocal cords assume cadaveric position

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Wagener & Grossman’s theory

  • In the absence of cricoarytenoid fixation, an immobile cord in the paramedian position -unilateral RLN paralysis
  • An immobile cord in cadaveric position- combined paralysis of superior & recurrent laryngeal nerves & it is due to the absence of adductive action of cricothyroid muscle

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  • SEMON’S LAW

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  • HISTORICAL IMPORTANCE
  • 1ST ABDUCTOR PALSY(MEDIAN POSITION)
  • LATER ADDUCTOR

(CADAVERIC POSITION)

  • WAGNER AND GROSSMAN THEORY

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  • TOTAL PURE RECCURENT PALSY- CORD IN MEDIAN POSITION
  • COMBINED PALSY-

CORD IN CADAVERIC POSITION

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CAUSES

RIGHT

LEFT

BOTH

  • NECK
  • TRAUMA
  • BENIGN NECK LESION
  • THYROID SURGERY
  • THYROID DISEASE
  • CARCINOMA OESOPHAGUS
  • LUNG APEX CA
  • T.B APEX LUNG
  • IDIOPATHIC
  • SKULL BASE LESION

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  • NECK
  • TRAUMA
  • THYROID DISEASE
  • THYROID SURGERY
  • CA OESOPHAGUS
  • LUNG APEX CA
  • T.B APEX LUNG
  • CERVICAL LYMPHADEOPATHY
  • MEDIASTINUM
  • BRONCHOGENIC CARCINOMA
  • ENLARGED LEFT AURICLE
  • INTRA THORACIC SURGERY
  • MEDIASTINAL LYMPHADENOPATHY/GROWTH
  • IDIOPATHIC
  • SKULL BASE LESION
  • THROID SURGERY
  • CARCINOMA THYROID
  • CA OESOPHAGUS
  • CERVICAL LYMPHADENITIS
  • IDIOPATHIC

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RECCURENT LARYNGEAL NERVE PALSY

Cause

Unilateral %

Bilateral %

Surgery

24

26

Idiopathic

20

13

Malignancy

25

17

Trauma

11

11

Neurologic

8

13

Intubation

8

18

Other

5

5

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CLINICAL FEATURES

  • USUALLY ASYMTOMATIC
  • CHANGE OF VOICE
  • NO ASPIRATION
  • NO RESPIRATORY DISTRESS
  • IDL
    • IMMOBILE V.C IN PARAMEDIAN
    • COMPENSATORY MOVEMENT FROM OPPOSITE SIDE

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MANAGEMENT

  • DIAGNOSE THE CAUSE
  • TREAT THE CAUSE
  • NO SPECIFIC TREATMENT REQUIRED

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BILATERAL (RLP)ABDUCTOR PARALYSIS

  • CAUSE
    • IDIOPATHIC
    • THYROID SURGERY
  • SYMPTOMS
    • DIFFICULTY IN BREATHING
    • STRIDOR
    • GOOD VOICE
  • IDL / VIDEO LARYNGOSCOPY
    • BOTH CORDS IN PARAMEDIAN POSITION

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MANAGEMENT

  • TRACHEOSTOMY
  • LATERALISATION OF VOCAL CORD
    • ARYTHENOIDECTOMY
    • TYPE II THYROPLASTY
    • CORDECTOMY
      • ENDOSCOPIC
      • LASER ASSISTED
    • NERVE TRANSPLANT

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SUPERIOR LARYNGEAL PALSY (UNILATERAL)

  • RARE
  • RESULTS IN CRICOTHYRID WEAKNESS
  • ISPILATERAL ANAESTHESIA
  • CLINICAL FEATURE
    • WEAK VOICE
    • OCCAIONAL ASPIRATION
    • COUGH
    • IDL
      • ASYMENTRICAL GLOTTIS
      • SHORTENING OF CORD
      • FLAPPING OF PARALYSED CORD
      • ARYTHENOID FALLEN FORWARD

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MANAGEMENT

  • SYMTOMATIC
  • REASSURANCE
  • TRACHEOSTOMY WITH CUFFED TUBE
  • MEDIALISATION THYROPLASTY

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BILATERAL

  • UNCOMMON VERY RARE
  • WEAK VOICE
  • ASPIRATION
  • MANAGEMENT
    • TRACHEOSTOMY CUFFED TUBE
    • EPIGLOTTOPEXY

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COMBINED PARALYSIS (UNILATERAL) ADDUCTOR

  • CAUSE
    • THYROID SURGERY
    • SKULL BASE LESION
    • INTRA CRANIAL LESION
  • CLINICAL FEATURE
    • HOARSE/ WEAK VOICE
    • ASPIRATION
    • COUGH
    • IDL
      • CORD IN CADAVERIC POSITION(3.5MM)

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MANAGEMENT

  • CAUSE
  • TREATMENT OPTIONS
  • VOCAL FOLD INJECTION
  • MEDIALISATION THYROPLASTY (TYPE I)
  • ARYTENOID ADDUCTION

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  • RE-INNERVATION

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BILATERAL

  • VERY RARE
  • FUNCTIONAL
  • BOTH CORD IN CADEVERIC POSITION
  • ANAESTESIA OF LARYNX
  • APHONIA
  • ASPIRATION
  • INABILITY TO COUGH

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MANAGEMENT

  • TRACHEOSTOMY
  • EPIGLOTTOPEXY
  • VOCAL CORD PLICATION
  • LARYNGECTOMY

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PATIENT EVALUATION

  • HISTORY
    • CHIEF COMPLAINT
      • HOARSENESS, BREATHINESS
      • DYSPHAGIA, COUGHING, CHOKING, ASPIRATION, STRIDOR
    • ONSET, DURATION, VARIABILITY, PAST VOCAL PROBLEMS
    • MEDICAL HISTORY
      • ALLERGIES, REFLUX, LIFE STRESS, DIABETES, MEDICATION
    • SURGICAL HISTORY
      • HEAD AND NECK SURGERY, CHEST SURGERY, TRAUMA

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PATIENT EVALUATION

  • VOCAL
    • VOICE DEMANDS
    • SINGING
    • EPISODES ABUSE
    • SMOKING
    • WATER INTAKE
    • CAFFEINE
    • ENVIRONMENTAL IRRITANTS

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PATIENT EVALUATION

  • PHYSICAL EXAM
    • GENERAL HEAD AND NECK EXAMINATION
      • IMPORTANT: NECK PALPATION INCLUDING THYROID
      • CRANIAL NERVE EXAM
    • INDIRECT LARYNGOSCOPY
      • EVALUATE ATROPHY, MOVEMENT OF VOCAL CORDS
      • ASSES ANTERIOR AND POSTERIOR GLOTTIC GAP WITH ADDUCTION

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PATIENT EVALUATION

  • FIBEROPTIC LARYNGOSCOPY
    • EVALUATE RUNNING SPEECH
  • DIRECT LARYNGOSCOPY
    • RULE OUT ARYTENOID JOINT FIXATION

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VOCAL CORD PARALYSIS

  • SPECIFIC WORK-UP
    • IMPORTANT TO PALPATE ARYTENOIDS TO RULE OUT JOINT FIXATION
    • CHEST X-RAY
    • CT SCAN
      • FROM SKULL BASE TO MEDIASTINUM
    • MRI
      • PREFERRED FOR CHILDREN, PREGNANT WOMEN, AND SUSPECTED CENTRAL NEUROLOGIC ABNORMALITY

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Phonosurgery

  • Phonosurgery is any surgery designed primarily for the improvement or restoration of voice.
  • Phonosurgery is therefore not restricted to one or more surgical techniques but is defined by its intended functional goal.

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Classification of (primary) phonosurgery

  • Vocal fold surgery (VFS)
  • Laryngeal framework surgery (LFS)
  • Neuromuscular surgery (NMS)
  • Reconstructive surgery (RCS)
  • – Partial defect of the larynx
  • – Total loss of the larynx

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Classification of (primary) phonosurgery

  • 1. Excision of benign or malignant lesions by microlaryngeal surgery or laser.
  • 2. Injection of vocal cord with teflon paste or gelfoam to augment and medialise the paralysed cord so that the opposite healthy cord can easily approximate.
  • 3. Thyroplasty.
  • 4. Laryngeal reinnervation procedures. In this, a segment of anterior belly of omohyoid muscle, carrying its nerve (ansa hypoglossi) and vessels, is implanted into the thyroarytenoid muscle after making a window in thyroid cartilage. It is supposed to innervate the paralysed thyroarytenoid muscle.

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Thyroplasty

  • Isshiki divided thyroplasty procedures into four categories to produce functional alteration of vocal cords.
    • (a) Type I. It is medial displacement of vocal cord as is achieved in teflon paste injection.
    • (b) Type II. It is lateral displacement of vocal cord and is used to improve the airway.
    • (c) Type III. It is used to shorten (relax) the vocal cord. Relaxation of vocal cord lowers the pitch. This procedure is done in mutational falsetto or in those who have undergone gender transformation from female to male.
    • (d) Type IV. This procedure is used to lengthen (tighten) the vocal cord and elevate the pitch. It converts male character of voice to female and has been used in gender transformation. It is also used when vocal cord is lax and bowing due to aging process or trauma.

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