vocal cord paralysis

1. Vocal cord paralysis
Aparna JK

2. Nerve supply???
• Motor
• Sensory
• Recurrent laryngeal
• Superior laryngeal

4. Muscles??
• Intrinsic vs Extrinsic
• Abductors (only muscle)
• Adductors
• Tensors
• Relaxors
• Openers of inlet
• Closers of inlet

5. Abductors: Posterior cricoarytenoid
Adductors: Lateral cricoarytenoid
Transverse arytenoid
Thyroarytenoid (external
part)
Tensors: Cricothyroid
Relaxors: Thyroarytenoid (internal
part) or Vocalis
Openers: Thyroepiglottic part of
Thyroarytenoid
Closer: Aryepiglotticus
Tranverse arytenoid

7. Normal positions of vocal cords
Phonatory glottis – anterior 2/3
Respiratory glottis – posterior 1/3

8. Trivia..
Identify???

9. Classification of Paralysis
• Unilateral or Bilateral
• Involving
 Recurrent LN
 Superior LN
 Combined or Complete

10. Causes
Supranuclear: Rare
Nuclear: vascular
neoplastic
motor neuron disease
polio
syringobulbia
(associated CN palsies)
High vagal: at Jugular Foramen or
parapharyngeal space
Low vagal or RLN: uni/bi lateral
Systemic causes: DM, syphilis,
diphtheria, lead poisoning
Idiopathic: 30%

11. Recurrent Laryngeal Nerve Palsy
Causes:
• Neck trauma
• Thyroid surgery
• CA esophagus
• Cervical Lymphadenopathy
• Bronchogenic Carcinoma
• Subclavian artery aneurysm
• TB apex of lung
• Idiopathic

12. UNILATERAL PALSY
 ipsilateral
 all intrinsic muscles… except ?
 Anaesthesia?
 Median or Paramedian position (ABDUCTOR PALSY)
Semon’s law: Abductor fibres are phylogenetically newer and more susceptible
Wagner and Grossman hypothesis: Adductor function of cricothyroid
Clinical features:
 1/3rd asymptomatic
 Change in voice; improves due to compensation by the healthy cord
WHICHSIDEISIT??

13. Investigations:
• Voice Assessment – phonetogram, aerodynamic analysis,
spectrogram
• Analysis of cord movement –
 Fibro-optic video laryngoscopy
 Stroboscopy
• Radiology –
 X-Ray neck; AP and Lateral
 CXR – AP and Lateral
 Barium Swallow
 HRCT with contrast from skull base to mid thorax
 MRI; base of skull lesions
 Thyroid scan
• Histopathology – suspected malignancy

14. Treatment –
• Speech therapy; compensation, spontaneous recovery
• Type1 thyroplasty (medialization with implant); no compensation
• Type1 with arytenoid adduction if posterior glottis also incompetent
• Teflon injection for medialization (not preferred)

15. BILATERAL PALSY
 Surgical trauma, Diphtheritic neurtitis
 Median or Paramedian cords
Clinical features: airway? voice?
Treatment:
• Tracheostomy
• Widening the airway without tracheostomy: arytenoidectomy,
arytenoidopexy, cordectomy, lateralisation (invasive methods)

16. Widening airway (newer, less invasive):
1. Transverse cordotomy (Kashima op)
2. Partial arytenoidectomy
3. Reinnervation procedures; implantation of nerve-muscle pedicle,
not very successful
4. Thyroplasty type 2

17. Superior Laryngeal Nerve Palsy
UNILATERAL PALSY
• Rare, part of combined palsy usually
• Muscle paralysis? Anaesthesia?
Clinical features-
 Pitch cannot be raised
 Aspiration
 Askew glottis; anterior commissure rotated to normal side
 Shortened, wavy cord; loss of tension
 Flapping of cord; sags and bulges up

18. BILATERAL PALSY
• Uncommon
• Both cricothyroids(ELN), Anaesthesia of upper larynx(ILN)
• Aetiology: Trauma, Diphtheritic neuritis, pressure, tumours infiltrating
Clinical features:
 Aspiration; husky, weak voice
Treatment:
 Neuritis; spontaneous recovery
 Repeated aspiration; tracheostomy + oesophageal feeding tube
 Epiglottopexy; to close the inlet, reversible

19. Combined Palsy
UNILATERAL COMBINED PALSY
• All muscles on one side except Transverse arytenoid… WHY??
• Anaesthesia of entire mucosa on one side
• Aetiology: Thyroid surgery, High vagal lesions
Clinical features:
 CADAVERIC POSITION; 3.5mm from midline
 Hoarseness of voice
 Aspiration
 Ineffective cough
a – adduction
b – paramedian
c – cadaveric
d - abduction

20. Treatment:
 Speech Therapy; healthy cord may compensate
 Medialize the cord;
 Injection of Teflon paste, fat, hyaluronic acid
Thyroplasty type1; preferred

21. BILATERAL COMBINED PALSY
• Rare
• All muscles paralysed, total anaesthesia
• Both cords in CADAVERIC POSITION
Clinical features:
 Aphonia
 Aspiration
 Inability to cough; retention of secretions
 Pneumonia

22. Treatment:
 Tracheostomy
 Gastrostomy
 Epiglottopexy
 Vocal cord plication; mucosa removed, approximated with sutures
 Total laryngectomy; unsalvageable conditions
 Diversion procedures; intractable aspiration

23. Congenital vocal cord paralysis
• Unilateral>Bilateral
• Unilateral: Birth trauma, congenital anomaly
• Bilateral: Hydrocephalus, Arnold-Chiari malformation, N Ambiguus
agenesis, meningocoele
• Clinical features: Respiratory obstruction

24. PHONOSURGERY
• Excision of lesions by microlaryngeal surgery or laser
• Injection of Teflon paste; to augement and medialise
• Thyroplasty
• Reinnervation procedures

25. Thyroplasty
• Isshiki
• Functional alteration of vocal cords
a. Type 1: Medial displacement (like teflon injection)
b. Type 2: Lateral displacement; to improve airway
c. Type 3: Shorten/Relax cord; mutational falsetto/gender transformation
d. Type 4: Lenghthen/Tighten cord

26. Type 1

27. Type 2

28. Type 3

29. Type 4

30. Reinnervation procedures

31. THANK YOU! 