Vocal cord Paralysis

Vocal cord Paralysis

Moderator: DR.AVS HANUMANTHA RAO Professor, ent,head&neck surgery Done by: DR. POLUNAIDU pg in ent

1/10/2012 www.nayyarENT.com 1

It is a sign of disease and not a diagnosis.

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


LARYNX HAS TWO MAJOR FUNCTIONS

To protect airway

As organ of voice


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


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


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


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


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.


Anatomy of larynxLarynx 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)


Ligaments& membranes:Thyrohyoid membrane(extrinsic)Thyrohyoid ligamentCricothyroid membrane(extrinsic)Cricovocal membrane(internal)Cricotracheal membrane(extrinsic)Quadrangular membrane(internal)Anterior commissure tendon(broyle’s ligament)Hyoepiglottic ligamentCricothyroid ligament

Joints:Cricothyroidcricoarytenoid


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


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.

Adductors:


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


Anatomy of the Larynx - Motion Adductors of the Vocal Folds:


Position of vocal cords

A, median

B,3.5 mm gap

C,cadaveric(intermediate)

D,full abduction(9.5mm)


Causes of vocal cord paralysis

Malignant : This accounts for 25% of cases, one half being caused by carcinoma of lung


Causes of vocal cord paralysisSurgical/Traumatic: (20% cases)• Thyroidectomy• Pneumonectomy• Penetrating neck or chest trauma.• Post intubation• Whiplash injuries• Posterior fossa surgery


Causes of vocal cord paralysisNeurological (5-10%) • Wallenberg syndrome (lateral medullary stroke)• Syringomyelia• Encephalitis• Parkinsons, • Poliomyelitis• Multiple Sclerosis• Myasthenia Gravis, • Guillian-Barre• Diabetes


Causes of vocal cord paralysisInflammatory:• Rheumatoid arthritis ,( really a "fixed" cord

here)

Infectious:• Syphilis• Tuberculosis• Thyroiditis• Viral


Causes of vocal cord paralysisIdiopathic (20-25%):•Sarcoidosis, •Lupus•Polyarteritis nodosa•Ortner's syndrome (left atrial hypertrophy).


Intracranial causes

Distinctive features

Other neurological signs and symptoms due to combined paralysis of soft palate, pharynx and larynx


Cranial

Fracture base of skull

• Juglar foramen lesions (Glomus tumours, Naspharyngeal Carcinoma)

• Skull base osteomyelitis


• Other cranial nerve palsies (IX,X,XI)

• Pharyngeal, superior and Recurrent Laryngeal nerve


Neck

Thyroidectomy

Thyroid Tumours

Post Cricoid Carcinoma

Malignant Cervical Lymphnodes


Superior and Recurrent Laryngeal nerves involved


Chest

Bronchogenic Carcinoma

Cardiothoracic Surgery

Aortic Aneurysm

Mediastinal Lymphadenopathy

Tracheal/Oesophageal surgery

Distinctive feature

• Involvement of Left Recurrent Laryngeal Nerve


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


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


Evaluation – Physical ExaminationComplete 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


Evaluation - Videostroboscopy

Demonstrates subtle mucosal motion abnormalities


Evaluation - Electromyography

Assesses integrity of laryngeal nerves

Differentiates denervation from mechanical obstruction of vocal cord movement

Electrode placed in Thyroarytenoid and Cricothyroid


Evaluation - ElectromyographyNormal• Joint Fixation

Fibrillation• Denervation

Polyphasic• Synkinesis• Reinnervation1/10/2012 www.nayyarENT.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


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


Evaluation – Unilateral ParalysisManual Compression Test


Evaluation – Unilateral Paralysis

Assess extent of posterior glottic gap

Consider consent for both anterior and posterior medialization procedures


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


“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)”

Wegner and Grossman Theory


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.


Pictures of Vocal Fold Paralysis

Recurrent Laryngeal N. Paralysis

Unilateral left vocal fold paralysis (Superior N. Paralysis)


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.


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


Bilateral Recurrent Laryngeal Nerve InjuryUsually 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


ManagementBilateral 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

Expiration

Inspiration


ManagementBilateral Abductor ParalysisTracheostomy• Gold standard• Most adults will require this• Speaking valves aid in phonation

Laser Cordectomy

Laser Cordotomy

Woodman Arytenoidectomy


Cordotomy


Vocal cord lateralisation through endoscopre

Thyroplasty type 2

Nerve musle implant

ManagementBilateral Abductor Paralysis


Bilateral Abductor ParalysisPhrenic 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. Uncommon

2. Inhalation of food & pharyngeal secretions giving rise to cough and choking fits

3. Voice is weak and husky

Bilateral superior laryngeal nerve palsy


treatment1.Tracheostomy with a cuffed tube and an oesophageal feeding tube2.epiglottopexy


Unilateral combined paralysisParalysis 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.nayyarENT.com 49

management1.Speech therapy2.Medialisation of cord(static procedures) a, injection of teflon paste

b, thyroplasty type 1

c, muscle or cartilage implant

d, arthodesis of cricoarytenoid joint


Management – Unilateral ParalysisVocal 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


Management – Unilateral ParalysisVocal Cord Injection

External landmarks – several mm anterior to oblique line horizontally, midpoint between thyroid notch and inferior thyroid border vertically


Management – Unilateral ParalysisVocal Cord Injection


Management – Unilateral ParalysisVocal Cord Injection - MaterialsTeflon

Fat

Collagen• Autologous Collagen• Homologous Micronized Alloderm (Cymetra)• Heterologous Bovine Collagen (Zyderm

Hyaluronic Acid

Calcium Hydroxyapatite gel (Radiance FN)

Polydimethylsiloxane gel (Bioplastique)


Management – Unilateral ParalysisType I Thyroplasty


Medialization Laryngoplasty


Medialization Laryngoplasty


Management – Unilateral ParalysisArytenoid 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 1/10/2012 www.nayyarENT.com 58

Arytenoid Adduction




Complications•Sutures too tight – may displace arytenoid complex anteriorly, adversely affecting voice

•Entry of piriform sinus



Management – Unilateral ParalysisReinnervation(dynamic procedures)

Results in synkynetic tone of vocal cord

Ansa to Recurrent Laryngeal Nerve

Ansa to Omohyoid to Thyroarytenoid


Management – Unilateral ParalysisReinnervation(dynamic procedures)

Hypoglossal to recurrent laryngeal nerve

Crossed nerve grafts or wire conduction prostheses from one muscle to its paralyzed counterpart are being researched


Bilateral combined paralysis

Rare condition

Both cords in cadaveric position

Total anaesthesia of larynx

Aphonia & aspiration

Inability to cough

bronchopneumonia


Management – bilateral ParalysisTracheostomy

Epiglottopexy

Vocal cord plication

Total laryngectomy

Divertion procedures


Tracheostomy:

Emergency

elective


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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Vocal cord Paralysis

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