Devashish Kamra Roll no.

45/09

SENSORY SUPPLY SUPRAGLOTTIC PART internal branch of superior laryngeal nerve

GLOTTIC & INFRAGLOTTIC PART Recurrent Laryngeal Nerve

 MOTOR

SUPPLY All the muscles of larynx are supplied by recurrent laryngeal nerve except the cricothyroid which is supplied by external branch of superior laryngeal nerve. Motor cortex has a b/l representation of both vocal cords.

ADDUCTORS
Lateral cricoarytenoid Transverse arytenoid Oblique arytenoid

ABDUCTOR
Posterior cricoarytenoid

TENSOR
Thyroarytenoid (including vocalis muscle) Cricothyroid

PROTECTION & MAINTENANCE OF AIRWAYS

Sphincteric closure of laryngeal opening Cessation of respiration Cough reflex

i. ii.

iii.

PHONATION(aerodynamic myeloelastic theory of voice production) REGULATION OF RESPIRATORY FLOW FIXATION OF CHEST

SUPRANUCLEAR-rare as only b/l cortical lesions will

produce paralysis. When present ,they are ass. with other neurological defects. Laryngeal paralysis is b/l & after short period of flaccidity becomes spastic.

NUCLEAR-Nucleus Ambiguous involved. It leads to complete

motor paralysis without sensory involvement. Vocal cord is flaccid.ass. with lesion of cranial nerves.

HIGH VAGAL LESION(leading to combined SLN & RLN

paralysis)-Vagus nerve involved in skull, exit from jugular foramen or parapharyngeal space.

LOW VAGAL LESION-RLN paralysis

Supranuclear and nuclear lesions are caused due to neurological defects like Amyotrophic Lateral sclerosis,diabetes,Poliomyelitis,Shy-Dragger Syndrome ,Arnold Chiari Malformation,syringobulbia,vascular & neoplastic disorders. HIGH VAGAL LESIONS CAUSESINTRACRANIAL Tumors of posterior fossa Basal meningitis SKULL BASE Fractures Nasopharyngeal cancers Glomus tumor NECK Penetrating injury Parapharyngeal tumors Metastatic nodes

Lymphoma

MOST COMMON CAUSE IS TOTAL THYROIDECTOMY

NECK CAUSES
Thyroid surgery Benign or malignant thyroid disease Carcinoma cervical esophagus Neck trauma Cervical lymphadenopathy

MEDIASTINAL CAUSES
RIGHT Aneurysm of subclavian artery Carcinoma apex right lung TB of cervical pleura Idiopathic LEFT Bronchogenic cancer Carcinoma thoracic esophagus Aortic aneurysm Mediastinal LAP Enlarged left auricle Intrathoracic surgery idiopathic

Early detection requires thorough evaluation of any paralysis with no apparent cause. Complete ENT examination exam with endoscopy is the baseline. Associated nerve deficits esp. cranial nerves is seen to determine 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 stimulation laryngeal muscles gives more info. & potential of recovery.

UNILATERAL PARALYSIS

Vocal cord median or paramedian position generally but not always

Semons

law- abductor fibres more

susceptible than adductor as they are phylogenetically new.

Wagner

and Grossman Hypothesis- cricothyroid spared causing

adduction
But vocal cords can tense, move slightly.

 CLINICAL

FEATURES-

Asymptomatic in 1/3rd patients.

ACUTE ONSET PARALYSIS-weak voice but later gets compensated . GRADUAL ONSET PARALYSIS-compensation occurs progressively & symptoms are minimal. TREATMENT Depends on the final position of vocal cord. If the paralyzed cord is unable to bridge the gap leading to hoarseness of voice then medialisation of cord is done. It could be done by vocal cord injection or by surgical procedures like thyroplasty.

 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

TREATMENT
TRACHEOSTOMY 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 lateralization of the cord is done to secure the airway. Tracheostomy relieves stridor & preserve good voice with 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 compromise with voice.

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 laryngeal tissue Requires a mobile arytenoid Complete laser cordectomy considered rarely.

 Endoscopic techniques with

arytenoidectomy(Thornell 1948) Mucosal incision made on top of arytenoid and the cartilage dissected & extracted. Complications

granuloma formation at site of incision web formation in posterior commissure

It was simplified by Laser

 Extralaryngeal

approach arytenoids are removed by an external approach. This is a difficult approach mastered by few operators. Implantable devices
Midline thyrotomy

Induced Paralysis to SLN Motor Reinnervation

Practically obsolete

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

BILATERAL PARALYSIS Leads to paralysis of both cricothyroid muscles along with anaesthesia of upper larynx. Paralysis + anaesthesia b/l leads to repeated aspiration Voice weak and husky TREATMENT Depends upon cause; neuritis patients recover spontaneously. Patients with repeated aspiration require tracheostomy with a cuffed tube & an esophageal feeding tube. Epiglottopexy done to close laryngeal inlet to protect lungs from aspiration.

 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(earlier known as cadaveric position) i.e. 3.5 mm from midline. Healthy cord is unable to reach paralyzed cord, therefore leads to hoarseness of voice and aspiration of liquids through glottis. Cough ineffective due to improper adduction.

TREATMENT Speech Therapy-helps in compensating the function of paralyzed cord due to movement of healthy cord across the midline.
PROCEDURES TO MEDIALISE THE PARALYSED CORDa) Vocal cord injectionPrinciple-lateral side of vocal process is injected with an inert material so as to push the cord to medial side. If necessary then lateral midportion of cord is injected. Materials used for injection Paraffin initially Gelfoam Fat Teflon(with glycerine as a base) Bovine collagen

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 lateral to vocal cord, pushing the cord medially. Done in the presence of a very large gap >3-4mm at posterior commissure can be done in severely scarred larynx where vocal cord injection is not possible.

Vocal cord reinnervation selective reinnervation of adductors is done to bring cords to midline. Arthrodesis of cricoarytenoid joint-Larynx is opened by a laryngofissure,arytenoid cartilage rotated medially and fixed with a screw.

BILATERAL PARALYSISBoth RLN & SLN of both sides are paralyzed. It is a rare condition. Both cords lie in intermediate position with total anaesthesia of larynx. CLINICAL FEATURES Aphonia Aspiration Inability to cough Bronchopneumonia due to repeated aspiration and retention of secretions.

TREATMENT Tracheostomy Epiglottopexy Vocal Cord plication-mucosa of true and false cords is removed & then they are approximated with sutures. It helps prevent aspiration and can be reversed when required. Total laryngectomy done when cause is progressive and speech is unserviceable. Diversion Procedures

Median

Phonation RLN paralysis

Paramedian (1.5mm)

Strong whisper RLN paralysis

Intermediate (3.5 mm)

Paralysis of both RLN & SLN cadaver Quiet respiration Paralysis of adductors

Gentle abduction(7mm)

Full abduction
(9.5mm)

Deep inspiration

May be unilateral or bilateral; Unilateral paralysis 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 hemorrhage during birth, meningocoele or cerebral or nucleus ambiguous agenesis.

a) b) c)

d)

Excision of benign & malignant lesions by laser or microsurgery. Vocal Cord Injection THYROPLASTY-Ishikki divided thyroplasty procedures into 4 categoriesType I-medial displacement of vocal cord Type II-lateral displacement of vocal cord Type III-it shortens(Relax) the vocal cord. This procedure lowers the pitch. It is done in mutational falsetto or in those who have undergone gender transformation from female to male. Type IV-It lengthens(tightens) the vocal cord & elevate the pitch. It converts male character of voice to female and thus used in gender transformation. Also used when vocal cord is lax due to ageing process or trauma. REINNERVATION

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