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4/14/2009 1 Vocal Cord Paralysis Prof. Mohamed Hesham ENT-Head & Neck Surgery Department Alexandria Faculty of Medicine Alexandria, Egypt Cricothyroid muscle Tensor Adductor !
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  • 4/14/2009

    1

    Vocal Cord Paralysis

    Prof. Mohamed HeshamENT-Head & Neck Surgery Department

    Alexandria Faculty of MedicineAlexandria, Egypt

    Cricothyroid muscle Tensor

    Adductor !

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    Posterior cricoarytenoid The only abductor muscle

    Cortex

    Medulla

    SLN

    RLN

    Nerve supply of the larynx

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    Vocal cord positionsSix position are described by Negus,1947g ,

    MedianParamedianCadavericFull abduction

    Median

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    Acquired Cord paralysis

    It is a sign of a disease and not a diagnosisIt may be due to a lesion at any point from the cerebral cortex to the neuromusular junction Left RLN is more affected than the right due to its longer course

    Cortex

    Medulla

    SLN

    CentralRLN

    Central CorticalBulbar

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    Vagus

    SLNSLN

    RLN

    Peripheral injuryTotal vagusSLNRLN

    RLN

    Acquired Cord paralysis

    Malignant disease Surgical trauma Surgical trauma Idiopathic Nonsurgical trauma Inflamatory Neurologic MiscellaneousMiscellaneous

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    Acquired Cord paralysis

    Malignant disease Surgical trauma Surgical trauma Idiopathic Nonsurgical trauma Inflamatory Neurologic Miscellaneous

    Thyroid surgery Partial laryngeal surgery Tracheal resection Neck dissection Cardiac SurgeryMiscellaneous g y

    Acquired Cord paralysis

    Malignant disease Surgical trauma Surgical trauma Idiopathic Nonsurgical trauma Inflamatory Neurologic Miscellaneous

    No cause is ever found for paralysis

    Follow up for at least 18 months

    Viral !

    Miscellaneous

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    Acquired Cord paralysis

    Malignant disease Surgical trauma Surgical trauma Idiopathic Nonsurgical trauma Inflamatory Neurologic MiscellaneousMiscellaneous

    Acquired Cord paralysis

    Malignant disease Surgical trauma Surgical trauma Idiopathic Nonsurgical trauma Inflamatory Neurologic Miscellaneous

    Viral

    Bacterial

    Miscellaneous

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    Acquired Cord paralysis

    Malignant disease Surgical trauma Surgical trauma Idiopathic Nonsurgical trauma Inflamatory Neurologic Miscellaneous

    Cerebrovascular disease

    Parkinsonism

    Neuropathies; Alcohol,DM

    Miscellaneous

    Acquired Cord paralysis

    Malignant disease Surgical trauma Chest causes Surgical trauma Idiopathic Nonsurgical trauma Inflamatory Neurologic Miscellaneous

    Chest causes

    Rt Apical TB

    LeftCorpulmonaleAortic aneurysmOpen heart surgeryMiscellaneousMediastinal massesHypertrophied heart

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    AssessmentSymptoms and Sings

    SLN paralysis

    Voice

    Breathing

    Aspiration

    Cord positionPhonation Slight hoarsenessRespiration No stridorAspiration Slight

    AssessmentSymptoms and Sings

    Unilateral RLN Paralysis Voice Breathing Aspiration

    Cord position ParamedianPhonation Mild hoarseness

    Unilateral RLN Paralysis

    Phonation Mild hoarsenessRespiration No stridorAspiration Mild

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    AssessmentSymptoms and Sings

    Bilateral RLN Paralysis Voice Breathing Aspiration

    Bilateral RLN Paralysis

    Cord position ParamedianPhonation Mild hoarsenessPhonation Mild hoarsenessRespiration Severe stridorAspiration Mild

    AssessmentSymptoms and Sings

    Unilateral Vagal Paralysis Voice Breathing Aspiration

    Unilateral Vagal Paralysis

    Cord position IntermediatePhonation Breathy voiceRespiration No stridorAspiration Severe

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    AssessmentInvestigations

    RadiologyCh t X R Chest X Ray

    Barium swallow CT Scan

    AssessmentInvestigations

    LaboratoryCBC CBC

    FBS TB

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    AssessmentInvestigations

    PanendoscopyDi t L Direct Laryngoscopy

    Bronchscoy Esophagoscopy Nasopharyngoscopy

    TreatmentUnilateral Paralysis

    General rulesI WhI. When Unless the nerve is mechanically interupted recovry is the

    rule rather than the exception. Most recoveries take up from 6-12 months. In unrecoverable cases; the contralateral vc compensates

    by moving across the midline to achieve a satisfactory glottic closure.g

    So, Expectant policy is advised for 6-12 months + speech therapy before definitive treatment.

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    TreatmentUnilateral Paralysis

    General rulesI WhI. WhenIndications for early surgical intervention Professional voice users If one could not expect complete or adequate

    recovery so the distress of weak voice and cough should be treated earlyshould be treated early.

    TreatmentUnilateral Paralysis

    General rulesI Wh t t dI. What to doDisplace the paralysed vocal cord from the paramedian

    position to or near the midline

    Medialization procedures Intracordal Injection

    S i l di li ti Surgical medialization Vocal fold reinnervation

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    TreatmentUnilateral Paralysis

    TreatmentUnilateral Paralysis

    Surgical Medialization Prcedures ML

    I. Idea Isshiki 1974 (Thyroplasty I)An implant is placed between the thyroid cartilage and the vocalis muscle to medialize the membranous vocal cord.

    Surgical Medialization Prcedures MLLaryngeal Framework Surgeries

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    TreatmentBilateral Paralysis

    Paramedian position

    StridorBil. RLN injury Lateralization

    Widening procedures

    Reinnervation

    TreatmentBilateral Paralysis

    Arytenoidopexyy p y

    Endoscopic

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    TreatmentBilateral Paralysis

    Arytenoidopexy

    External

    TreatmentBilateral Paralysis

    ArytenoidectomyArytenoidectomy

    External Aproach

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    TreatmentBilateral Paralysis

    Endoscopic

    Posterior Cordectomy

    Arytenoidectomy

    Post partial cordectomy

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    Reinnervation

    Reinnervation

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    Reinnervation

    TreatmentComplete paralysis

    Inractable aspirationNasogastric tube Cuffed tracheostomyNasogastric tube, Cuffed tracheostomyVocal cord augmentation, Cricothyroid myotomyTotal LaryngectomySurgical Closure of the larynx

    Epiglottic flap operation Diversion procedure Glottic closure

    E i l tt Epiglottopexy

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