Vocal Cord Paralysis

Overview

Anatomy of the Larynx Function of the Larynx Causes of Vocal Cord Paralysis Evaluation of Vocal Cord Paralysis Treatment for unilateral & Bilateral Vocal Cord Paralysis

Anatomy of the Larynx - Cartilages

Anatomy of the Larynx - Cartilages

Anatomy of Larynx - Muscles

Anatomy of Larynx - Muscles

Anatomy of Larynx - Nerves

Anatomy of Larynx - Nerves

Anatomy of Larynx - Motion

Tensor: cricothyroid muscle

Anatomy of the Larynx - Motion

Adductors of the Vocal Folds:

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Anatomy of the Larynx - Motion

Abductor of Larynx: posterior cricoarytenoid muscle

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Histology of vocal folds

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Function of Larynx

Passage for Respiration Prevents Aspiration Allows Phonation Allows Stabilization of Thorax

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Respiration

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Phonation

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Vocal Cord Paralysis

o Etiology o Evaluation o Treatment

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Etiology:

Thyroid
Tumors Surgery

Thoracic
Tumors:

mediastinal, bronchial & esophageal Surgery

Skull base:
Nasopharyneal

metastasis Surgery

carcinoma, Cervical
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Etiology: surgeries and procedures

Cervical surgery:thyroid and parathyroid surgery, anterior approach to cx. Spine, carotid endarterectomy, cricopharyneal myotomy Thoracic surgery: pneumonectomy, repair of crotid aneurysm, aortic valve replacement, CAPG, esophageal surgery, tracheal surgery, ligation of PDA, cardiac transplant. Neurosurgery: skull base surgery, brain stem surgery Endotracheal intubation & central venous line 18

Etiology: in adults
Cause Surgery Idiopathic Malignancy Trauma Neurologic Intubation Other Unilateral % 24 20 25 11 8 8 5 Bilateral % 26 13 17 11 13 18 5

Benninger et al.,Otolaryngol Head Neck Surg 1994;111-497-508

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Etiology in children

Meningoencephalocele Arnold Chiari malformation Patent ductus arteriosus Encephalitis Guillain-Barre syndrome Diphtheria Neurotoxicity e.g. Vincristine
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Clinical symptoms

Dysphonia: breathiness of voice or aphonia Stridor Aspiration and choking

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Evaluation: history taking

Tobacco Usage Voice Abuse URI Reflux Neurologic Disorders History of Trauma or Surgery Systemic Illness Rheumatoid Duration Affects Prognosis
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Evaluation Physical Examination

Complete Head and Neck examination Cranial nerves examination Mirror laryngoscopy Telescopic laryngoscopy Flexible transnasal Laryngoscopy 23

Mirror laryngoscopy

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Left cord paralysis- more common

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Evaluation - Imaging

Chest X-ray
Screen

for intrathoracic lesions for CNS disorders

MRI of Brain
Screen

CT Skull Base to Mediastinum

Thin

cuts through the laryngeal joints

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Left cord paralysis

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Evaluation
Barium swallow Thyroid scan Respiratory function tests Lab studies: VDRL, glucose tolerance test, lumbar puncture, ESR, Monospot test, arsenic , lead and mercury levels.

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Evaluation - Electromyography

Assesses integrity of laryngeal nerves Differentiates denervation from mechanical fixation of vocal cord movement
Electrode

in Thyroarytenoid and Cricothyroid

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EMG: for cricothyroid and thyroarytenoid

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Evaluation - Electromyography

Normal

Joint Fixation Post. Scar

Fibrillation

Denervation

Polyphasic

Synkinesis Reinnervation

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Evaluation- DL

Under general anesthesia Value:

Palpate

arytenoids with a laryngeal spatula esp. if no L-EMG Exclude laryngeal tumors Bronchoscopy & esophagoscopy

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Decision making: unilateral vocal paralysis

Primary cause Assess patients vocal requirements Adequacy of Airway and laryngeal competence

Assess extent of posterior glottic gap Position of Cords: Median, Paramedian, Lateral Surgery often not necessary in paramedian position

Duration of problem:

Do not perform irreversible interventions in patients with possibility of functional return for 6-12 months

Speech therapy initiated to remove hyperfunctional compensation 34

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Surgical management- Anesthesia

Local allows patient to phonate

Careful

administration of IV sedation Internal superior laryngeal nerve block at the thyrohyoid membrane Glossopharyngeal nerve block at the inferior pole of the tonsils Flexible endoscope allows visualization

General

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Transoral route under LA

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Percutaneous route under LA

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Management Vocal Cord Injection

In unilateral paralysis Adds fullness to the vocal cord to help it better appose the other side Into thyro-arytenoid/vocalis

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Vocal Cord Injection - Materials

Teflon: granuloma & migration Fat: absorption/ needs overcorrection Collagen

Autologous Collagen Homologous Micronized Alloderm Bovine Collagen: immune reaction

Hyaluronic Acid

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Injector

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Management Vocal Cord Injection

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Vocal Cord Injection

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Medialization thyroplasty- Ishiki type I

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Medialization thyroplasty- Ishiki type I

Different materials: cartilage, silastic Surgically reversible Excellent at closing anterior gap More invasive Misplacement Under-correction Infection 45

Manual compression

Helps to predict benefit of medialization thyroplasty

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Thyroplasty- Ishiki type I

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ManagementBilateral Abductor Paralysis

Patients exhibit lack of abduction during inspiration, but good phonation Maintenance of airway is the primary goal Airway preservation often damages an otherwise good voice

Inspiration

Expiration

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Management Bilateral Abductor Paralysis

Tracheostomy
Emergency procedure Most adults will require this Speaking valves aid in phonation

Laser Cordectomy/Cordotomy

Widening posterior glottis for respiration and leaving anterior glottis for phonation

External approach: arytenoidocordopexy (Woodman operation )

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Laser Microlaryngosurgery

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Posterior laser cordotomy

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Recent procedures:

Reinnervation:
Ansa

cervicalis Phrenic nerve

Electrical Pacing
Timed

to inspiration with electrode placed on posterior cricoarytenoid Long-term efficacy not yet shown

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Acute laryngeal infection

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Acute laryngeal infections:

Acute laryngitis Acute epiglottitis Viral laryngotracheobronchitis Bacterial laryngotracheobronchitis Spasmodic croup Diphtheria

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Acute laryngitis

Viral/bacterial, irritant fumes, allergy Presentation: common cold, sore throat, rough deep voice, aphonia Laryngoscopy: erythema, edema of vocal cords, excess secretions Management: voice rest, steam
inhalation, excess fluids mucolytics, antibiotics only when there is evidence of bacterial infection, steroids in professional voice users

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Acute laryngitis

Acute epiglottitis: Clinical

Age 3-6 years Toxic feverish child Acute sore throat and drooling Tachypenia, muffled voice and inspiratory stridor: rapidly progressive Typical posture: sitting upright, extending the neck
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Acute epiglottitis: Bacteriology:

Changing:
Hemophilus

influenzae type B: is decreasing due to immunization (by 90%) Meningococci Hemophilus parainfluenzae Beta hemolytic streptococci Staphylococcus aureus

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Acute epiglottitis: Diagnosis:

Pharyngeal examination should not be attempted Patient taken to OR or pediatric ICU X-ray soft tissue lateral film for the neck: thumb sign and blunting of vallecula.

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Acute epiglottitis

Acute epiglottitis: Management:

Confirm diagnosis in controlled setting with direct laryngoscopy Secure the airway with endotracheal intubation or tracheostomy
Depending

experience

on nursing care &

IV antibiotics: third generation cephalosporins for 5-7 days. Chloramphenicol is an alternative

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Croup: Viral laryngotracheobronchitis

Viruses: para-influenza virus I, II,

respiratory syncytial virus, influenza A and B, measles

Age : 6 months -3years Boys more More in winter Airway inflammation Edema of subglottic area (Poiseilles law)
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Croup: diagnosis

Clinical scenario characterized by

Fever

and malaise, Symptoms of cold Inspiratory or biphasic stridor Hoarseness barking cough.

Plain x-ray AP view: narrowing of the subglottis : steeple sign

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Croup Score: (Westley system)

Score
Inspiratory stridor Retraction Air entry Cyanosis Conscious level

0
None

1
Audible with stethoscope Mild Decreased

2
Audible without stethoscope Moderate Severely decreased

None Normal Non Normal

severe

With agitation

At rest altered

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Croup Scoring:

Mild Moderate Severe

2-3 4-7 >8

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Croup: Treatment

Reassurance Observation/admission Oxygen and hydration Nebulized epinephrine: 1ml 1/1000 in 3ml saline) Steroids:
Improve

croup score Reduce admission/stay/intubation Oral dexamethasone (0.6mg/kg)

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Croup: natural course

Self limiting Admitted Airway intervention

50% 20% 10%

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Croup vs. epiglottitis

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Bacterial laryngotracheobronchitis

There is sloughing of respiratory mucosa (subglottic and trachea) and profuse mucopururlent secretions Less common than croup

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Bacterial laryngotracheobronchitis: diagnosis

Age is older than croup Child is feverish & toxic Clinically, radiologically similar to croup No response to steroids Diagnosis confirmed on endoscopy: pseudomembrane in the subglottis and trachea, thick mucopus
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Bacterial laryngotracheobronchitis: management

Endoscopy: Confirm diagnosis, remove of secretions Secure airway: IT intubation Nursing care/ suction Oxygen and hydration Antibiotics: staphylococcus aureus commonly isolated from tracheal culture
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Spasmodic croup:

Similar to croup Recurrent Not infection:?allergy, atopy, ?reflux Typically at night and resolve within hours Management: assurance, single dose of dexamethasone Endoscopy should be done in persistent cases to exclude stenosis
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Diphtheria

Rare now due immunization Corynebacterium diphtheriae: toxic strains Pharyngeal diphtheria: sore throat, malaise, feve, pharyngeal pseudomembrane, huge neck lymph nodes. Laryngeal diphtheria: inspiratory stridor becomes evident and cough Myocarditis : slow to resolve Neuropathy: soft palate paralysis Management: early diagnosis, antitoxin, high dose penicillin, secure the airway 73

Thank You

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