ppt on RLNP, defn, causes, clinical features and management

1. RECURRENT
LARYNGEAL NERVE
PARALYSIS
BY:
NILUFER

2. For normal voice production:
• VOCAL CORDS must :
• 1. be able to approximate with each
other
• 2. have proper size and stiffness
• 3. have an ability to vibrate reg. in
response to air column

3. • in vocal cord palsy ;
•
• - loss of approximation of vc
• - decreased stiffness of vc

4. ANATOMY OF LARYNX
LOCATION :
in the middle and ant.part of
the neck , opp. C3 - C6
CARTILAGES :
1. paired
2.unpaired

5. Unpaired :
• *epiglottis
* thyroid
*cricoid
Paired :
* arytenoid
* corniculate
* cuneiform

8. 1. ABDUCTORS :
Post. cricoarytenoid
2. ADDUCTORS:
Lat.cricoarytenoid
interarytenoid
Thyroarytenoid
3.TENSORS:
Cricothyroid
4.RELAXERS :

9. Vocalis
Thyroarytenoid (int part)
Acting on l.inlet:
1.OPENERS
Thyroepiglottic
2.CLOSERS
Interarytenoid
(oblique p.)
Aryepiglottic
(post. ob. p.)

10. Extrinsic muscles :
• 1. elevators
• 2. depressors

11. NERVE SUPPLY OF LARYNX
1. sensory :
* above vocal cords - SLN (ILN)
* below vocal cords - RLN
2.motor:
* all intrinsic muscles - RLN
# except . cricothyroid ( SLN -
external)

12. VOCAL CORDS
• *DEFN : are pearly white mucous memb.
infoldings that stretch horizontally across
mid.laryngeal cavity.
• ATTACHMENTS: Ant : thyroid cartilage
Post : arytenoid cartilage (
vocal process)
EDGES: Outer - attached to muscle in larynx
Inner - free ( form rima glottidis)
• TYPES:
• 1. TRUE : formed from conus
elasticus (inf layer of
infolded membrane)

14. 2. FALSE : formed from quadrangular
membrane ( sup. layer of
infol.mem )
• ant. 2/3 -
membranous
• post 1/3 -
cartilagenous

17. position of vocal cords
normally :
breathing -
abducted
phonation -
adducted
swallowing -
add.

18. COURSE OF RLN

20. vagus - tenth. CN
Cranial part ; 2 nuclei
vagus descends down
exits skull via jugular.f
sup. ganglion
inf.ganglion
descends down and enters
carotid sheath

21. below inf.gang.
• gives SLN
• at level of hyoid bone it
divides into
external internal

23. at level of SCA - GIVES RIGHT RLN
• at thr level of arch of aorta - gives LEFT
• RLN
• GALEN 'ANASTOMOSIS: btw SLN &
RLN
• NON RECURRENT LARYNGEAL N.
• WHY LEFT RLN more prone for
paralysis?

25. CLASSIFICATION
• 1. RLN
• 2. SLN
• 3. COMBINED
• * 1. CONGENITAL/ ACQUIRED
• 2. U/L or B/L
• 3. COMPLETE/ INCOMPLETE
• 4. ABDUCTOR / ADDUCTOR/ BOTH

26. 5. SENSORY / MOTOR
• * ETIOLOGY :
• 1. supranuclear
• 2. nuclear
• 3. vagus nerve ( high vagal )
• 4. low vagal trunk
• - right RLN
• - left RLN
• - both
• 5. systemic causes

27. CAUSES OF RLNP
• RIGHT : neck
• - neck trauma
• - thyroid disease
• -malignancy
• - iatrogenic
• - cer. lymphadenopathy
• - aneurysm of SCA
• - CA.apex rt.lung
• - TBofcer.pleura
• - idiopathic

28. LEFT : 1. in the NECK;
• - acc.trauma
• - thy. disease
• - iatrogenic
• - malignancy
• - c.lymph.
• in the MEDIASTINUM ;
• - Bronchogenic.CA
• - CA.tho.eso
• - aortic aneurysm
• - M. lymph
• - ortner s syn.
• - intrathoracic surgry

29. BOTH ;
• thy.surgry
• CA.thyroid
• CAcer. oeso
• cer. lymphadenopathy

30. TYPES OF RLNP
1. UNILATERAL
2. BILATERAL
1.UNILATERAL RLNP :
DEFN: Condition which leads to ipsilateral
paralysis of all intrinsic laryngeal muscles
except cricothyroid .
INCIDENCE :
usually affects adults
SEX : both males n females

31. •clinical
• features

33. THEORIES TO EXPLAIN THE POSITION
OF VOCAL CORDS IN PARALYSIS
• 1. SEMON 'S LAW :
• "in all the prog. org. lesions,
abd.fibres of nerve which are
phylogenetically newer, are more
susceptible & are first to be paralysed
compared to adductors.
• 2. WAGNER AND GROSSMAN 'S LAW

34. " cricothyroid muscle ( supplied by SLN)
which has adductor function, keeps cord in
paramedian position."
VOCAL
CORDS
PM pure
RLNP
C comb.palsy

35. • ETIO :
• - BRONCHOGENIC CA.
• - THYROID SURGERY
C/F :
- VOICE
- POSITION OF VOCAL CORDS
- RESPIRATION ( stridor)
- SWALLOWING ( aspiration )

36. • 1. VOICE :
- asympotomatic in 1/3 cases
- left sided; hoarseness
-no change
- improves gradually by
compensation
2. POSITION OF VC : median or paramedian
- aff. vc may lie at a lower
level
3. no prob. of aspiration or breathing

38. INVESTIGATIONS :
• 1. Chest X-Ray
• 2. biopsy
• 3. radiography of barium swallow
• 4. panendoscopy - dir.laryngoscopy,
bronchoscopy, esophagoscopy
• 5. blood sugar
• 6. VDRL
• 7. ESR
• 8. neurological invest.
• 9. CVS
• 10. CT- SCAN and MRI

40. MANAGEMENT :
- if asymptomatic - no trtmnt reqd,.
- temporary paralysis recovers in 6 to 12
months
- advisable to wait
- voice improvement during waiting period
- 1. speech therapy
-

41. • if paralysis persists for 9 to 12 months,
then following procedures performed:
• 1. laryngoplasty type 1 with vc inj.
• 2. laryngoplasty type 2 with arytenoid
adduction
• 3. thyroplasty type 1 - medialization of vc
• - make window through
thy.cartilage
• then implant silastic prosthesis

46. BILATERAL RLNP
( ABDUCTOR PARALYSIS)
DEFN: condition in which al the intrinsic
muscles of larynx are paralysed
bilaterally. except cricothyroid
ETIO : neuritis
thyroid surgery
C/F :
- Acute in onset
- dyspnea
- stridor

48. • - becomes worse during exertion and
infection
• voice : good
• position of vc: median / paramedian
INVESTIGATIONS
MANAGEMENT :
1. Surgical treatmnt

49. 2 modalities;
1. permanent tracheostomy
with speaking valve
2. lateralization of cord

50. • by endoscopy or ext.cervical approach
• 1.arytenoidectomy
• 2. arytenoidopexy
• 3.transverse cordotomy ( kashima op.)
• 4. thyroplasty type 2
• 5. reinnervation

52. thyroplasty
• type 1. - medialization
• type 2 . - lateralization
type 3. - vc. are relaxed (shortening)
type 4 . - vc. are tensed

54. reinnervation
• innervate the paralysed post.
cricoarytenoid muscle by
• implanting nerve muscle pedicle from
sternohyoid or omohyoid with its n.s.
from ansa cervicalis.