laryngeal paralysis 3

7/28/2019 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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laryngeal paralysis 3

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