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Respiration Airway protection phonation
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Normally : breathing - abduction phonation - adduction
swallowing - adduction
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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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Superior laryngeal nerve-internal branch is sensory supplies larynx above the level of vocal cords and external branch supplies cricothyroid muscle.
Recurrent laryngeal nerve-Motor branch supplies all muscles of larynx except the cricothyroid and sensory branch supplies subglottis
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Right RLN arises from vagus, hooks around subclavian artery and ascends upwards in tracheo-oesophageal groove
Left RLN arises from vagus, hooks around arch of aorta and ascends upwards in tracheo-oesophageal groove
Left RLN has longer course thus its prone for injury
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Arises in inferior ganglion of vagus, descends behind internal carotid artery and at the level of greater cornua of hyoid it divides into internal and external branches
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May be unilateral or bilateral and may involve Recurrent laryngeal nerve Superior laryngeal nerve Both recurrent and superior laryngeal
nerve (combined or complete paralysis)
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Supranuclear: Rare Nuclear: involvement of nucleus ambiguus in
medulla, usually associated with other lower cranial nerve paralysis
High vagal lesions: may be involved at the level of jugular foramen or parapharyngeal space
Low vagal or RLN Systemic causes: diabetes mellitus,
diphtheria, typhoid, lead poisoning Idiopathic: in about 30% of cases
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Unilateral Results in ipsilateral paralysis of all
intrinsic muscles except the cricothyroid Vocal cord assumes a median or
paramedian position and does not move laterally on deep inspiration
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This law explains median or paramedian position of the vocal cords
• It states that ‘In all progressive lesions of RLN, In all progressive lesions of RLN, abductor fibres of the nerve, which are abductor fibres of the nerve, which are phylogenetically newer, are more susceptible and phylogenetically newer, are more susceptible and thus first to be paralysed compared to adductor thus first to be paralysed compared to adductor fibresfibres’
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It states that cricothyroid muscle which receives innervation from superior laryngeal nerve keeps the cord in paramedian position due to adductor function
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May be undetected as 1/3rd of patients remain asymptomatic
Some patients may complain of change of voice
Voice gradually improves due to compensation by healthy cord which crosses the midline to meet paralysed one
Treatment: Generally treatment is not required
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Direct medialization of the vocal cord Performed alone or with
arytenoid adduction or reinnervation procedure
Implant material Carved or prefabricated Silastic
implant Hydroxyapatite implant Gore-Tex strips
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Bilateral RLN paralysis Aetiology: neuritis and trauma
(thyroidectomy) are the most common causes. The condition is often acute in onset
Position of cords: as all the intrinsic muscles are paralysed the vocal cords lie in median or paramedian position due to unopposed action of cricothyroid
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AETIOLOGY POSITION OF CORDS
CLINICAL FEATURES
TREATMENT
NeuritisSurgical trauma (thyroidectomy)
Paramedian position of both the cords
Good VoiceStridor – Degree VariableDyspnoea
Dyspnoea and stridor become worse on exertion or during an attack of acute laryngitis
Tracheostomy
Cord lateralisation:1.Arytenoidectomy2.Cord lateralisation through endoscope3.Thyroplasty type II4.Cordectomy5.Nerve muscle implant (sternohyoid muscle with its nerve supply is transplanted into the paralysed posterior cricoarytenoid)
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Aim to move and fix the cord in lateral position to improve the airway
Various procedures are Arytenoidectomy: can be done by external approach,
endoscopic or by using LASER Thyroplasty type 2 Cordectomy: can be done through external,
endoscopic or by using LASER Nerve muscle implant: sternohyoid muscle with its
nerve supply is transplanted into the paralysed posterior cricoarytenoid to bring some movement
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• Unilateral Unilateral Usually it’s a part of combined paralysis,
isolated lesions are rare Causes paralysis of cricothyroid muscle and
ipsilateral anesthesia of the larynx above the vocal cord
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Voice is weak and pitch can not be raised Occasional aspiration may be present Askew position of glottis as anterior
commissure is rotated to the healthy side Shortening of the cord with loss of
tension As tension of the cord is lost , it sags
down during inspiration and bulges up during expiration
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• Bilateral Bilateral This is uncommon condition Both Cricothyroids are paralysed along with
anesthesia of upper part of larynx Etiology: surgical, accidental trauma,
neuritis, neoplastic (pressure by metastatic lymph nodes)
Clinical features: weak and husky voice, aspiration causing cough and choking fits
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Depends on cause, neuritis recovers spontaneously
Troublesome aspiration requires tracheostomy with cuffed tube and esophageal feeding tube
Epiglottopexy is an operation to close laryngeal inlet to protect the lungs from repeated aspiration, it’s a reversible process
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• UnilateralUnilateral This causes paralysis of all the muscles of larynx on
one side except interarytenoid which receives innervation from the opposite side
EtiologyEtiology: thyroid surgery is the most common cause
It may also occur in the lesions of nucleus ambiguus or that of the vagus nerve proximal to origin of SLN
Thus lesion may lie in medulla, posterior cranial fossa, jugular foramen or parapharyngeal space
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• Clinical features:Clinical features: Vocal cord will lie in cadeveric position Healthy cords fails to compensate This causes hoarseness of voice and
aspiration of liquids through the glottis Cough is ineffective due to air waste
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Speech therapy Procedures to medialise the cord Injection of Teflon paste Thyroplasty type 1 Muscle or cartilage implant Arthrodesis of cricothyroid joint
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• Bilateral Bilateral Both RLN and SLN are paralysed on both
sides Both cords lie in cadeveric position and there
is total anaesthesia of the larynx
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Clinical features
Dysphonia Aspiration Inability to cough Bronchopneumonia
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• Treatment:Treatment: Tracheostomy Epiglottopexy: epiglottis is folded backwards
and fixed to the arytenoids Vocal cord plication Total laryngectomy
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May be unilateral or bilateral Unilateral is more common May be due to birth trauma, congenital
anomalies of great vessels of heart Bilateral paralysis may be due to
hydrocephalus, arnold-chiari malformations, intracerebral hemorrhage during birth, meningocoele, nucleus ambiguus agenesis
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AETIOLOGY POSITION OF CORDS
CLINICAL FEATURES
TREATMENT
Discussed above Median or paramedian position
Does not move laterally on deep inspiration
No symptoms Initial hoarseness
(disappears) Aspirate liquids Weak cough Voice gradually
improves due to compensation by the healthy cord
Generally no treatment required
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AETIOLOGY POSITION OF CORDS
CLINICAL FEATURES
TREATMENT
NeuritisSurgical trauma (thyroidectomy)
Paramedian position of both the cords
Good VoiceStridor – Degree VariableDyspnoea
Dyspnoea and stridor become worse on exertion or during an attack of acute laryngitis
Tracheostomy
Cord lateralisation:1.Arytenoidectomy2.Cord lateralisation through endoscope3.Thyroplasty type II4.Cordectomy5.Nerve muscle implant (sternohyoid muscle with its nerve supply is transplanted into the paralysed posterior cricoarytenoid)
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AETIOLOGY LARYNGEAL FINDINGS
CLINICAL FEATURES
TREATMENT
Thyroid surgeryTrauma to neckTumorsNeuritisDiphtheria
Askew position of glottis as anterior commissure is rotated to the healthy side
Shortening of cord with loss of tension
The paralysed cord appears wavy due to lack of tension
Flapping of the paralysed cord
Voice is weak
Pitch cannot be raised
Anaesthesia of the larynx on one side may pass unnoticed or cause occasional aspiration
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AETIOLOGY LARYNGEAL FINDINGS
CLINICAL FEATURES
TREATMENT
Very rare
Both cricothyroid muscles are paralysed along with anaesthesia of upper larynx
•Surgical or accidental trauma•Neuritis (mostly diphtheritic)•Pressure by cervical nodes•Involvement in a neoplastic process
Absence of anterior tilt allows the epiglottis to hang more over endolarynx.
Slightly flaccid, bowed and hyperaemic vocal cord.
Voice is weak and husky
Cough and choking fits due to inhalation of food and pharyngeal secretions
Depends on cause:•Neuritis : May recover spontaneously•Repeated aspiration: Tracheostomy with a cuffed tube and oesophageal feeding tube•Epiglottopexy: Operation to close the laryngeal inlet to protect the lungs from repeated aspiration
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AETIOLOGY LARYNGEAL FINDINGS
CLINICAL FEATURES
TREATMENT
Thyroid surgery (most common)
Lesions of the nucleus ambiguus
Lesions of the vagus nerve proximal to the origin of the SLN (lesions in the medulla, posterior cranial fossa, jugular foramen or parapharyngeal space)
Vocal cord in cadaveric position
The healthy cord is unable to approximate the paralysed cord, thus causing glottic incompetence
Hoarseness of voice
Aspiration of liquids
Weak cough
Speech therapy
Procedures to medialise the cord:1.Injection of teflon paste lateral to paralysed cord2.Thyroplasty type I3.Muscle or cartilage implant4.Arthrodesis of cricoarytenoid joint
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AETIOLOGY LARYNGEAL FINDINGS CLINICAL FEATURES TREATMENT
Rare Both cords lie in cadaveric position
All laryngeal muscles are paralysed
Total anaesthesia of the larynx
Dysphonia
Aspiration
Inability to cough
Bronchopneumonia due to repeated aspiration and retention of secretions
Tracheostomy
Epiglottopexy
Vocal cord plication
Total laryngectomy (in cases where the cause is progressive and irreversible and speech is unserviceable)
Diversion procedures
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Surgical procedures designed to improve quality of voice
Excision of benign or malignant lesions by Microlaryngeal surgery or laser
Teflon paste injection to vocal cords Thyroplasty Laryngeal reinnervation procedures: segment
of anterior belly of omohyoid muscle carrying its nerve and vessels is implanted into thyroarytenoid muscle
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• ISSHIKI CLASSIFICATIONISSHIKI CLASSIFICATION Type 1: Medialization …Type 1: Medialization … Type 2: Lateralization…Type 2: Lateralization… Type 3: Shortening……..Type 3: Shortening…….. Type 4: Lengthening Type 4: Lengthening
( tightening) ………………( tightening) ………………
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