approach to a patient with vocal cord paralysis
TRANSCRIPT
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APPROACH TO A PATIENT WITH VOCAL CORD PARALYSIS
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EPIDEMIOLOGY• Acquired and congenital• Asymptomatic: 30-50%• Incidence increases with age.• left recurrent laryngeal nerve is more
frequently involved: lung ca, esophageal ca, aortic aneurysm, tuberculosis, sarcoidosis, lymphoma,
mediastinal Tm etc.• Surgical etiology more frequent than tumors.
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Unilateral vocal fold palsy• Iatrogenic:
Nonthyroidthyroid
• Malignancy :LungNon lung
• Idiopathic• Neurogenic• Intubation• Trauma• Aortic/cardic• other
• 30.6%• 15.7%
• 6.6%• 6.9%• 17.6%• 7.9%• 4.4%• 2.2%• .6%• 12.6%
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Bilateral vocal cord palsy
• Iatrogenic:ThyroidNon thyroid
• Malignancy• Intubation• Neurological• Trauma• others
• 55.5%• 48.6%• 6.9%• 9.7%• 8.3%• 6.9%• 1.4%• 8.4%
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Vagus nerve
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Causes of laryngeal palsy
• Supranuclear• Nuclear: vascular, neoplastic, motor, neuron
disease, polio and syringomyelia.• High vagal lesion: skull, jugular foramen or in
parapharyngeal space• Low vagal• Systemic causes• Idiopathic: 30%
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Causes of combined palsy• Intracranial: Tumors of posterior fossa, basal
meningitis .
• Skull base: fracture, nasopharyngeal Tumors and glomus Tumors
• Neck: penetrating injury, parapharyngeal Tumors, metastatic nodes and lymphoma.
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Causes of RLN paralysis
RIGHT(15%)• Neck trauma• Thyroid surgery• Ca cx esophagus• Cx LAP• Subclavian artery
aneurysm• Ca apex of lung• idiopathic
LEFT(75%)• Neck
Mediastinal • Bronchogenic Ca• Ca thoracic esophagus• Aortic aneurysm• Mediastinal LAP• Enlarged left
auricle(oatner’s syndrome)• idiopathic
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Approach to patient with vocal cord palsy
Voice change
• Mode of onset
• Duration• Progressive, intermittent or constant.• Aggravating and relieving factors.• Effortful phonation• Vocal fatigue
acute
insidious
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• H/o preceding URI, trauma, vocal abuse, surgery. Associated Throat symptoms
• Throat pain• Discomfort, dryness or soreness, frequent
clearing, burning sensation. Cough
• With or without sputum or blood• Diurnal variation• Aggravating factors : after meals or on lying
down.
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• relieving factors
Breathing difficulty
• Duration• Mode of onset• Progressive• Noisy breathing• Chocking
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Difficult swallowing• Duration
• Onset
• For liquids/solids
• Pain
• Progressive or non progressive
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H/o:• trauma• Fever with evening rise• Weight loss• Decrease appetite• Swelling neck or other sites of body• Symptoms of hyper/hypothyroidism• Chest pain• Weakness & numbness
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Past history• Trauma• Viral infection or URI• Previous surgery • Prolonged intubation• Drug intake• DM/ Tuberculosis/ HT• radiation
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Family history• DM , HT, tuberculosis• Heart disease• Carcinoma• Neurogenic disorders
Personal history• Tobacco chewing• Smoking• Alcohol intake• Sleep habits
Professional history
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EXAMINATIONGeneral physical examination.
• Build and nourishment• Vitals• Pallor, ictreus, anemia, clubbing, LAP,JVP• Cranial nerve examination.• Chest examination• CVS examination• GIT examination
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LOCAL EXAMINATIONVoice evaluation(perceptual)
Quality: - normal( 50% Pt with u/l RLN or SLN palsy) - mild to moderately breathy( u/l SLN) - mod to severe breathy (u/l RLN) - hoarse
- mild to moderate or severe hypernasality - strained
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• loudness: Soft
• Pitch• Reduced
• High ( paralytic falsetto )
• Pitch breaks
• Diplophonia ( u/l palsy)
• Weak cough
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Quantitative analysis• Magneting tape recording• Performance assesment: MFT & range of speech
frequencies• Phonetogram: pitch vs. intensity• Spectogram: time, frequency and amplitude
• Aerodynamics analysis: phonatory airflow rate, subglottic air pressure & air volume.
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Fourier’s spectral analysis:• Fundamental frequency: sustaining a single
tone at fundamental frequency.
• Shimmer: avg cycle to cycle difference in amplitude of sound
• Jitter: avg cycle to cycle difference in pitch of sound.
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ENT examinationNose and PNS
Lips, vestibule, oral cavity and oropharynx
Palatopharyngeal gag reflex reduced or absent, inability to elevate soft palate.
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Neck examination
Inspection: -laryngeal framework - swelling
Palpation: - laryngeal crepitus - swelling - lymph nodes
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Indirect laryngoscopy• BOT, Vallecula, epiglottis, vocal
cord, arytenoids, pyriform fossa.
• Vocal cords: appearance, position at rest, in relation to each other, symmetry, glottic closure, movements in quite breathing and vocalization.
• ee sniff test : maximum adduction and abduction.
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Features • U/L SLN palsy: during phonation.• Usually normal and difficult to appreciate• Floppy, lower level of paralysed cord.• Askew position of glottis• Short, bowed and bulky cords • hyperemia of hemilarynx ( loss of sympathetic
nerve supply)
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• B/L SLN palsy: difficult to detect.• Epiglottis hangs over due to anterior tilt of larynx.• Cords are flaccid, bowed and hyperemic.• Guttmann’s test: frontal pressure on the thyroid
cartilage will normally lower voice pitch by counteracting cricothyroid, whereas lateral pressure has opposite effect.
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• RLN palsy ( abductor palsy):• Cord is not mobile• Floppy• Flickers on phonation• Paralysed cord balloons out on phonation• Arytenoid crosses midline • B/L : cord in median position
- tends to limit activity- URTI precipitates laryngeal obstruction
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Combined paralysis U/L: healthy cord not able to approximate paralysed cord
• Glottic incompetence.
Bilateral combined: • Cords lie in cadaveric position
• Aphonia & aspiration.
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Adavntages: simple opd procedure, max information.
Disadvantages: brief duration, anterior glottic not seen, depth perception handicapped, ventricles , post cricoid, apex of pyriform sinus not seen and mucosal waves cannot be seen
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• Vocal cord position: 6 positions not valid anymore
• Semon’s law • Wager & grossman hypothesis
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• Modern theory: final position not static depends on – degree of muscle atrophy & fibrosis
- degree of reinnervation -Extent of synkinesis of musclesThree positions: abduction, adduction and
midline
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Specific investigations of cord movement
• Rigid 70° video- telescopy.• Fiberoptic video laryngoscopy.
• Laryngostroboscopic: glottic closure pattern evaluation - mucosal wave in response - of pitch
and loudness- Lesion- Vocal fold opening and closing pattern- Supraglottic appearance- Symmetry of arytenoids
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LARYNGEAL ELECTROMYOGRAPHY
Gold standard• Degree of paralysis & prognosis• Differiating from mechanical fixation of CA joint• Neurological diagnosis• Site of lesion• Synkinesis & dysfunction reinnervation• Intaoperative nerve monitoring• Therapeutic inspection• Biofeedback in speech & swallowing disorder.
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INVESTIGATIONSVocal cord palsy is not a disease per se, it’s just a sign of underlying disease.
57% of cases can be diagnosed by taking proper history and detailed examination
Routine : CBC , RBS, SE, VDRL and LFT, barium swallow & thyroid scan.
low diagnostic yield ( usually not recommended)
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Radiological chest xray:- secondaries, primary carcinoma,
apiration pneumonia, metastatic lymph nodes, aortic arch aneurysm and TB. (54% diagnostic yield)
No other detectable lesion: contrast CT ( skull base to aortic arch)
No mass lesion – idiopathic.Palatal & pharyngeal paralysis and other
neuropathies: gadolinium enhanched MRI skull base and neck.
If negative- HRCT temporal bone for bony mets
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• Flexible or rigid esophagoscopy with biopsy.
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Treatment Unilateral vocal fold palsy
Known permanent etiology/ unknown etiology > 9 months
Healthy pt, no aspiration
Healthy pt, with aspiration
sick pt, with or w/o aspiration
VOICE THERAPY PHONOSURGERY
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Temporary or unknown etiology < 9 months
Healthy pt,no aspiration
Healthy pt,with aspiration & strong need of voice
sick pt, with or w/o aspiration
VOICE THERAPY TEMPORARY AUGMENTATION
after 9 months
DEFINITE PHONOSURGERY
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• Educational information regarding phonation
• Vocal hygiene: voice rest, avoid shouting, talking loudly, clearing throat
- adequate hydration- steam inhalation - smoking cessation, reducing alcohol,- Diet and reflux reduction
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VOICE THERAPY
• Vocal exercise : strengthening the muscle groups, improving glottic closure and efficiency.
• Reducing excessive tension in muscles around larynx, neck and shoulders.
• Advice on posture and breathing during speech• Laryngeal massage• General relaxation exercise• Psychological counseling.
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Bilateral vocal cord paralysis• Tracheostomy
• Posterior transverse cordotomy( CO2 laser)
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• Medial arytenoidectomy
• Total arytenoidectomy
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• Endo-extralaryngeal suture.
• Laryngeal pacing.
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In cases of contraindication• Epiglottopexy
• Vocal cord plication
• Total laryngectomy: cause is progressive, irreversible and speech is unservicable.
• Diversion procedures: intractable aspiration
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PHONOSURGERYTYPES :• Microlaryngosurgery
• Laryngeal injection
• Laryngeal framework surgery
• Nerve pedicle rinnervation
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• Laryngeal injection techniques:- for phonatory gap in u/l abductor or adductor palsy
• Teflon, fat, collagen, gelfoam, silicone etc
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Laryngeal framework surgery
• THYROPLASTY: type 1( medial displacement)
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• Arytenoid adduction: large posterior glottic gap.
• Laryngeal reinnervation: nerve muscle pedicle graft technique.
• Anterior belly of omohyoid with ansa hypoglossi and vessels.
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THANK YOU