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Vocal cord palsy & evaluation of hoarseness. Dr. Vishal Sharma. Nerve supply of larynx. Motor supply of intrinsic muscles: Cricothyroid muscle: superior laryngeal nerve All other muscles: recurrent laryngeal nerve Sensory: Above vocal cord: superior laryngeal nerve

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nerve supply of larynx
Nerve supply of larynx

Motor supply of intrinsic muscles:

Cricothyroid muscle:superior laryngeal nerve

All other muscles:recurrent laryngeal nerve

Sensory:

Above vocal cord:superior laryngeal nerve

Below vocal cord:recurrent laryngeal nerve

recurrent laryngeal nerve
Recurrent laryngeal nerve

Right:

  • Arises from vagus at level of right subclavian artery & hooks around it

Left:

  • Arises from vagus in mediastinum at level of arch of aorta & loops around it
superior laryngeal nerve
Superior laryngeal nerve
  • Arises from inferior ganglion of vagus
  • Descends behind internal carotid artery at level of greater cornu of hyoid bone divides into external & internal branches
  • External motor branch:to cricothyroid muscle
  • Internal sensory branch:pierces thyrohyoid membrane to enter larynx
classification
Classification

A. Incomplete paralysis

1. Recurrent laryngeal nerve palsy

a. Left (75% ), Right (15%), B/L (10%)

b. Abductor, Adductor

2. Superior laryngeal nerve palsy

B. Combined paralysis / complete paralysis

causes of laryngeal paralysis
Causes of laryngeal paralysis

Supra-nuclear

Nuclear:nucleus ambiguus

High vagal lesions:combined palsy

Low vagal lesions: recurrent laryngeal nerve palsy

Systemic causes

Idiopathic

causes of combined paralysis
Causes of combined paralysis

IntracranialNeck

Tumors of posterior fossaPenetrating injury

Basal meningitis (TB) Parapharyngeal tumors

Skull baseMetastatic neck nodes

Fractures Lymphoma

Nasopharyngeal cancer Thyroid surgery

Glomus tumour

slide14
Malignancy (25%):lung (>50%), thyroid, esophageal, nasopharyngeal, metastatic neck node

Surgical trauma (20%):during surgeries of lung, heart, thyroid, esophagus, mediastinum

Inflammatory (13%):tuberculosis, syphilis

Idiopathic (13%):viral neuritis

Non-surgical trauma (11%):accidental neck trauma,

left atrial enlargement (Ortner), aortic aneurysm

Neurological (7%):CVA, head injury, Parkinsonism, multiple sclerosis, alcoholic / diabetic neuropathy

Others (11%):rheumatoid arthritis, haemolytic anemia

causes of left rln palsy 75
Neck

 Accidental trauma

 Thyroid disease

 Thyroid surgery

 Ca esophagus

 Lymphadenopathy

Mediastinum

 Bronchogenic ca

 Ca esophagus

 Aortic aneurysm

 Lymphadenopathy

 Enlarged left atrium

 Intra-thoracic surgery

Causes of left RLN palsy (75%)
causes of right rln palsy 15
Causes of right RLN palsy (15%)
  • Neck trauma
  • Thyroid disease
  • Thyroid surgery
  • Ca cervical esophagus
  • Cervical lymphadenopathy
  • Aneurysm of subclavian artery
  • Ca apex right lung
  • TB of cervical pleura
causes of b l rln palsy 10
Causes of B/L RLN palsy (10%)
  • Thyroid surgery
  • Ca thyroid
  • Cancer cervical esophagus
  • Cervical lymphadenopathy
congenital vocal cord paralysis
Congenital vocal cord paralysis

Unilateral:birth trauma, congenital anomaly of great vessel or heart

Bilateral:

 Hydrocephalus Meningocoele

 Arnold-Chiari malformation Cerebral agenesis

 Intra-cerebral hemorrhage Nucleus ambiguus agenesis

thyroid surgery
Thyroid surgery

Joll’s sterno-thyro-laryngeal triangle for S.L.N.:

Lateral = superior thyroid vessels & upper thyroid pole; superior = attachment of strap muscles to thyroid cartilage; medially = midline

Beahr’s triangle for recurrent laryngeal nerve:

Lateral = common carotid artery; superior = inferior thyroid artery; medial = tracheo-esophageal groove + recurrent laryngeal nerve

why right rln commonly damaged in thyroid surgery
Why right RLN commonly damaged in thyroid surgery?
  • Right recurrent laryngeal nerve more superficial
  • Right nerves enters thyroid at 450 angle but left lies in tracheo-esophageal groove
  • Right nerve mostly passes superior to or b/w branches of inferior thyroid artery; left nerve mostly passes deep to inferior thyroid artery
semon s law
Semon’s Law

Rosenbach (1880) & Semon (1881)

“In all progressive organic lesions, abductor fibres of recurrent laryngeal nerve, which are phylogenetically newer, are more susceptible and thus first to be paralyzed compared to adductor fibres.”

slide26

1st stage:only abductor fibres damaged; vocal folds approximate in midline; adduction still possible (paramedian position)

2nd stage:contracture of adductors; vocal folds immobilized in median position

3rd stage:adductors become paralyzed; vocal fold assumes cadaveric position

why abductors affected first
Why abductors affected first ?
  • Nerve fibres supplying abductors are in periphery of recurrent laryngeal nerve
  • Muscle bulk for the abductors is less, more susceptible
  • Phylogenetically, larynx’s main function is protection, so adductor functions are maintained
wagner grossman theory
Wagner & Grossman Theory

In isolated paralysis of recurrent laryngeal nerve, cricothyroid muscle (which receives innervation from superior laryngeal nerve) keeps vocal cord in paramedian position due to adductor function

In superior laryngeal nerve palsy, cord lies in intermediate (cadaveric) position

modern theory
Modern theory

Final position of paralyses vocal cord is not static & is decided by:

  • Degree of paralyzed muscle atrophy& fibrosis
  • Degree of re-innervation following injury
  • Extent of synkinesis (mass movement) of all intrinsic muscles
  • Fibrosis & ankylosis of crico-arytenoid joint
slide30

Intermediate position of vocal cords in RLN palsy?

Retrograde atrophy of vagus nerve occurs up to nucleus ambiguus

Stretching of RLN by enlarged intra-thoracic lesions pulls vagus nerve down from skull base, injuring superior laryngeal nerve

lesion above pharyngeal branch
Lesion above pharyngeal branch
  • Inability to elevate soft palate, nasal intonation, nasal regurgitation & nasal emissions
  • Gag reflex reduced or absent due to palsy of internal branch of superior laryngeal nerve
  • Hoarseness due to palsy of intrinsic muscles of larynx
voice assessment
Voice assessment

1. Magnetic tape recording:for self assessment

2. Performance assessment by examiner: maximum phonation time & range of speech frequencies

3. Phonetogram:plot of pitch vs. intensity of voice

4. Aerodynamic analysis: phonatory airflow rate, subglottic pressure & laryngeal resistance

slide41
5. Fourier’s Spectral analysis (Spectrogram)
  • Fundamental frequency:lowest speech frequency
  • Shimmer:average cycle to cycle difference in amplitude of sound
  • Jitter:average cycle to cycle difference in duration of glottal cycle

In hoarseness there is increased shimmers & jitters

analysis of cord movement
Analysis of cord movement

1. Rigid 700 video-telescopy ↓LA

2. Fibreoptic video-laryngoscopy

3. Stroboscopy: Intermittent flash light focussed on vocal cords during phonation. Frequency of light made 2 msec slower to cord frequency. Produces slow motion movement of vocal cords for better analysis of cord movement

slide46
4. Electro-glottography: 2 electrodes placed on both sides of thyroid cartilage & current passed b/w them. Recorded waveform shows impedance across larynx & is highest during contact b/w vocal cords. Records closing phase of glottal cycle.

5. Photo-glottography:fibreoptic light source passes light via glottis & is received by photo-sensor on neck skin. Light received  glottic chink. Records opening phase of glottal cycle.

radiological
Radiological
  • Submento-vertical skull base view
  • X-ray neck AP & lateral view
  • Chest X-ray PA view
  • Barium swallow AP & lateral oblique view
  • High resolution CT scan with contrast from skull base to mid thorax:gold standard
  • M.R.I.:ideal for skull base lesions
  • Thyroid scan
endoscopy
Endoscopy

1. Rigid 700 Telescopy ↓ LA

2. Fibreoptic Laryngoscopy ↓ LA

3. Pan-endoscopy ↓ GA (for metastatic node):

a. Nasopharyngoscopy

b. Micro-laryngoscopy: probe test on arytenoids

c. Bronchoscopy & bronchial washings

d. Hypopharyngoscopy

e. Oesophagoscopy

fibre optic laryngoscopy
Fibre-optic laryngoscopy

paralyzed vocal fold is foreshortened, lateralized & flaccid

b l abductor palsy
B/L abductor palsy

Inspiration

Expiration

biopsy for suspected malignancy
Biopsy for suspected malignancy

1. F.N.A.B. from enlarged lymph nodes

2. Punch biopsy from visible growth

3. Blind biopsy from (if metastatic node present):

  • Fossa of Rosenmuller
  • Base of tongue
  • Pyriform fossa
  • Laryngeal ventricles
  • Bronchial carina
respiratory function test
Respiratory function test

1. Conventional spirometry

2. Flow-Volume Loop analysis

  • Variable extra-thoracic obstruction:↓ed inspiratory flow
  • Intra-thoracic obstruction:↓ed expiratory flow
  • Fixed obstruction:↓ed inspiratory + expiratory flow
other investigations
Other investigations

Blood: ESR, serology for syphilis

Electromyography of intrinsic laryngeal muscles:

a. Normal: Joint fixation, post - scarring

b. Fibrillation:Denervation (bad prognosis)

c. Polyphasic:Synkinesis, Re-innervation (good prognosis)

slide59

Speech therapy:for 2-12 months(usual treatment)

Vocal cord injection:with Teflon / fat / collagen

Medialization thyroplasty (Isshiki type I)

Arytenoid adduction: for posterior approximation

Arytenoidopexy: medial rotation + fixation

Laryngeal re-innervation

Combination of above

indications for immediate surgical intervention
Indications for immediate surgical intervention
  • Electromyography shows fibrillation (complete loss of function with no signs of recovery)
  • Vocal cord palsy due to nerve entrapment in thyroid / bronchial malignancy where recovery is not expected
per oral teflon injection
Per-oral Teflon injection
  • Kleinsasser’s microlaryngoscope introduced
  • Bruning’s syringe loaded with Teflon paste
  • Needle pushed lateral to thyroarytenoid muscle
  • First injection at postero-lateral angle of middle third of vocal cord, 2.5 mm lateral to cord margin
  • Second injection (0.2 ml) made at antero-lateral angle till both cords approximate in phonation
  • I.V. Dexamethasone given for 24 hours
percutaneous teflon injection
Percutaneous Teflon injection
  • Needle introduced in midline through crico-thyroid membrane angled 300 - 450 upward & laterally into vocal cord
  • Direct lateral penetration of larynx through thyroid ala is alternate route of injection
  • Vocal cord entered under endoscopic control
isshiki s thyroplasty
Isshiki’s Thyroplasty
  • Type 1 (medial displacement)
  • Type 2 (lateral displacement)
  • Type 3 (shortening or relaxation)
  • Type 4 (elongation of tensioning)

Thyroplasty is reversible, does not invade vocal folds nor alters their mass or stiffness unlike vocal fold injection

thyroplasty type i2
Thyroplasty type I

Horizontal skin incision made over mid-point of thyroid cartilage lamina (from a point 2 cm lateral to midline on opposite side to posterior margin of thyroid cartilage on affected side)

Subplatysmal flaps elevated & strap muscles retracted laterally to expose thyroid cartilage

Window made in thyroid lamina with scalpel or 1 mm cutting burr, as per Koufman’s formula

slide73

Window’s superior border lies at level with vocal cords (midpoint b/w thyroid notch & inferior margin of thyroid cartilage) & its anterior border situated 8 mm posterior to midline

Cartilage removal started postero-inferiorly

Inner perichondrium elevated off thyroid cartilage & silastic prosthesis inserted

Patient asked to phonate while moving silastic prosthesis into its optimal position under flexible laryngoscopy guidance

koufman s formula
Koufman’s formula

Window height (mm)=thyroid alar height (mm) – 4 ------------------------------------- 4  

Window width (mm) =thyroid alar height (mm) – 4 ------------------------------------ 2

Average = 12 X 6 mm (male); 10 X 5 mm (female)

arytenoid adduction
Arytenoid adduction

Portion of posterior thyroid cartilage margin cut to expose muscular process of arytenoid

Two 4-0 Prolene sutures passed through muscular process & through thyroid cartilage

Sutures pulled parallel to lateral cricoarytenoid

After optimal medialization of vocal fold, sutures tied on external aspect of thyroid lamina

laryngeal re innervation
Laryngeal re-innervation

Neuromuscular pedicle of superior belly of omohyoid (or sternohyoid) + ansa hypoglossi nerve transferred into thyro-arytenoideus for vocal fold medialization; or posterior crico-arytenoideus for lateralization (Tucker)

Neural anastomosis of ansa hypoglossi nerve directly to recurrent laryngeal nerve (Crumley)

combination surgeries
Combination surgeries

Neuromuscular pedicle re-innervation + Thyroplasty type 1

Thyroplasty type 1 + arytenoid adduction

Arytenoid adduction has advantage of posterior glottic approximation unlike thyroplasty

slide89
Tracheostomy:temporary / permanent in acute stridor

Vocal cord lateralization:endoscopic, external (King)

Vocal cordectomy:external, endoscopic

Endoscopic vocal cordotomy:knife, cautery, laser

Arytenoidectomy:endoscopic, external (Woodman)

Lateralization thyroplasty (Isshiki type II)

Laryngeal re-innervation:ansa hypoglossi-omohyoid pedicle transfer into posterior crico-arytenoideus

vocal cord lateralization
Vocal cord lateralization
  • Thyroid cartilage exposed via horizontal incision
  • 16-gauge IV cannula inserted through thyroid cartilage 4 mm anterior & 2 mm below mid-point of oblique line, into laryngeal lumen, just above tip of vocal process, under M.L.S. guidance
  • Another 16-gauge IV cannula inserted 5 mm below 1st cannula, just below tip of vocal process
vocal cord lateralization1
Vocal cord lateralization
  • 1-0 Prolene suture threaded through inferior cannula into laryngeal lumen
  • Suture thread brought out with forceps into laryngeal lumen & inserted into superior cannula
  • External traction put on both suture ends to pull vocal cord laterally to give a 5 mm airway
  • Threads tied over thyroid lamina 8 times
slide100
Endolaryngeal stenting (solid & vented)
  • Epiglottic flap closure
  • Epiglottopexy to posterior pharyngeal wall
  • Epiglottic tube laryngoplasty
  • Glottic closure
  • Sub-perichondrial cricoidectomy
  • Tracheo-esophageal diversion
  • Laryngo-tracheal separation
  • Narrow field laryngectomy
tracheo esophageal diversion
Tracheo-esophageal diversion
  • Proximal trachea anastomosed with esophagus
  • Distal trachea opens into permanent tracheostomy
laryngo tracheal separation
Laryngo-tracheal separation
  • Proximal trachea closed
  • Distal trachea opens into permanent tracheostomy
other procedures for aspiration
Other procedures for aspiration
  • Double cuff tracheostomy
  • Laryngeal suspension
  • Feeding Gastrostomy
  • Feeding Jejunostomy
  • Vocal cord injection
  • Medialization thyroplasty
  • Laryngeal re-innervation
  • Tympanic / Chorda tympani neurectomy
thyroplasty type iii shortening
Thyroplasty type III (shortening)

Used for mutational falsetto

thyroplasty type iv elongation
Thyroplasty type IV (elongation)

Used for raising vocal pitch & ing vocal tension

mechanism of hoarseness
Mechanism of hoarseness
  • Loss of approximation of vocal cords:in paralysis, fixation or intervening tumor / lesions
  • Alteration of size of vocal cord:ed in edema, tumor; ed in partial surgical excision, fibrosis
  • Alteration of stiffness of vocal cord:ed in spasmodic dysphonia, fibrosis; ed in paralysis
  • Improper vibration of vocal cord:hyperemia, vocal nodule, vocal polyp
slide118
10 organic dysphonia20 organicdysphonia

1. Congenital *1. Laryngitis *

2. Laryngeal tumor *2. Vocal nodule

3. Vocal cord palsy3. Vocal polyp

4. Spasmodic4. Reinke’s edema

5. Muscular *Functional dysphonia

6. Neurological *1. Psychogenic

7. Endocrine *2. Habitual

8. Senile3. Puberphonia

9. Fixation by arthritis4. Ventricular *

10. Traumatic *5. Malingering

slide119
Congenital:laryngomalacia, laryngocoele, haemangioma, web
  • Laryngeal tumor:papilloma, malignancy
  • Muscular:myasthenia gravis
  • Neurological:Parkinsonism, Multiple sclerosis, cerebro-vascular accident, bulbar palsy
  • Endocrine:hypothyroidism, inter-sex, pregnancy
  • Traumatic: accidental, foreign body, intubation
  • Laryngitis:bacterial, viral, TB, allergic, GERD
  • Ventricular:dysphonia plica ventricularis
history taking
History taking

1. Duration:> 3 weeks in pt > 40 years is laryngeal malignancy until proven otherwise

2. Progression:due to mass effect or malignancy

3. Voice quality:

a. Forced whisper:Organic adductor paralysis

b. Faint whisper:Functional adductor paralysis

c. Tires with use:U/L abductor paralysis, myasthenia

slide121
4. Associated symptoms:

a. Stridor:B/L abductor paralysis

b. Aspiration:B/L adductor paralysis

c. Dysphagia + exertion dyspnea:Ortner’s syndrome

d. Hemoptysis:lung malignancy, tuberculosis

e. Nasal regurgitation & intonation: high vagal lesion

5. Past history:

a. Trauma:accidental, foreign body, intubation

b. Surgery:thyroid, intra-thoracic

c. Viral upper respiratory tract infection, smoking

physical examination
Physical Examination
  • Listening to patient’s voice: for hoarseness
  • Indirect laryngoscopy:laryngeal lesions
  • Otoscopy:rule out glomus tumor
  • Neck:lymph node enlargement, thyroid disease
  • Chest:lung malignancy, tuberculosis
  • Cardiovascular:mitral stenosis
  • Neurological:Parkinsonism, multiple sclerosis
manual compression test
Manual compression test

Improvement in voice = do thyroplasty (anterior

medialization procedure).No improvement in voice = do

arytenoid adduction (posterior medialization procedure)

routine investigations
Routine investigations
  • Fibre-optic laryngoscopy
  • Microlaryngoscopy: crico-arytenoid joint mobility
  • CT scan skull base to diaphragm:best
  • X-ray chest:for hemoptysis
  • Ba swallow:for dysphagia
  • Thyroid scan:for thyroid enlargement
  • Panendoscopy:in presence of hard neck node
ad