Transcript Vocal cord Paralysis

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

Below vocal cord: 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
Final position of B/L RLN
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
Dual innervation of inter-arytenoid muscles
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

Supra-nuclear

Nuclear: nucleus ambiguus

High vagal lesions: combined palsy

Low vagal lesions: recurrent laryngeal nerve palsy

Systemic causes

Idiopathic
Causes of combined paralysis
Intracranial
Neck
Tumors of posterior fossa
Penetrating injury
Basal meningitis (TB)
Parapharyngeal tumors
Skull base
Metastatic neck nodes
Fractures
Lymphoma
Nasopharyngeal cancer
Thyroid surgery
Glomus tumour
Etiology of recurrent
laryngeal nerve palsy
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
Mediastinum
 Accidental trauma
 Bronchogenic ca
 Thyroid disease
 Ca esophagus
 Thyroid surgery
 Ca esophagus
 Lymphadenopathy
 Aortic aneurysm
 Lymphadenopathy
 Enlarged left atrium
 Intra-thoracic surgery
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%)
• Thyroid surgery
• Ca thyroid
• Cancer cervical esophagus
• Cervical lymphadenopathy
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
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
Beahr’s triangle for RLN
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
Distance
vocal cord from centre
Healthy
Diseased
Median
Midline
Phonation
RLN paralysis
Paramedian
1.5 mm
Strong
whisper
RLN paralysis
Intermediate
(Cadaveric)
3.5 mm
(neutral
position)
Paralysis of
both RLN &
SLN
Gentle
abduction
7 mm
Quiet
respiration
Paralysis of
adductors
Full
abduction
9.5 mm
Deep
inspiration
--
Position of vocal cords
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.”
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 ?

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

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
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
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
Vocal cord paralysis
Cricoarytenoid
joint fixation
1. Floppy, vocal cords with bowing
1. Absent
2. Arytenoids falls antero-medially
2. In position
3. Vocal cord at a higher level
3. Same level
4. Tilting of larynx  paralysed side
4. Absent
5. Flickering of cord on phonation
5. Absent
6. Shallow pyriform fossa
6. Normal
7. Fixed in specific position
7. Any position
8. Arytenoids can be moved
8. Arytenoids fixed
Clinical Features
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

Asymptomatic (1/3rd unilateral paralysis)
Faint whisper
Functional adductor
paralysis
Forced whisper
Organic adductor
paralysis
Voice tires with use
Unilateral abductor
paralysis
Stridor & aspiration
Bilateral abductor
paralysis
U/L S.L.N. palsy
• Disability in professional
voice user only
• Voice weak, breathy,
inability to raise pitch
• Anterior commissural tilt
to healthy side
• Short & flabby vocal fold
• Flapping cord during
respiration
B/L S.L.N. palsy
• Professional voice
compromised
• Voice weak, breathy,
inability to raise pitch
• Absence of anterior
commissural tilt
• Cough & choking due
to aspiration
U/L combined palsy
• Cord in cadaveric
position  hoarseness
• Glottic incompetence
 ineffective cough
B/L combined palsy
• B/L cords in cadaveric
position  aphonia
• Glottic incompetence
 ineffective cough
• Total anesthesia of
• Partial anesthesia of
larynx  aspiration
larynx  aspiration +
bronchopneumonia
Specific
Investigations
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
Aerodynamic analysis
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
Shimmer & Jitter
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
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
Photoglottography
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
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
paralyzed vocal fold is foreshortened, lateralized & flaccid
B/L abductor palsy
Inspiration
Expiration
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
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
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
Treatment for phonatory
gap in U/L abductor or
adductor palsy
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
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

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 injection
Vocal fold Teflon injection
Percutaneous Teflon injection

Needle introduced in midline through cricothyroid 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 injection
Midline & lateral routes
Vocal fold fat injection
Vocal fold collagen injection
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 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

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
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 silastic prosthesis
Silastic implant
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 adduction
Arytenoid adduction
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 cricoarytenoideus for lateralization (Tucker)

Neural anastomosis of ansa hypoglossi nerve
directly to recurrent laryngeal nerve (Crumley)
Neuromuscular pedicle
Neuromuscular pedicle
Neuromuscular pedicle
Ansa-R.L.N. anastomosis
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
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

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 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 + lateralization
Posterior cordotomy
Arytenoidectomy
Cordotomy + arytenoidectomy
Thyroplasty type II (lateralization)
Treatment for bilateral
adductor paralysis
causing chronic
aspiration
• 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
Epiglottic flap closure
Epiglottopexy
Epiglottic tube laryngoplasty
Glottic closure
Subperichondrial cricoidectomy
Tracheo-esophageal diversion

Proximal trachea
anastomosed with
esophagus

Distal trachea opens
into permanent
tracheostomy
Laryngo-tracheal separation

Proximal trachea
closed

Distal trachea
opens into
permanent
tracheostomy
Narrow field laryngectomy
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
Other vocal cord
surgeries
Thyroplasty type III (shortening)
Used for mutational falsetto
Thyroplasty type IV (elongation)
Used for raising vocal pitch & ing vocal tension
Evaluation of
Hoarseness
(dysphonia)
Causes 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
10 organic dysphonia
20 organic dysphonia
1. Congenital *
1. Laryngitis *
2. Laryngeal tumor *
2. Vocal nodule
3. Vocal cord palsy
3. Vocal polyp
4. Spasmodic
4. Reinke’s edema
5. Muscular *
Functional dysphonia
6. Neurological *
1. Psychogenic
7. Endocrine *
2. Habitual
8. Senile
3. Puberphonia
9. Fixation by arthritis
4. Ventricular *
10. Traumatic *
5. Malingering

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
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
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

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
Improvement in voice = do thyroplasty (anterior
medialization procedure). No improvement in voice = do
arytenoid adduction (posterior medialization procedure)
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