Download - Recurrent laryngeal nerve paralysis
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RECURRENT LARYNGEAL NERVE
PARALYSIS
BY: NILUFER
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For normal voice production:
• VOCAL CORDS must :
• 1. be able to approximate with each other
• 2. have proper size and stiffness • 3. have an ability to vibrate reg. in
response to air column
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• in vocal cord palsy ; • • - loss of approximation of vc• - decreased stiffness of vc
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ANATOMY OF LARYNX LOCATION : in the middle and ant.part of the neck , opp. C3 - C6
CARTILAGES : 1. paired
2.unpaired
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Unpaired : • *epiglottis * thyroid *cricoid Paired : * arytenoid * corniculate * cuneiform
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1. ABDUCTORS : Post. cricoarytenoid
2. ADDUCTORS: Lat.cricoarytenoid
interarytenoid Thyroarytenoid3.TENSORS: Cricothyroid4.RELAXERS :
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Vocalis Thyroarytenoid (int part)
Acting on l.inlet: 1.OPENERS Thyroepiglottic 2.CLOSERS Interarytenoid (oblique p.)
Aryepiglottic (post. ob. p.)
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Extrinsic muscles :• 1. elevators• 2. depressors
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NERVE SUPPLY OF LARYNX1. sensory : * above vocal cords - SLN (ILN) * below vocal cords - RLN
2.motor: * all intrinsic muscles - RLN # except . cricothyroid ( SLN - external)
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VOCAL CORDS• *DEFN : are pearly white mucous memb.
infoldings that stretch horizontally across mid.laryngeal cavity.
• ATTACHMENTS: Ant : thyroid cartilage Post : arytenoid cartilage ( vocal process) EDGES: Outer - attached to muscle in larynx Inner - free ( form rima glottidis) • TYPES: • 1. TRUE : formed from conus elasticus (inf layer of
infolded membrane)
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2. FALSE : formed from quadrangular membrane ( sup. layer of infol.mem )
• ant. 2/3 - membranous
• post 1/3 - cartilagenous
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position of vocal cordsnormally : breathing -
abducted phonation -
adducted
swallowing - add.
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COURSE OF RLN
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vagus - tenth. CNCranial part ; 2 nuclei vagus descends down
exits skull via jugular.f sup. ganglion inf.ganglion descends down and enters
carotid sheath
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below inf.gang.
• gives SLN
• at level of hyoid bone it divides into
external internal
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at level of SCA - GIVES RIGHT RLN
• at thr level of arch of aorta - gives LEFT• RLN• GALEN 'ANASTOMOSIS: btw SLN &
RLN• NON RECURRENT LARYNGEAL N.• WHY LEFT RLN more prone for
paralysis?
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CLASSIFICATION• 1. RLN• 2. SLN• 3. COMBINED
• * 1. CONGENITAL/ ACQUIRED• 2. U/L or B/L• 3. COMPLETE/ INCOMPLETE• 4. ABDUCTOR / ADDUCTOR/ BOTH
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5. SENSORY / MOTOR• * ETIOLOGY :• 1. supranuclear • 2. nuclear• 3. vagus nerve ( high vagal )• 4. low vagal trunk • - right RLN• - left RLN• - both• 5. systemic causes
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CAUSES OF RLNP• RIGHT : neck• - neck trauma• - thyroid disease• -malignancy• - iatrogenic• - cer. lymphadenopathy• - aneurysm of SCA• - CA.apex rt.lung• - TBofcer.pleura• - idiopathic
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LEFT : 1. in the NECK; • - acc.trauma• - thy. disease• - iatrogenic• - malignancy• - c.lymph.• in the MEDIASTINUM ;• - Bronchogenic.CA• - CA.tho.eso• - aortic aneurysm• - M. lymph• - ortner s syn.• - intrathoracic surgry
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BOTH ;
• thy.surgry• CA.thyroid• CAcer. oeso• cer. lymphadenopathy
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TYPES OF RLNP1. UNILATERAL2. BILATERAL
1.UNILATERAL RLNP : DEFN: Condition which leads to ipsilateral
paralysis of all intrinsic laryngeal muscles except cricothyroid .
INCIDENCE : usually affects adults SEX : both males n females
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•clinical • features
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THEORIES TO EXPLAIN THE POSITION OF VOCAL CORDS IN PARALYSIS
• 1. SEMON 'S LAW : • "in all the prog. org. lesions,
abd.fibres of nerve which are phylogenetically newer, are more susceptible & are first to be paralysed compared to adductors.
• 2. WAGNER AND GROSSMAN 'S LAW
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" cricothyroid muscle ( supplied by SLN)which has adductor function, keeps cord in paramedian position."
VOCAL CORDS
PM pure RLNP
C comb.palsy
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• ETIO : • - BRONCHOGENIC CA.• - THYROID SURGERY
C/F : - VOICE - POSITION OF VOCAL CORDS - RESPIRATION ( stridor) - SWALLOWING ( aspiration )
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• 1. VOICE : - asympotomatic in 1/3 cases - left sided; hoarseness -no change - improves gradually by compensation
2. POSITION OF VC : median or paramedian - aff. vc may lie at a lower level
3. no prob. of aspiration or breathing
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INVESTIGATIONS :• 1. Chest X-Ray • 2. biopsy• 3. radiography of barium swallow• 4. panendoscopy - dir.laryngoscopy,
bronchoscopy, esophagoscopy• 5. blood sugar• 6. VDRL• 7. ESR• 8. neurological invest.• 9. CVS • 10. CT- SCAN and MRI
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MANAGEMENT : - if asymptomatic - no trtmnt reqd,. - temporary paralysis recovers in 6 to 12
months - advisable to wait - voice improvement during waiting period - 1. speech therapy -
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• if paralysis persists for 9 to 12 months, then following procedures performed:
• 1. laryngoplasty type 1 with vc inj.• 2. laryngoplasty type 2 with arytenoid
adduction• 3. thyroplasty type 1 - medialization of vc• - make window through
thy.cartilage• then implant silastic prosthesis
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BILATERAL RLNP ( ABDUCTOR PARALYSIS)
DEFN: condition in which al the intrinsic muscles of larynx are paralysed bilaterally. except cricothyroid
ETIO : neuritis thyroid surgery C/F : - Acute in onset - dyspnea - stridor
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• - becomes worse during exertion and infection
• voice : good • position of vc: median / paramedian
INVESTIGATIONS MANAGEMENT : 1. Surgical treatmnt
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2 modalities; 1. permanent tracheostomy
with speaking valve 2. lateralization of cord
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• by endoscopy or ext.cervical approach• 1.arytenoidectomy• 2. arytenoidopexy• 3.transverse cordotomy ( kashima op.)• 4. thyroplasty type 2 • 5. reinnervation
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thyroplasty
• type 1. - medialization
• type 2 . - lateralization
type 3. - vc. are relaxed (shortening)
type 4 . - vc. are tensed
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reinnervation
• innervate the paralysed post. cricoarytenoid muscle by
• implanting nerve muscle pedicle from sternohyoid or omohyoid with its n.s. from ansa cervicalis.
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