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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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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 positions•Six 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 diagnosis•It 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 •Cortical•Bulbar
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Vagus
SLNSLN
RLN
Peripheral injury•Total vagus•SLN•RLN
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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