Vocal cord palsy evaluation of hoarseness
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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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Vocal cord palsy & evaluation of hoarseness

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Vocal cord palsy evaluation of hoarseness

Vocal cord palsy & evaluation of hoarseness

Dr. Vishal Sharma


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


Development of arterial arches

Development of arterial arches


Final position of b l rln

Final position of B/L RLN


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


Vocal cord palsy evaluation of hoarseness

Dual innervation of inter-arytenoid muscles


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


Etiology of recurrent laryngeal nerve palsy

Etiology of recurrent laryngeal nerve palsy


Vocal cord palsy evaluation of hoarseness

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


Joll s triangle for sln

Joll’s triangle for SLN


Beahr s triangle for rln

Beahr’s triangle for RLN


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


Position of vocal cords

Position of vocal cords


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.”


Vocal cord palsy evaluation of hoarseness

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


Vocal cord palsy evaluation of hoarseness

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


Clinical features

Clinical Features


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


Vocal cord palsy evaluation of hoarseness

Asymptomatic (1/3rd unilateral paralysis)


Specific investigations

Specific Investigations


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


Phonetogram

Phonetogram


Aerodynamic analysis

Aerodynamic analysis


Vocal cord palsy evaluation of hoarseness

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


Spectrogram

Spectrogram


Shimmer jitter

Shimmer & Jitter


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


Video stroboscopy

Video-stroboscopy


Vocal cord palsy evaluation of hoarseness

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.


Electroglottography

Electroglottography


Photoglottography

Photoglottography


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


Flow volume loop analysis

Flow volume loop analysis


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)


Electromyography

Electromyography


Treatment for phonatory gap in u l abductor or adductor palsy

Treatment for phonatory gap in U/L abductor or adductor palsy


Vocal cord palsy evaluation of hoarseness

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


Per oral teflon injection1

Per-oral Teflon injection


Vocal fold teflon injection

Vocal fold Teflon injection


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


Percutaneous teflon injection1

Percutaneous Teflon injection


Midline lateral routes

Midline & lateral routes


Vocal fold fat injection

Vocal fold fat injection


Vocal fold collagen injection

Vocal fold collagen injection


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 i

Thyroplasty type I


Thyroplasty type i1

Thyroplasty type I


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


Vocal cord palsy evaluation of hoarseness

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


Type i thyroplasty

Type I thyroplasty


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)


Insertion of prosthesis

Insertion of prosthesis


Insertion of silastic prosthesis

Insertion of silastic prosthesis


Silastic implant

Silastic implant


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


Arytenoid adduction1

Arytenoid adduction


Arytenoid adduction2

Arytenoid adduction


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)


Neuromuscular pedicle

Neuromuscular pedicle


Neuromuscular pedicle1

Neuromuscular pedicle


Neuromuscular pedicle2

Neuromuscular pedicle


Ansa r l n anastomosis

Ansa-R.L.N. anastomosis


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


Treatment of stridor in b l abductor paralysis

Treatment of stridor in B/L abductor paralysis


Vocal cord palsy evaluation of hoarseness

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 laterofixation cordopexy

Vocal cord lateralization (laterofixation / cordopexy)


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


Cordectomy

Cordectomy


Cordectomy lateralization

Cordectomy + lateralization


Posterior cordotomy

Posterior cordotomy


Arytenoidectomy

Arytenoidectomy


Cordotomy arytenoidectomy

Cordotomy + arytenoidectomy


Thyroplasty type ii lateralization

Thyroplasty type II (lateralization)


Treatment for bilateral adductor paralysis causing chronic aspiration

Treatment for bilateral adductor paralysis causing chronic aspiration


Vocal cord palsy evaluation of hoarseness

  • 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


Endolaryngeal stent

Endolaryngeal stent


Epiglottic flap closure

Epiglottic flap closure


Epiglottopexy

Epiglottopexy


Epiglottic tube laryngoplasty

Epiglottic tube laryngoplasty


Glottic closure

Glottic closure


Subperichondrial cricoidectomy

Subperichondrial cricoidectomy


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


Narrow field laryngectomy

Narrow field laryngectomy


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


Laryngeal suspension

Laryngeal suspension


Other vocal cord surgeries

Other vocal cord surgeries


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


Evaluation of hoarseness dysphonia

Evaluation of Hoarseness (dysphonia)


Causes of hoarseness

Causes of Hoarseness


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


Vocal cord palsy evaluation of hoarseness

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


Vocal cord palsy evaluation of hoarseness

  • 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


Vocal cord palsy evaluation of hoarseness

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


Thank you

Thank You


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