Downloaded 14 times
More Related Content
Similar to Neurological conditions of larynx ashly
Neurological conditions of larynx ashly
- 1. Dr.ASHLY ALEXANDER ENT PGRESIDENT GMC,BHOPAL
- 2. Nerve supplyof larynx
- 3. 10th cranialnerve So called due to its vague course through the head, neck, thorax and the abdomen. Longest nerve of the autonomic nervous system in the body MIXED NERVE: sensory, motor and parasympathetic
- 5.
- 7. Arises frominferior ganglion of the Vagus Descends behind the internal carotid artery At the level of greater cornua of hyoid bone, divides into external and internal branches External Motor branch: Cricothyroid muscle Internal Sensory branch: Pierces thyrohyoid membrane and supplies sensory innervation to larynx above vocal cord.
- 8. Right Arises fromthe Vagus, at the level of Subclavian artery Ascends between the trachea and oesophagus Left Arises from Vagus in mediastinum At the level of Arch of Aorta Then ascends into the neck in the trachea-oesophageal groove. Thus, Left recurrent laryngeal nerve has a much longer course which make it more prone to paralysis compared to the right one. ( About 75%)
- 11. Motor Supply Allintrinsic muscle : Recurrent Laryngeal Nerve Except, The Cricothyroid Muscle : External Laryngeal Nerve –the branch of Superior Laryngeal nerve Sensory Supply Above the vocal cords: Internal Laryngeal Nerve –the branch of Superior Laryngeal Nerve Below the vocal cords: Recurrent Laryngeal Nerve
- 12. Laryngeal Palsy Nerve involved Partial/ Incomplete RLN RIGHT (15%) LEFT (75%) B/L (10%) SLN U/L B/L Combined / Complete location HighVagal Combined palsy Low Vagal RLN Palsy
- 13. Right Left Both Necktrauma Neck trauma Thyroid surgery Benign or malignant thyroid ds. Benign or malignant thyroid ds. Carcinoma thyroid Ca cervical esophagus Ca cervical esophagus Ca cervical esophagus Cervical LAP Cervical LAP Cervical LAP Aneurysm of subclavian A. Bronchogenic ca. Ca apex right lung Ca thoracic oseophagus Mediastinal LAP TB of cervical pleura Aortic aneurysm Intrathoracic sx
- 14. Common Recurrent laryngeal nervepalsy = Left MCC of RLN Palsy- Bronchogenic carcinoma Common Recurrent Laryngeal Nerve Palsy during Thyroidectomy= Right
- 15. U/L paralysisof all muscles except cricothyroid C/F : Asymptomatic - one third Change in voice which gradually improves due to compensation by healthy cord. Tiring voice Diplophonia O/E Affected VC in median/paramedian position.
- 16. Semon’s Law “Inall 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.” Wagner and Grossman hypothesis 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
- 17. Position of cord Location from midline HealthDisease Median midline Phonation Paramedian 1.5 mm Strong whisper RLN paralysis Intermediate (cadaveric) 3.5 mm Neutral position Both RLN and SLN nerves Gentle abduction 7 mm Quite respiration Paralysis of adductors Full abduction 9.5 mm Deep inspiration
- 18. Treatment Asymptomatic –spontaneous recovery Speech therapy Intracordal inj of teflon paste Medialization thyroplasty
- 20. Abductor paralysis.There is unopposed action of cricothyroid muscle Etiology – thyroidetomy (mc), trauma, neoplasm C/F Acute onset Dyspnoea and inspiratory stridor which becomes worst on exertion or infection Aspiration in elderly Patient may retain good voice O/E Both VC in median or paramedian position, immobile, flabby, flickers on phonation
- 22. Diagnosis – CT,MRI ,Chest X Ray, Panendoscopy, Stroboscopy, Barium swallow Treatment Intubation/emergency tracheostomy Permanent tracheostomy with a speaking valve – to retain good voice Lateralisation of VC – VC is moved and fixed in lateral position which improves airway. Not preferred in patients with good voice as voice is lost
- 23. Partial arytenoidectomy Medialpart of arytenoid is excised with laser. Sometimes only the vocal process of arytenoid is ablated
- 24. Arytenoidectomy –removal of arytenoid by external approach (woodman’s operation), by endoscopic approach (thornell operation) Endoscopic CO2 LASER cordotomy ( Kashima Operation) Soft tissue at the junction of membranous cord and vocal process of arytenoid is excised laterally with laser, which provides good airway. Endoscopic CO2 LASER cordectomy Laterialisation thyroplasty Type 2 Nerve muscle implant – sternohyoid muscle with nerve supply is transplanted into post cricoarytenoid Arytenoidopexy ( fixing the arytenoid in lateral position)
- 26. Rare Paralysisof unilateral cricothyroid muscle Unilateral supraglottic anaesthesia Etiology – thyroid surgery, tumours, trauma, neuritis C/F Weak and low pitch voice (loss of tension) Occasional aspiration (anaesthesia) O/E I/L VC flabby and bowed, wavy appearance Oblique laryngeal inlet Post commissure deviated medially towards affected side
- 27. Prognosis Voice recoveredby compensation from healthy cord Singers cant produce high pitch voice Treatment Speech therapy During ligation of Superior thyroid vessels in thyroid surgeries, the dissection should stay close to the thyroid to avoid nerve damage. External branch of superior laryngeal nerve lies posteromedial to the thyroid vessels and should be identified and preserved.
- 28. Least common Both cricothyroid paralysed Anaesthesia of supraglottic larynx Etiology – surgical trauma, RTA, neoplasm C/F Coughing and choking during swallowing due to aspiration Weak and husky/breathy voice Short phonation time O/E B/L flaccid and bowed VC Electromyography of the cricoithyroid muscle helps to diagnose the condition.
- 29. Treatment Ryle’s/NG tubefeed Tracheostomy with cuffed tube Thyroplasty Type 1 Injection teflon/collagen for medialization Epiglottoplexy – reversible procedure where in laryngeal inlet is closed to protect the lungs from aspiration. Epiglottis is fixed to arytenoids
- 31. Intracranial : IntracranialTumors of posterior fossa Basal meningitis(tubercular) Skull base Fractures Skull base: Nasopharyngeal cancer Glomus tumour Neck Penetrating injury Neck : Parapharyngeal tumours Metastatic nodes Lymphoma
- 32. Paralysis ofall unilateral muscles except interarytenoid which receive innervation from other side Etiology – high vagal lesions, thyroid surgery C/F Hoarseness of voice Aspiration of fluids Inadequate cough (d/t air wastage) O/E Unilateral paralysed VC in cadaveric position
- 33. Prognosis No compensationby healthy cord Treatment Speech therapy Medialisation of paralysed vc by teflon injection or thyroplasty
- 34. Rare Totalanaesthesia of larynx All laryngeal muscles paralysed Etiology Neoplasm in skull base, medulla, upper neck CNS disorder C/F Aphonia – VC dont approximate Aspiration – laryngeal anaesthesia Inability to cough leading to collection of secretions Bronchopneumonia due to aspiration and secretions
- 35. O/E Both VCin cadaveric position Treatment Ryle’s tube feed Reversible Tracheostomy with cuffed tube Epiglottoplexy VC plication – approximation of VC with sutures Irreversible Total laryngectomy – for progessive and irreversible disease, when voice is lost- to protect lungs
- 36. Second mccause of stridor in neonates (1st laryngomalacia) Unilateral mc, Right VC Etiology Idiopathic U/L – birth trauma, congenital anomaly of heart or vessel B/L – anomalies of CNS, hydrocephalus, meningitis C/F Weak or hoarse cry Inspiratory or biphasic stridor Difficulty in feeding Prognosis – 70% U/L and 50% B/L recover spontaneously within six months
- 37. Diagnosis Awake flexiblelaryngoscopy MRI X Ray Neck/Chest Treatment- NG tube feed U/L (if severe aspiration or dyspnoea) Inj teflon/thyroplasty B/L (after 5 yrs of age if recovery has not happened) Arytenoidectomy (endoscopic/external) Endoscopic lateral cordotomy
- 38. “any surgery designedprimarily for the improvement or restoration of the voice”
- 39. Microlaryngoscopic Surgery Vocal Fold Injection Laryngeal Framework Surgery Nerve Grafting / Rennervation Surgery
- 40.
- 41. Type of Anesthesia Local- allows patient to phonate Careful administration of IV sedation Internal br. of superior laryngeal nerve is blocked at the thyrohyoid membrane Glossopharyngeal nerve block at the inferior pole of the tonsils Flexible endoscope allows visualization Pt sitting and injecting through cricothyroid membrane
- 42. General Visualizaation problemsd/t ETT Abnormal anatomical position of neck Lack of pt feedback
- 43. Adds fullnessto the vocal cord to help it better oppose the other side Injection technique is similar regardless of material used Injection into thyroarytenoid/vocalis Injection can be done endoscopically or percutaneously
- 44. External landmarks– several mm anterior to oblique line horizontally, midpoint between thyroid notch and inferior thyroid border vertically
- 48. Teflon Fat Glycerine Collagen Silicone gel Hyaluronic Acid Calcium Hydroxyapatite gel
- 49. Teflon Polymer ofTetrafluroethylene Produces localised inflammmatory response Irreversible Used in persons with short life expentency Poor long term voice results High density & injected deep into thyroarytenoid muscle Risk of granuloma formation
- 50. Fat Autogenous material Easily harvested, readily available, no FB reaction Overcorrection is necessary – about 50% Resorption in months to years
- 51. Glycerine Completely reversible Absorbed in 2-6 wks Injected deep within vocal fold Collagen Natural constituent of lamina propria Bovine collage used Skin testing required
- 52. Over injection Airway compromise Under injection Misplacement & migration (silicon) Granuloma (teflon)
- 56. First described byPayr and reintroduced by Ishiki in 1974 Variety of materials used for implants: Autologous Cartilage Silastic Hydroxyapatite Gortex Titanium Useful for anterior glottic gap
- 57. Type Ithyroplasty- medialization of VC. Type II thyroplasty- lateralization of VC. Type III thyroplasty- shortening or relaxation of VC. It lowers pitch of voice, done in mutational falsetto or in those who have gone gender transformation from female to male Type IV thyroplasty- lengthening of VC to elevate pitch. It is also used when vocal cord is lax and bowing due to aging process on trauma.
- 64. Advantages: Permanent, butsurgically reversible No need to remove implant if vocal function returns Excellent at closing anterior gap Disadvantages: More invasive Poor closure of posterior glottic gap
- 65. Complications Extrusion/Displacement (Intraoperativeor Postop) Misplacement – most often superior Infection Undercorrection – important to overcorrect by 1-2mm Controversies Location of graft placement Status of inner perichondrium Many series have shown low extrusion rate with sacrificed perichondrium
- 67. First describedby Ishiki with modifications by Zeitels and others Addresses posterior glottic gap by pulling arytenoid into adducted position Difficult to predict which patients will benefit preoperatively. Most advocate use in combination with anterior medialization
- 71. Endoscopic Approaches: Suture Placedto Cricoid Cartilage Simulates action of lateral cricoarytenoid Zeitels Modification – Arytenopexy Presumably allows a more physiologic positioning of the arytenoid Involves suturing the arytenoid in a more posterior and medial position to allow more tension on flaccid cord Cricothyroid subluxation mimics action of cricothyroid muscle Modifications should be used selectively
- 72. Complications Sutures tootight – may displace arytenoid complex anteriorly, adversely affecting voice Entry in pyriform sinus
- 73. Open method– lateral / Median approach Vocal fold abduction - Suture technique - Thyroarytenoid myectomy
- 77. RLN anastomosisfirst described by Horsely in 1909 Crumly showed Ansa cervicalis to RLN anastomosis
- 78. Results insynkynetic tone of vocal cord Ansa to Recurrent Laryngeal Nerve Ansa to Omohyoid to Thyroarytenoid
- 79. Hypoglossal torecurrent laryngeal nerve Crossed nerve grafts or wire conduction prostheses from one muscle to its paralyzed counterpart are being researched
- 81.