This document discusses recurrent laryngeal nerve paralysis (RLNP). It begins by describing normal vocal cord function and the effects of paralysis. It then covers the anatomy of the larynx and nerves involved. The causes, types, clinical features and investigations of unilateral and bilateral RLNP are explained. Management options are also summarized, including wait and see approach, laryngoplasty procedures, and in severe bilateral cases - tracheostomy or surgical techniques to lateralize the vocal cords.

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.