4/14/2009
1
Vocal Cord Paralysis
Prof. Mohamed HeshamENT-Head & Neck Surgery Department
Alexandria Faculty of MedicineAlexandria, Egypt
Cricothyroid muscle Tensor
Adductor !
4/14/2009
2
Posterior cricoarytenoid The only abductor muscle
Cortex
Medulla
SLN
RLN
Nerve supply of the larynx
4/14/2009
3
4/14/2009
4
Vocal cord positionsSix position are described by Negus,1947g ,
MedianParamedianCadavericFull abduction
Median
4/14/2009
5
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
4/14/2009
6
Vagus
SLNSLN
RLN
Peripheral injuryTotal vagusSLNRLN
RLN
Acquired Cord paralysis
Malignant disease Surgical trauma Surgical trauma Idiopathic Nonsurgical trauma Inflamatory Neurologic MiscellaneousMiscellaneous
4/14/2009
7
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
4/14/2009
8
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
4/14/2009
9
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
4/14/2009
10
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
4/14/2009
11
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
4/14/2009
12
AssessmentInvestigations
RadiologyCh t X R Chest X Ray
Barium swallow CT Scan
AssessmentInvestigations
LaboratoryCBC CBC
FBS TB
4/14/2009
13
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.
4/14/2009
14
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
4/14/2009
15
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
4/14/2009
16
TreatmentBilateral Paralysis
Paramedian position
StridorBil. RLN injury Lateralization
Widening procedures
Reinnervation
TreatmentBilateral Paralysis
Arytenoidopexyy p y
Endoscopic
4/14/2009
17
TreatmentBilateral Paralysis
Arytenoidopexy
External
TreatmentBilateral Paralysis
ArytenoidectomyArytenoidectomy
External Aproach
4/14/2009
18
TreatmentBilateral Paralysis
Endoscopic
Posterior Cordectomy
Arytenoidectomy
Post partial cordectomy
4/14/2009
19
Reinnervation
Reinnervation
4/14/2009
20
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
4/14/2009
21
