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APPROACH TO A PATIENT WITH VOCAL CORD PARALYSIS

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APPROACH TO A PATIENT WITH VOCAL CORD PARALYSIS
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Page 1: APPROACH TO A PATIENT WITH VOCAL CORD PARALYSIS

APPROACH TO A PATIENT WITH VOCAL CORD PARALYSIS

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EPIDEMIOLOGY• Acquired and congenital• Asymptomatic: 30-50%• Incidence increases with age.• left recurrent laryngeal nerve is more

frequently involved: lung ca, esophageal ca, aortic aneurysm, tuberculosis, sarcoidosis, lymphoma,

mediastinal Tm etc.• Surgical etiology more frequent than tumors.

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Unilateral vocal fold palsy• Iatrogenic:

Nonthyroidthyroid

• Malignancy :LungNon lung

• Idiopathic• Neurogenic• Intubation• Trauma• Aortic/cardic• other

• 30.6%• 15.7%

• 6.6%• 6.9%• 17.6%• 7.9%• 4.4%• 2.2%• .6%• 12.6%

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Bilateral vocal cord palsy

• Iatrogenic:ThyroidNon thyroid

• Malignancy• Intubation• Neurological• Trauma• others

• 55.5%• 48.6%• 6.9%• 9.7%• 8.3%• 6.9%• 1.4%• 8.4%

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Vagus nerve

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Causes of laryngeal palsy

• Supranuclear• Nuclear: vascular, neoplastic, motor, neuron

disease, polio and syringomyelia.• High vagal lesion: skull, jugular foramen or in

parapharyngeal space• Low vagal• Systemic causes• Idiopathic: 30%

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Causes of combined palsy• Intracranial: Tumors of posterior fossa, basal

meningitis .

• Skull base: fracture, nasopharyngeal Tumors and glomus Tumors

• Neck: penetrating injury, parapharyngeal Tumors, metastatic nodes and lymphoma.

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Causes of RLN paralysis

RIGHT(15%)• Neck trauma• Thyroid surgery• Ca cx esophagus• Cx LAP• Subclavian artery

aneurysm• Ca apex of lung• idiopathic

LEFT(75%)• Neck

Mediastinal • Bronchogenic Ca• Ca thoracic esophagus• Aortic aneurysm• Mediastinal LAP• Enlarged left

auricle(oatner’s syndrome)• idiopathic

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Approach to patient with vocal cord palsy

Voice change

• Mode of onset

• Duration• Progressive, intermittent or constant.• Aggravating and relieving factors.• Effortful phonation• Vocal fatigue

acute

insidious

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• H/o preceding URI, trauma, vocal abuse, surgery. Associated Throat symptoms

• Throat pain• Discomfort, dryness or soreness, frequent

clearing, burning sensation. Cough

• With or without sputum or blood• Diurnal variation• Aggravating factors : after meals or on lying

down.

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• relieving factors

Breathing difficulty

• Duration• Mode of onset• Progressive• Noisy breathing• Chocking

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Difficult swallowing• Duration

• Onset

• For liquids/solids

• Pain

• Progressive or non progressive

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H/o:• trauma• Fever with evening rise• Weight loss• Decrease appetite• Swelling neck or other sites of body• Symptoms of hyper/hypothyroidism• Chest pain• Weakness & numbness

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Past history• Trauma• Viral infection or URI• Previous surgery • Prolonged intubation• Drug intake• DM/ Tuberculosis/ HT• radiation

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Family history• DM , HT, tuberculosis• Heart disease• Carcinoma• Neurogenic disorders

Personal history• Tobacco chewing• Smoking• Alcohol intake• Sleep habits

Professional history

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EXAMINATIONGeneral physical examination.

• Build and nourishment• Vitals• Pallor, ictreus, anemia, clubbing, LAP,JVP• Cranial nerve examination.• Chest examination• CVS examination• GIT examination

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LOCAL EXAMINATIONVoice evaluation(perceptual)

Quality: - normal( 50% Pt with u/l RLN or SLN palsy) - mild to moderately breathy( u/l SLN) - mod to severe breathy (u/l RLN) - hoarse

- mild to moderate or severe hypernasality - strained

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• loudness: Soft

• Pitch• Reduced

• High ( paralytic falsetto )

• Pitch breaks

• Diplophonia ( u/l palsy)

• Weak cough

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Quantitative analysis• Magneting tape recording• Performance assesment: MFT & range of speech

frequencies• Phonetogram: pitch vs. intensity• Spectogram: time, frequency and amplitude

• Aerodynamics analysis: phonatory airflow rate, subglottic air pressure & air volume.

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Fourier’s spectral analysis:• Fundamental frequency: sustaining a single

tone at fundamental frequency.

• Shimmer: avg cycle to cycle difference in amplitude of sound

• Jitter: avg cycle to cycle difference in pitch of sound.

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ENT examinationNose and PNS

Lips, vestibule, oral cavity and oropharynx

Palatopharyngeal gag reflex reduced or absent, inability to elevate soft palate.

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Neck examination

Inspection: -laryngeal framework - swelling

Palpation: - laryngeal crepitus - swelling - lymph nodes

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Indirect laryngoscopy• BOT, Vallecula, epiglottis, vocal

cord, arytenoids, pyriform fossa.

• Vocal cords: appearance, position at rest, in relation to each other, symmetry, glottic closure, movements in quite breathing and vocalization.

• ee sniff test : maximum adduction and abduction.

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Features • U/L SLN palsy: during phonation.• Usually normal and difficult to appreciate• Floppy, lower level of paralysed cord.• Askew position of glottis• Short, bowed and bulky cords • hyperemia of hemilarynx ( loss of sympathetic

nerve supply)

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• B/L SLN palsy: difficult to detect.• Epiglottis hangs over due to anterior tilt of larynx.• Cords are flaccid, bowed and hyperemic.• Guttmann’s test: frontal pressure on the thyroid

cartilage will normally lower voice pitch by counteracting cricothyroid, whereas lateral pressure has opposite effect.

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• RLN palsy ( abductor palsy):• Cord is not mobile• Floppy• Flickers on phonation• Paralysed cord balloons out on phonation• Arytenoid crosses midline • B/L : cord in median position

- tends to limit activity- URTI precipitates laryngeal obstruction

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Combined paralysis U/L: healthy cord not able to approximate paralysed cord

• Glottic incompetence.

Bilateral combined: • Cords lie in cadaveric position

• Aphonia & aspiration.

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Adavntages: simple opd procedure, max information.

Disadvantages: brief duration, anterior glottic not seen, depth perception handicapped, ventricles , post cricoid, apex of pyriform sinus not seen and mucosal waves cannot be seen

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• Vocal cord position: 6 positions not valid anymore

• Semon’s law • Wager & grossman hypothesis

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• Modern theory: final position not static depends on – degree of muscle atrophy & fibrosis

- degree of reinnervation -Extent of synkinesis of musclesThree positions: abduction, adduction and

midline

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Specific investigations of cord movement

• Rigid 70° video- telescopy.• Fiberoptic video laryngoscopy.

• Laryngostroboscopic: glottic closure pattern evaluation - mucosal wave in response - of pitch

and loudness- Lesion- Vocal fold opening and closing pattern- Supraglottic appearance- Symmetry of arytenoids

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Page 40: APPROACH TO A PATIENT WITH VOCAL CORD PARALYSIS

LARYNGEAL ELECTROMYOGRAPHY

Gold standard• Degree of paralysis & prognosis• Differiating from mechanical fixation of CA joint• Neurological diagnosis• Site of lesion• Synkinesis & dysfunction reinnervation• Intaoperative nerve monitoring• Therapeutic inspection• Biofeedback in speech & swallowing disorder.

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INVESTIGATIONSVocal cord palsy is not a disease per se, it’s just a sign of underlying disease.

57% of cases can be diagnosed by taking proper history and detailed examination

Routine : CBC , RBS, SE, VDRL and LFT, barium swallow & thyroid scan.

low diagnostic yield ( usually not recommended)

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Radiological chest xray:- secondaries, primary carcinoma,

apiration pneumonia, metastatic lymph nodes, aortic arch aneurysm and TB. (54% diagnostic yield)

No other detectable lesion: contrast CT ( skull base to aortic arch)

No mass lesion – idiopathic.Palatal & pharyngeal paralysis and other

neuropathies: gadolinium enhanched MRI skull base and neck.

If negative- HRCT temporal bone for bony mets

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• Flexible or rigid esophagoscopy with biopsy.

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Treatment Unilateral vocal fold palsy

Known permanent etiology/ unknown etiology > 9 months

Healthy pt, no aspiration

Healthy pt, with aspiration

sick pt, with or w/o aspiration

VOICE THERAPY PHONOSURGERY

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Temporary or unknown etiology < 9 months

Healthy pt,no aspiration

Healthy pt,with aspiration & strong need of voice

sick pt, with or w/o aspiration

VOICE THERAPY TEMPORARY AUGMENTATION

after 9 months

DEFINITE PHONOSURGERY

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• Educational information regarding phonation

• Vocal hygiene: voice rest, avoid shouting, talking loudly, clearing throat

- adequate hydration- steam inhalation - smoking cessation, reducing alcohol,- Diet and reflux reduction

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VOICE THERAPY

• Vocal exercise : strengthening the muscle groups, improving glottic closure and efficiency.

• Reducing excessive tension in muscles around larynx, neck and shoulders.

• Advice on posture and breathing during speech• Laryngeal massage• General relaxation exercise• Psychological counseling.

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Bilateral vocal cord paralysis• Tracheostomy

• Posterior transverse cordotomy( CO2 laser)

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• Medial arytenoidectomy

• Total arytenoidectomy

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• Endo-extralaryngeal suture.

• Laryngeal pacing.

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In cases of contraindication• Epiglottopexy

• Vocal cord plication

• Total laryngectomy: cause is progressive, irreversible and speech is unservicable.

• Diversion procedures: intractable aspiration

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PHONOSURGERYTYPES :• Microlaryngosurgery

• Laryngeal injection

• Laryngeal framework surgery

• Nerve pedicle rinnervation

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• Laryngeal injection techniques:- for phonatory gap in u/l abductor or adductor palsy

• Teflon, fat, collagen, gelfoam, silicone etc

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Laryngeal framework surgery

• THYROPLASTY: type 1( medial displacement)

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• Arytenoid adduction: large posterior glottic gap.

• Laryngeal reinnervation: nerve muscle pedicle graft technique.

• Anterior belly of omohyoid with ansa hypoglossi and vessels.

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THANK YOU


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