Laryngealparalysis ug class - 03.10.16, prof.s.gopalakrishnan

2.  Respiration
 Airway protection
 phonation

3. Normally :
breathing - abduction
phonation - adduction
swallowing - adduction

4.  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

5.  in vocal cord palsy ;

 - loss of approximation of vc
 - decreased stiffness of vc

7.  Superior laryngeal nerve-internal branch is
sensory supplies larynx above the level of vocal
cords and external branch supplies
cricothyroid muscle.
 Recurrent laryngeal nerve-Motor branch
supplies all muscles of larynx except the
cricothyroid and sensory branch supplies
subglottis

8.  Right RLN arises from vagus, hooks
around subclavian artery and ascends
upwards in tracheo-oesophageal groove
 Left RLN arises from vagus, hooks around
arch of aorta and ascends upwards in
tracheo-oesophageal groove
 Left RLN has longer course thus its prone for
injury

10.  Arises in inferior ganglion of vagus,
descends behind internal carotid artery
and at the level of greater cornua of hyoid
it divides into internal and external
branches

13. May be unilateral or bilateral and may involve
 Recurrent laryngeal nerve
 Superior laryngeal nerve
 Both recurrent and superior laryngeal
nerve (combined or complete paralysis)

14.  Supranuclear: Rare
 Nuclear: involvement of nucleus ambiguus in
medulla, usually associated with other lower
cranial nerve paralysis
 High vagal lesions: may be involved at the
level of jugular foramen or parapharyngeal
space
 Low vagal or RLN
 Systemic causes: diabetes mellitus,
diphtheria, typhoid, lead poisoning
 Idiopathic: in about 30% of cases

17. Unilateral
 Results in ipsilateral paralysis of all
intrinsic muscles except the cricothyroid
 Vocal cord assumes a median or
paramedian position and does not move
laterally on deep inspiration

20. This law explains median or paramedian position of
the vocal cords
• It states that ‘In all progressive lesions of RLN,In all progressive lesions of RLN,
abductor fibres of the nerve, which areabductor fibres of the nerve, which are
phylogenetically newer, are more susceptible andphylogenetically newer, are more susceptible and
thus first to be paralysed compared to adductorthus first to be paralysed compared to adductor
fibresfibres’

21. It states that cricothyroid muscle which
receives innervation from superior laryngeal
nerve keeps the cord in paramedian position
due to adductor function

22.  May be undetected as 1/3rd
of patients
remain asymptomatic
 Some patients may complain of change
of voice
 Voice gradually improves due to
compensation by healthy cord which
crosses the midline to meet paralysed one
 Treatment: Generally treatment is not
required

23.  Direct medialization of
 the vocal cord
 Performed alone or with
arytenoid adduction or
reinnervation procedure
 Implant material
 Carved or prefabricated Silastic
implant
 Hydroxyapatite implant
 Gore-Tex strips

27.  Bilateral RLN paralysis
 Aetiology: neuritis and trauma
(thyroidectomy) are the most common
causes. The condition is often acute in onset
 Position of cords: as all the intrinsic muscles
are paralysed the vocal cords lie in median or
paramedian position due to unopposed action
of cricothyroid

29. AETIOLOGY POSITION OF
CORDS
CLINICAL
FEATURES
TREATMENT
Neuritis
Surgical trauma
(thyroidectomy)
Paramedian
position of both
the cords
Good Voice
Stridor – Degree
Variable
Dyspnoea
Dyspnoea and
stridor become
worse on exertion
or during an attack
of acute laryngitis
Tracheostomy
Cord lateralisation:
1.Arytenoidectomy
2.Cord lateralisation
through endoscope
3.Thyroplasty type II
4.Cordectomy
5.Nerve muscle implant
(sternohyoid muscle with
its nerve supply is
transplanted into the
paralysed posterior
cricoarytenoid)

30. Aim to move and fix the cord in lateral position to
improve the airway
 Various procedures are
 Arytenoidectomy: can be done by external approach,
endoscopic or by using LASER
 Thyroplasty type 2
 Cordectomy: can be done through external,
endoscopic or by using LASER
 Nerve muscle implant: sternohyoid muscle with its
nerve supply is transplanted into the paralysed
posterior cricoarytenoid to bring some movement

33. • UnilateralUnilateral
 Usually it’s a part of combined paralysis,
isolated lesions are rare
 Causes paralysis of cricothyroid muscle and
ipsilateral anesthesia of the larynx above
the vocal cord

34.  Voice is weak and pitch can not be raised
 Occasional aspiration may be present
 Askew position of glottis as anterior
commissure is rotated to the healthy side
 Shortening of the cord with loss of
tension
 As tension of the cord is lost , it sags
down during inspiration and bulges up
during expiration

35. • BilateralBilateral
 This is uncommon condition
 Both Cricothyroids are paralysed along with
anesthesia of upper part of larynx
 Etiology: surgical, accidental trauma,
neuritis, neoplastic (pressure by metastatic
lymph nodes)
 Clinical features: weak and husky voice,
aspiration causing cough and choking fits

36.  Depends on cause, neuritis recovers
spontaneously
 Troublesome aspiration requires
tracheostomy with cuffed tube and
esophageal feeding tube
 Epiglottopexy is an operation to close
laryngeal inlet to protect the lungs from
repeated aspiration, it’s a reversible
process

37. • UnilateralUnilateral
 This causes paralysis of all the muscles of larynx on
one side except interarytenoid which receives
innervation from the opposite side
 EtiologyEtiology: thyroid surgery is the most common
cause
 It may also occur in the lesions of nucleus ambiguus
or that of the vagus nerve proximal to origin of SLN
 Thus lesion may lie in medulla, posterior cranial
fossa, jugular foramen or parapharyngeal space

38. • Clinical features:Clinical features:
 Vocal cord will lie in cadeveric position
 Healthy cords fails to compensate
 This causes hoarseness of voice and
aspiration of liquids through the glottis
 Cough is ineffective due to air waste

39.  Speech therapy
 Procedures to medialise the cord
 Injection of Teflon paste
 Thyroplasty type 1
 Muscle or cartilage implant
 Arthrodesis of cricothyroid joint

40. • BilateralBilateral
 Both RLN and SLN are paralysed on both
sides
 Both cords lie in cadeveric position and there
is total anaesthesia of the larynx

41.  Clinical features
 Dysphonia
 Aspiration
 Inability to cough
 Bronchopneumonia

42. • Treatment:Treatment:
 Tracheostomy
 Epiglottopexy: epiglottis is folded backwards
and fixed to the arytenoids
 Vocal cord plication
 Total laryngectomy

43.  May be unilateral or bilateral
 Unilateral is more common
 May be due to birth trauma, congenital
anomalies of great vessels of heart
 Bilateral paralysis may be due to
hydrocephalus, arnold-chiari malformations,
intracerebral hemorrhage during birth,
meningocoele, nucleus ambiguus agenesis

44. AETIOLOGY POSITION OF
CORDS
CLINICAL
FEATURES
TREATMENT
Discussed above Median or
paramedian
position
Does not move
laterally on deep
inspiration
No symptoms
Initial hoarseness
(disappears)
Aspirate liquids
Weak cough
Voice gradually
improves due
to
compensation
by the healthy
cord
Generally no
treatment required

45. AETIOLOGY POSITION OF
CORDS
CLINICAL
FEATURES
TREATMENT
Neuritis
Surgical trauma
(thyroidectomy)
Paramedian
position of both
the cords
Good Voice
Stridor – Degree
Variable
Dyspnoea
Dyspnoea and
stridor become
worse on exertion
or during an attack
of acute laryngitis
Tracheostomy
Cord lateralisation:
1.Arytenoidectomy
2.Cord lateralisation
through endoscope
3.Thyroplasty type II
4.Cordectomy
5.Nerve muscle implant
(sternohyoid muscle with
its nerve supply is
transplanted into the
paralysed posterior
cricoarytenoid)

47. AETIOLOGY LARYNGEAL
FINDINGS
CLINICAL
FEATURES
TREATMENT
Thyroid surgery
Trauma to neck
Tumors
Neuritis
Diphtheria
Askew position of
glottis as anterior
commissure is
rotated to the
healthy side
Shortening of cord
with loss of tension
The paralysed cord
appears wavy due
to lack of tension
Flapping of the
paralysed cord
Voice is weak
Pitch cannot be
raised
Anaesthesia of the
larynx on one side
may pass unnoticed
or cause occasional
aspiration

48. AETIOLOGY LARYNGEAL
FINDINGS
CLINICAL
FEATURES
TREATMENT
Very rare
Both cricothyroid
muscles are
paralysed along with
anaesthesia of upper
larynx
•Surgical or
accidental trauma
•Neuritis (mostly
diphtheritic)
•Pressure by cervical
nodes
•Involvement in a
neoplastic process
Absence of anterior
tilt allows the
epiglottis to hang
more over
endolarynx.
Slightly flaccid,
bowed and
hyperaemic vocal
cord.
Voice is weak and
husky
Cough and choking
fits due to inhalation
of food and
pharyngeal
secretions
Depends on cause:
•Neuritis : May
recover
spontaneously
•Repeated
aspiration:
Tracheostomy with a
cuffed tube and
oesophageal feeding
tube
•Epiglottopexy:
Operation to close
the laryngeal inlet to
protect the lungs
from repeated
aspiration

49. AETIOLOGY LARYNGEAL
FINDINGS
CLINICAL
FEATURES
TREATMENT
Thyroid surgery
(most common)
Lesions of the
nucleus ambiguus
Lesions of the
vagus nerve
proximal to the
origin of the SLN
(lesions in the
medulla, posterior
cranial fossa,
jugular foramen or
parapharyngeal
space)
Vocal cord in
cadaveric position
The healthy cord is
unable to
approximate the
paralysed cord,
thus causing glottic
incompetence
Hoarseness of voice
Aspiration of liquids
Weak cough
Speech therapy
Procedures to
medialise the cord:
1.Injection of teflon
paste lateral to
paralysed cord
2.Thyroplasty type I
3.Muscle or
cartilage implant
4.Arthrodesis of
cricoarytenoid joint

50. AETIOLOGY LARYNGEAL FINDINGS CLINICAL FEATURES TREATMENT
Rare Both cords lie in cadaveric
position
All laryngeal muscles are
paralysed
Total anaesthesia of the
larynx
Dysphonia
Aspiration
Inability to cough
Bronchopneumonia
due to repeated
aspiration and
retention of
secretions
Tracheostomy
Epiglottopexy
Vocal cord plication
Total laryngectomy
(in cases where the
cause is progressive
and irreversible and
speech is
unserviceable)
Diversion procedures

51. Surgical procedures designed to improve
quality of voice
 Excision of benign or malignant lesions by
Microlaryngeal surgery or laser
 Teflon paste injection to vocal cords
 Thyroplasty
 Laryngeal reinnervation procedures: segment
of anterior belly of omohyoid muscle carrying
its nerve and vessels is implanted into
thyroarytenoid muscle

52. • ISSHIKI CLASSIFICATIONISSHIKI CLASSIFICATION
 Type 1: Medialization …Type 1: Medialization …
 Type 2: Lateralization…Type 2: Lateralization…
 Type 3: Shortening……..Type 3: Shortening……..
 Type 4: LengtheningType 4: Lengthening
( tightening) ………………( tightening) ………………