laryngeal paralysis 3
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Devashish KamraRoll no. 45/09
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SENSORY SUPPLY-
SUPRAGLOTTIC PART internal branch ofsuperior laryngeal nerve
GLOTTIC & INFRAGLOTTIC PART RecurrentLaryngeal Nerve
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MOTOR SUPPLY
All the muscles of larynx are supplied by recurrentlaryngeal nerve except the cricothyroid which is
supplied by external branch of superior laryngealnerve.
Motor cortex has a b/l representation of both vocalcords.
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ADDUCTORS
Lateralcricoarytenoid
Transversearytenoid
Oblique
arytenoid
ABDUCTOR
Posteriorcricoarytenoid
TENSOR
Thyroarytenoid(including
vocalis muscle)
Cricothyroid
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PROTECTION & MAINTENANCE OFAIRWAYS
i. Sphincteric closure of laryngeal opening
ii. Cessation of respiration
iii. Cough reflex
PHONATION(aerodynamic myeloelastictheory of voice production)
REGULATION OF RESPIRATORY FLOW FIXATION OF CHEST
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SUPRANUCLEAR-rare as only b/l cortical lesions willproduce paralysis. When present ,they are ass. with otherneurological defects. Laryngeal paralysis is b/l & after shortperiod of f laccidity becomes spastic.
NUCLEAR-Nucleus Ambiguous involved. It leads to completemotor paralysis without sensory involvement. Vocal cord isflaccid.ass. with lesion of cranial nerves.
HIGH VAGAL LESION(leading to combined SLN & RLNparalysis)-Vagus nerve involved in skull, exit from jugular
foramen or parapharyngeal space.
LOW VAGAL LESION-RLN paralysis
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Supranuclear and nuclear lesions are caused due toneurological defects like Amyotrophic Lateralsclerosis,diabetes,Poliomyelitis,Shy-Dragger Syndrome,Arnold Chiari Malformation,syringobulbia,vascular &neoplastic disorders.
HIGH VAGAL LESIONS CAUSES-
INTRACRANIAL SKULL BASE NECK
Tumors of posterior
fossa
Fractures Penetrating injury
Basal meningitis Nasopharyngealcancers
Parapharyngealtumors
Glomus tumor Metastatic nodes
Lymphoma
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NECK CAUSES Thyroid surgery
Benign ormalignant thyroiddisease
Carcinoma cervical
esophagus Neck trauma
Cervicallymphadenopathy
RIGHT LEFT
Aneurysm ofsubclavian artery
Bronchogenic cancer
Carcinoma apex rightlung
Carcinoma thoracicesophagus
TB of cervical pleura Aortic aneurysm
Idiopathic Mediastinal LAP
Enlarged left auricle
Intrathoracic surgery
idiopathic
MEDIASTINAL CAUSES
MOST COMMON CAUSE IS TOTALTHYROIDECTOMY
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Early detection requires thorough evaluation of anyparalysis with no apparent cause.
Complete ENT examination exam with endoscopy is thebaseline.
Associated nerve deficits esp. cranial nerves is seen todetermine the cause of lesion.
Radiologic evaluation (CAT,MRI) of skull , neck &mediastinum can be done
Glucose tolerance done to rule out diabetes Serology
Stroboscopy, electromyography & transmural stimulationlaryngeal muscles gives more info. & potential of recovery.
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UNILATERAL PARALYSISVocal cord median or paramedian position
generally but not always
Semons law- abductor fibres more
susceptible than adductor as they arephylogenetically new.
Wagner and GrossmanHypothesis- cricothyroid spared causingadduction
But vocal cords can tense, move slightly.
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CLINICAL FEATURES-
Asymptomatic in 1/3rd patients.
ACUTE ONSET PARALYSIS-weak voice but later getscompensated.
GRADUAL ONSET PARALYSIS-compensation occursprogressively & symptoms are minimal.
TREATMENT - Depends on the final position of vocal cord.
If the paralyzed cord is unable to bridge the gapleading to hoarseness of voice then medialisation of
cord is done. It could be done by vocal cord injection orby surgical procedures like thyroplasty.
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BILATERAL- Thyroidectomy,upper esophageal Ca,neuritis.
POSITION OF CORDS-median or paramedian ;
Cricothyroid spared
CLINICAL FEATURES-
voice is good as vocal cords are adducted
airway is inadequate causing dyspnoea and stridor
Dyspnoea worsened on ac. laryngitis
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TREATMENTTRACHEOSTOMY-
Emergency tracheostomy done in acute cases or in ass.
with respiratory tract infection. Long standing cases-either permanent tracheostomy
with a speaking valve is done or surgical lateralizationof the cord is done to secure the airway.
Tracheostomyrelieves stridor & preserve good voicewith disadvantage of a tracheostomy hole in neck.
SURGICAL LATERALISATION OF CORD-
Aims to improve the airway at the expense of voice. Techniques that widen posterior commissure are most
likely to achieve this without too much compromisewith voice.
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Various procedures for surgical lateralization are
Endoscopic techniques without
arytenoidectomy(Kirchner 1979)- Use of microcautery or laser
Temporary sutures exiting through neck.
Without sutures relying on scar contracture
Now done by CO2 laser by vaporizing laryngealtissue
Requires a mobile arytenoid
Complete laser cordectomy considered rarely.
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Endoscopic techniques witharytenoidectomy(Thornell 1948)-
Mucosal incision made on top of arytenoid and thecartilage dissected & extracted.
Complications
granuloma formation at site of incision
web formation in posterior commissure
It was simplified by Laser
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Extralaryngeal approach arytenoids are removedby an external approach. This is a difficultapproach mastered by few operators.
Implantable devices
Midline thyrotomy
Induced Paralysis to SLN Motor Reinnervation
Practicallyobsolete
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UNILATERAL PARALYSIS-
Isolated lesions of this nerve rare.
Leads to supraglottic anaesthesia and
cricothyroid paralysis.Clinical Features-
Weak voice
Pitch cant be raised
Occasional aspiration
Anterior comm. rotated to healthy side
Flapping of paralyzed cord
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BILATERAL PARALYSIS- Leads to paralysis of both cricothyroid muscles
along with anaesthesia of upper larynx. Paralysis + anaesthesia b/l leads to repeated
aspirationVoice weak and huskyTREATMENT- Depends upon cause; neuritis patients recover
spontaneously.
Patients with repeated aspiration requiretracheostomy with a cuffed tube & an esophagealfeeding tube.
Epiglottopexy done to close laryngeal inlet toprotect lungs from aspiration.
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UNILATERAL PARALYSIS- Paralysis of all the muscles of larynx on one side
except interarytenoid
CLINICAL FEATURES-
All the muscles of one side are paralyzed
vocal cord lie in intermediate position(earlierknown as cadaveric position) i.e. 3.5 mm frommidline.
Healthy cord is unable to reach paralyzed cord,therefore leads to hoarseness of voice andaspiration of liquids through glottis.
Cough ineffective due to improper adduction.
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TREATMENT
Speech Therapy-helps in compensating the functionof paralyzed cord due to movement of healthy cord
across the midline. PROCEDURES TO MEDIALISE THE PARALYSED CORD-
a) Vocal cord injection-
Principle-lateral side of vocal process is injected with an inertmaterial so as to push the cord to medial side. If necessarythen lateral midportion of cord is injected.
Materials used for injection-
Paraffin initially
Gelfoam
Fat Teflon(with glycerine as a base)
Bovine collagen
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Requirements for injection- Cricoarytenoid joint should be mobile. Cord should be totally paralyzed otherwise the
material will migrate result is poor. Cord should not be more than 3-4 mm away from
midline.Procedure- it is done with direct laryngoscopy under
local anaesthesia.
Surgical medialisation- Muscle graft or piece of cartilage is inserted between
thyroid cartilage and its inner perichondrium lateralto vocal cord, pushing the cord medially.
Done in the presence of a very large gap >3-4mm atposterior commissure
can be done in severely scarred larynx where vocalcord injection is not possible.
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Vocal cord reinnervation selective reinnervation ofadductors is done to bring cords to midline.
Arthrodesis of cricoarytenoid joint-Larynx is opened by
a laryngofissure,arytenoid cartilage rotated medially andfixed with a screw.
BILATERAL PARALYSIS-Both RLN & SLN of both sides are paralyzed. It is a rare
condition. Both cords lie in intermediate position withtotal anaesthesia of larynx.
CLINICAL FEATURES-
Aphonia
Aspiration
Inability to cough
Bronchopneumonia due to repeated aspiration andretention of secretions.
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TREATMENT-
Tracheostomy
EpiglottopexyVocal Cord plication-mucosa of true and false
cords is removed & then they are approximatedwith sutures. It helps prevent aspiration and can
be reversed when required. Total laryngectomy done when cause is
progressive and speech is unserviceable.
Diversion Procedures
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Phonation
RLN paralysisMedian
Strong whisper
RLN paralysisParamedian
(1.5mm)
Paralysis of both RLN& SLN
cadaver
Intermediate
(3.5 mm)
Quiet respiration
Paralysis of adductorsGentle
abduction(7mm)
Deep inspirationFull abduction
(9.5mm)
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May be unilateral or bilateral; Unilateralparalysis more common
Cause of U/L-birth trauma or a congenital
anomaly of a great vessel or heart. Cause of B/L hydrocephalus ,Arnold Chiari
malformation, intra-cerebral hemorrhageduring birth, meningocoele or cerebral or
nucleus ambiguous agenesis.
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Excision of benign & malignant lesions by laser or microsurgery. Vocal Cord Injection THYROPLASTY-Ishikki divided thyroplasty procedures into 4
categories-a) Type I-medial displacement of vocal cord
b) Type II-lateral displacement of vocal cordc) Type III-it shortens(Relax) the vocal cord. This procedure lowers
the pitch. It is done in mutational falsetto or in those who haveundergone gender transformation from female to male.
d) Type IV-It lengthens(tightens) the vocal cord & elevate thepitch. It converts male character of voice to female and thus
used in gender transformation. Also used when vocal cord is laxdue to ageing process or trauma. REINNERVATION
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Thank
You
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