Vocal cord Paralysis Moderator DR AVS HANUMANTHA RAO

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

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. 1/10/2012 www. nayyar. ENT. com 2

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

The Vagus The vagus nerve has three nuclei located within the medulla: 1. The nucleus ambiguus 1/10/2012 2. The dorsal nucleus www. nayyar. ENT. com 3. The nucleus of the tract of solitarius 4

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. nayyar. ENT. com 5

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 2 cm from the nodose ganglion the nerve divides in to external & internal branches 1/10/2012 www. nayyar. ENT. com 6

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. nayyar. ENT. com 7

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. nayyar. ENT. com 8

Anatomy of larynx Larynx is a midline structure, extending from root of tongue to trachea, it lies in front of c 3 to c 6. 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) 1/10/2012 www. nayyar. ENT. com 9

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. nayyar. ENT. com 10

The Laryngeal Musculature n n n 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. nayyar. ENT. com 11

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. nayyar. ENT. com 12

n Thyroarytenoid - - very broad muscle, usually divided into three parts: q Thyroarytenoideus internus (vocalis) - adductor and major tensor of free edge of vocal fold. q Thyroarytenoideus externus - major adductor of vocal fold q Thyroepiglotticus - shortens vocal ligaments 1/10/2012 www. nayyar. ENT. com 13

Anatomy of the Larynx - Motion n Adductors of the Vocal Folds: 1/10/2012 www. nayyar. ENT. com 14

Position of vocal cords A, median B, 3. 5 mm gap C, cadaveric(intermediate) D, full abduction(9. 5 mm) 1/10/2012 www. nayyar. ENT. com 15

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

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. nayyar. ENT. com 17

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. nayyar. ENT. com 18

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

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

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

Cranial Fracture base of skull • Juglar foramen lesions (Glomus tumours, Naspharyngeal Carcinoma) • Skull base osteomyelitis 1/10/2012 Distinctive features • Other cranial nerve palsies (IX, X, XI) • Pharyngeal, superior and Recurrent Laryngeal nerve www. nayyar. ENT. com 22

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

Chest Bronchogenic Carcinoma Cardiothoracic Surgery Aortic Aneurysm Mediastinal Lymphadenopathy Tracheal/Oesophageal surgery 1/10/2012 Distinctive feature • Involvement of Left Recurrent Laryngeal Nerve www. nayyar. ENT. com 24

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. nayyar. ENT. com 25

Evaluation – Patient History n n n n 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. nayyar. ENT. com 26

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. nayyar. ENT. com 27

Evaluation - Videostroboscopy Demonstrates subtle mucosal motion abnormalities 1/10/2012 www. nayyar. ENT. com 28

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. nayyar. ENT. com 29

Evaluation - Electromyography Normal • Joint Fixation Fibrillation • Denervation Polyphasic • Synkinesis • Reinnervation 1/10/2012 www. nayyar. ENT. 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 1/10/2012 www. nayyar. ENT. com 31

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. nayyar. ENT. com 32

Evaluation – Unilateral Paralysis Manual Compression Test 1/10/2012 www. nayyar. ENT. com 33

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

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. nayyar. ENT. com 35

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. nayyar. ENT. com 36

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. nayyar. ENT. com 37

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

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. nayyar. ENT. com 39

Unilateral Recurrent Laryngeal Nerve Nonfunction of the intrinsic muscles of the larynx Injury 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. nayyar. ENT. com 40

Bilateral Recurrent Laryngeal Nerve Injuryresult of damage to both Usually 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. nayyar. ENT. com 41

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 1/10/2012 www. nayyar. ENT. com 42

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. nayyar. ENT. com 43

Cordotomy 1/10/2012 www. nayyar. ENT. com 44

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

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. nayyar. ENT. com 46

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. nayyar. ENT. com 47

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

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. nayyar. ENT. com 49

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. nayyar. ENT. com 50

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. nayyar. ENT. com 51

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. nayyar. ENT. com 52

Management – Unilateral Paralysis Vocal Cord Injection 1/10/2012 www. nayyar. ENT. com 53

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. nayyar. ENT. com 54

Management – Unilateral Paralysis Type I Thyroplasty 1/10/2012 www. nayyar. ENT. com 55

Medialization Laryngoplasty 1/10/2012 www. nayyar. ENT. com 56

Medialization Laryngoplasty 1/10/2012 www. nayyar. ENT. com 57

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. nayyar. ENT. com 58

Arytenoid Adduction 1/10/2012 www. nayyar. ENT. com 59

Management – Unilateral Paralysis Arytenoid Adduction 1/10/2012 www. nayyar. ENT. com 60

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. nayyar. ENT. com 61

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. nayyar. ENT. com 62

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. nayyar. ENT. com 63

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

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

Tracheostomy: Emergency elective 1/10/2012 www. nayyar. ENT. com 66

Conclusions – Key Points Management – Unilateral Paralysis • Anterior and Posterior Glottic gap must be addressed • Arytenoid adduction is irreversible • Continued improvement up to 1 yr after Type I thyroplasty Management – Bilateral Paralysis • Preservation of airway is most important goal 1/10/2012 www. nayyar. ENT. com 67

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