This document provides information on vocal cord paralysis, including:
1. Vocal cord paralysis is defined as total interruption of nerve impulses resulting in no movement of laryngeal muscles, while paresis is partial interruption causing weak movement.
2. Causes of laryngeal paralysis can be supranuclear, nuclear, related to high or low vagal lesions, or systemic. Paralysis may be unilateral, bilateral, or involve the recurrent laryngeal nerve, superior laryngeal nerve, or both.
3. In unilateral recurrent laryngeal nerve paralysis, the vocal cord assumes a median position and does not move laterally on inspiration. Bilateral paralysis causes stridor and dyspnea due to
Vocal cord paralysis and evaluation of hoarseness
Slides prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal, for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology.
A clear and concise explanation of the basic concepts in the subject matter concerned.
He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students
This is a seminar presentation conducted by 4th year medical students under supervision of a lecturer. Reference were not attached here, but all information are from google, few textbooks and also from previous ENT posting's seminar.
laryngeal paralysis is a specific issue ENT have to deal with.
It is a sign of Disease and not a final diagnosis, should a patient present with the symptoms it is prudent to investigate and find cause of the paralysis
Vocal cord paralysis and evaluation of hoarseness
Slides prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal, for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology.
A clear and concise explanation of the basic concepts in the subject matter concerned.
He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students
This is a seminar presentation conducted by 4th year medical students under supervision of a lecturer. Reference were not attached here, but all information are from google, few textbooks and also from previous ENT posting's seminar.
laryngeal paralysis is a specific issue ENT have to deal with.
It is a sign of Disease and not a final diagnosis, should a patient present with the symptoms it is prudent to investigate and find cause of the paralysis
A concise presentation about BPPV and Ménière's disease and other causes of vertigo, the difference between central and peripheral vertigo, symptoms and etiology and approach to physical examination and treatment.
VAGUS (X)
Accessory nerve (XI)
HYPOGLOSSAL (XII)
agus nerve (X):
Has a wide range of functions, including control of the heart, lungs, and digestive tract. It also has sensory and motor components. The vagus nerve emerges from the medulla. Located lateral to olive and below the glossopharyngeal nerve.
Accessory nerve (XI):
Controls the muscles of the neck and shoulders. It emerges from the medulla.
Hypoglossal nerve (XII):
Controls the muscles of the tongue. It emerges from the medulla behind pyramid.
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Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
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The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
2. INTRODUCTION
• Vocal cord Paralysis : defined as total
interruption of nerve impulse resulting in no
movement of laryngeal muscles.
• Vocal cord Paresis : defined as partial
interruption of nerve impulse resulting in weak or
abnormal movement of laryngeal muscles.
3. • Vocal cord paresis/paralysis can occur at any age
or sex.
• Effect of VC paralysis may vary & depends on the
patient’s use of his or her voice.
• A mild vocal cord paresis can be the end to a
singer's career but it have only marginal effect on
any other professional career life.
• Vocal cord Paralysis is a sign of a disease & not a
diagnosis by itself.
8. NERVE SUPPLY OF LARYNX
MOTOR
• All the muscles which move
the vocal cords (abductors,
adductors or tensors) are
supplied by the Recurrent
Laryngeal Nerve except the
cricothyroid muscle, which
is supplied by Superior
Laryngeal Nerve.
• Both of these are branches
of the Vagus Nerve.
SENSORY
• Above the vocal cords,
larynx is supplied by
Internal Laryngeal Nerve –
a branch of Superior
Laryngeal Nerve & below
the vocal cords by
Recurrent Laryngeal Nerve.
9. RECURRENT LARYNGEAL NERVE
• Rt. Recurrent laryngeal nerve
arises from the Vagus nerve at the
level of Subclavian artery, hooks
round it & then ascends between
the trachea & oesophagus.
• The Lt. Recurrent laryngeal nerve
arises from the Vagus in the
Mediastinum at the level of Arch of
aorta, loops round it & then
ascends into the neck in the
tracheo-oesophageal groove.
• Thus, Lt. Recurrent Laryngeal
Nerve has a much longer course
which makes it more prone to
paralysis as compared to the right
one.
10. SUPERIOR LARYNGEAL NERVE
• It arises from Inferior
Ganglion of the Vagus
nerve, descends behind
Internal Carotid artery & at
the level of Greater cornu of
Hyoid bone, divides into
External & Internal
branches.
• The external branch supplies
cricothyroid muscle while
the internal branch pierces
the thyrohyoid membrane &
supplies sensory innervation
to the larynx &
hypopharynx.
11. FUNCTIONS OF VOCAL CORDS
Vocal cord mainly has the following movements :
• Adduction : approximation of vocal cord with
each other.
• Abduction : movement of vocal cord away from
each other.
15. CLASSIFICATION OF LARYNGEAL PARALYSIS
• Laryngeal paralysis can be :
Unilateral or Bilateral & may involve –
1. Recurrent laryngeal nerve
2. Superior laryngeal nerve
3. Both (Combined / Complete)
16. CAUSES OF LARYNGEAL PARALYSIS
In topographical manner they are :
1. Supranuclear : Rare
2. Nuclear : Vascular disease, Neoplastic disease, Motor neuron disease,
Polio & Syringobulbia
3. High vagal lesions : Post. fossa tumors, Tubercular meningitis, Fracture of
skull base, Nasopharyngeal cancer, Glomus tumor, Penetrating injury of
neck, Parapharyngeal tumors, Metastatic neck nodes, Lymphoma
4. Low vagal or recurrent laryngeal nerve
5. Systemic causes : Diabetes, Syphilis, Diptheria, Typhoid, Viral infections,
Lead poisoning
6. Idiopathic
18. THEORIES ON POSITION OF VOCAL
CORD IN VOCAL CORD PARALYSIS
• SEMON’S LAW : states that, in all progressive organic
lesions, abductor fibres of the nerve which are
phylogenitically newer are more susceptible & thus the
first to be paralysed as compared to adductor fibres
• WAGNER & GROSSMAN HYPOTHESIS : is the most
widely accepted theory. It states that complete
paralysis of the recurrent laryngeal nerve results in the
vocal cord being in paramedian because of an intact
cricothyroid muscle, which adducts the vocal cord.
When the Superior laryngeal nerve is also paralysed,
the vocal cord will be in intermediate or cadaveric
position because of loss of this adductive force.
19. RECURRENT LARYNGEAL NERVE PARALYSIS
(A) UNILATERAL
• Unilateral injury to recurrent
laryngeal nerve results in
ipsilateral paralysis of all the
intrinsic muscles of larynx
ecxept the cricothyroid.
• The vocal cords thus assumes a
median or paramedian
position & doesn’t move
laterally on deep inspiration.
• Clinical features :
- Asymptomatic
- Change in voice
The voice in unilateral
paralysis gradually
improves due to
compensation by healthy
cord which crosses
midline to meet paralysed
one.
• Treatment : Generally no
treatment is required.
20.
21. (B) BILATERAL (B/L Abductor paralysis) :
• Position of vocal cords : All the intrinsic muscles of
larynx are paralysed, vocal cords lie in median or
paramedian position due to unopposed action of
cricothyroid muscles.
• Clinical features :
- Dyspnoea
- Stridor
23. • Treatment :
• Usually 6 months is an adequate time to wait for any spontaneous recovery.
• In acute stridor, Tracheostomy may be required.
- If patient doesn’t want tracheostomy following option can be considered :
• Lateralisation of the vocal cord: Aim is to move & fix the cord in a lateral
position to improve the airway. The various procedures are:
(a) Arytenoidectomy
(b) Vocal cord lateralisation through endoscope.
(c) Thyroplasty type II
(d) Cordectomy
(e) Nerve muscle implant
24. PARALYSIS OF SUPERIOR LARYNGEAL NERVE
(A) UNILATERAL
• Paralysis of cricothyroid muscle & ipsilateral
anaesthesia of the larynx above the vocal
cord.
• Causes :
- Thyroid surgery
- Thyroid Tumors
- Diptheria.
• Clinical features :
- Weak voice with decreased pitch
- Anaesthesia of the larynx on one side
- Occassional aspiration.
Laryngeal findings include :
- Askew position of glottis - Ant. Comissure is
rotated to healthy side.
- Shortening of V.C. with loss of tension & V.C.
appears wavy
- Flapping of the paralysed vocal cord – V.C. sags
down during inspiration & bulges up during
expiration.
(B) BILATERAL
• An uncommon condition. Both the cricothyriod
muscles are paralysed along with anaesthesia
of upper larynx.
• Causes:
- Surgical or accidental trauma
- Diptheria
- Cervical lymphadenopathy
- Neoplastic disease
• Clinical features:
- Both V.C. paralysis
- Anaesthesia of larynx
- Cough
- Chocking fits
- Weak & husky voice
Treatment:
- Tracheostomy with a cuffed tube & an
oesophageal feeeding tube.
- Epiglottopexy is an operation to close the
laryngeal inlet to protect the lungs from
repeated aspiration. It is a reversible
precedure.
25. COMBINED/COMPLETE VOCAL CORD PARALYSIS
(Recurrent & Superior Laryngeal Nerve Paralysis)
(A) UNILATERAL :
• Paralysis of all the muscles of the larynx on one side except
interarytenoid which also receives innervation from opposite side.
Aetiology :
• Thyroid surgery
• Lesions of nucleus ambigus which may lie medulla, post. cranial fossa,
jugular foramen or parapharyngeal space.
Clinical features :
• All the muscles of larynx on one side are paralysed
• V.C. lie in cadeveric position ie. 3.5mm from the midline
• Glottic incompetence results in hoarseness of voice & aspiration of
liquids
26. • Treatment:
1. Speech therapy
2. Procedures to medialise the cord- Aim is to bring the
paralysed vocal cord towards the midline so that healthy cord
can meet it. This is achieved by :
(a) Injection of teflon paste
(b) Muscle or cartilage implant
(c) Arthrodesis of cricoarytenoid joint
(d) Thyroplasty type I
27. (B) Bilateral:
• Both recurrent & superior laryngeal nerves on both sides are
paralysed.
• Rare condition.
• Both cords lie in cadaveric position.
• Total anaesthesia of the larynx.
Clinical features :
-Aphonia: As V.C. cords doesn’t meet at all.
-Aspiration: due to incompetent glottis & laryngeal anaesthesia.
-Inability to cough: due to inability of V.C. to meet which results in retention of
secretions in the chest.
-Bronchopneumonia- due to repeated aspirations & retention of secretions.
29. CONGENITAL VOCAL CORD PARALYSIS
UNILATERAL
• More common
• Causes :
- Birth trauma
- Congenital anomaly of great
vessels or heart
BILATERAL
• Causes :
- Hydrocephalus
- Arnold-Chiari malformation
- Intracerebral haemorrhage
- Meningocele
- Cerebral agenesis
• Clinical features :
- Dyspnoea
- Stridor
30. EVALUATION OF VOCAL CORD PARALYSIS PATIENT
• History
• Symptoms:
(a) Change in voice
(b) Hoarseness
(c) Aphonia
(d) Vocal fatigue
(e) Neck pain
(f) Aspiration
(g) Cough
• Past Medical & Surgical History :
• Social History :
• General Examination :
• Local Examination :
(a) Examination of larynx & laryngopharynx – IDL,
FOL
(b) Neck examination
(c) Cranial nerve examination
• Investigations :
- Nasopharyngolaryngoscopy
- Videostroboscopy
- Chest X-ray PA view
- C.T. with contrast- may evaluate the entire
course of recurrent laryngeal nerve
- MRI
31. DIFFERENTIAL DIAGNOSIS
1. Cricoarytenoid Fixation: caused by joint
subluxation or dislocation with ankylosis.
- Joint fixation by rheumatoid arthritris or gout.
2. Laryngeal malignancy: