![RLN Left VCP >>>>Right VCP
1)Extensive Course
2)Pressure [Aortic Aneurism,
Intra thoracic Mass]](https://image.slidesharecdn.com/vocalcordpalsy-210323130348/75/Vocal-cord-palsy-7-2048.jpg)
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Similar to Vocal cord palsy
Vocal cord palsy
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- 5. 1 2 3 Add +Abd Add
- 6. SLN External Motor to Cricothyroid Internal Sensory+ Secretomotor (Glands Above VC) Superior Lingual Surface Epiglottic Foramen Laryngeal Surface Middle Aryepiglottic Fold Ventricular Fold Inferior Pyriform Fossa & Post Cricoid Sensory = Protection Laryngeal > Lingual Anterior VC > Posterior VC
- 7. RLN Left VCP>>>>Right VCP 1)Extensive Course 2)Pressure [Aortic Aneurism, Intra thoracic Mass]
- 8. Purely Motor ? PurelySensory ? Mixed ? Safety Nerve?
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- 11. Any Pathology OfLarynx Adductors Abductors Last to paralysed First to be recovered First to paralysed Last to be recovered Respiration Voice
- 12. SEMONS’s LAW 1) Adductors-- > embryologically old fibres --> strong --> last to be paralysed 2) Abductors -- > embryologically new -- > weak --> early paralysed WEGNER GROSSMAN LAW In case of RLN Palsy -- > VC will be in media or para median position because of normal cricothyroid muscle
- 13. Pathophysiology Series Of Process •Segmental Demyelination • Impaired Axonal Transport • Conduction Block Midline 1.5mm 3.5mm 7mm
- 14. 1. Median –in midline -- > phonation 2. Paramedian – 1.5 mm -- > whispering -- > RLN 3. Intermediate – 3.5 mm -- > never seen in live human -- > CADAVERIC POSITION -- > both SLN + RLN paralysed 4. Gentle Abduction -- > 7.5 mm -- > quite respiration -- > SLN 5. Full abduction -- > 9 mm -- > deep respiration -- > SLN
- 15. Evaluation • Change OfVoice – Vocal Fatigue to Near total aphonia • Dysphagia Related – indicate high vagal lesion -- > hemi laryngeal anaesthesia, pharyngeal constrictor atony • Respiration – stridor to dyspnoea • Speech Dyspnea, Difficulty in speaking in Noisy Environment • Neck – Lymphadenopathy, thyroid • Cranial Nerves Examination – XI, IX(jugular foramen) ; ipsilateral tongue deviation, palate droop or Horner syndrome • 70/90 degree Hopkin’s >>>>> Trans nasal flexible laryngoscopy • Examination under GA (if above two fails) • Ask patientto cough, sniff and whistle --> confirm neurological disorder
- 16. If you findparesis or doubting the compensation --- > ask patient to do speak “i” (Compensation by cricothyroid, interarytenoid, extra laryngeal muscle) • It will cause repetitive vocal fold motion and we can decide accurately. • Ask patient to raise the pitch of voice --- > if yes then intact SLN 1) VC movement before giving relaxant 2) Palate and pharynx 3) Supraglottic(Vestibule) region (if hyperfunction -- > glottic insufficiency) 4) Arytenoid palpation – prolapse antero medially -- > profound denervation 5) Posterior Glottic Scar – if post commissure moves with vocal process then its PG stenosis 6) Vocal fold – Abduction (cephalded) and adduction (caudaly) 7) Glottal Gap – Increased -- > Decreased maximum phonatory time
- 17. Further Study • VagalNerve Imaging From brain to mediastinum -- > Contrast CT = MRI • LEMG -- > costly , invasive , other studies are non diagnostic, 1 month to 6 months after onset of VFP • Lyme Disease titer – Ach receptor antibody level
- 18. Recurrent Laryngeal Nerve(Abductor) •Asymptomatic / Mild Change of voice • No airway Problem • Hopkins – Ipsilateral Vocal Cord In Median or Paramedian Position • Voice – Good • Dyspnoea and Stridor • Hopkins – B/L Vocal Cords median or paramedian position Unilateral Bilateral Wait & Watch 6 months to 1 year Tracheostomy
- 21. Superior Laryngeal Nerve (Usuallya part of combined) • Hoarseness/Change of voice + • No breathing Problem • Aspiration rare(anaesthesia of larynx) • Hopkins – Shortening of VC with loss of tension • Voice – Aphonia • Aspiration +++ • Hopkins – B/L Vocal Cords median or paramedian position Unilateral Bilateral Wait and Watch Surgery
- 22. Side Nerve PalsyClinical Features Management U/L RLN Hoarseness Wait and Watch B/L RLN Dyspnoea Tracheostomy U/L SLN Hoarseness Wait and Watch B/L SLN Aspiration + Aphonia Surgery
- 23. Combined Paralysis • m/c/c– Thyroid Surgery • Hoarseness + • Aspiration for liquid + • Hopkins – Intermediate Position • Voice – Aphonia • Aspiration +++ • Hopkins – Intermediate Position Unilateral Bilateral Speech Therapy & Medialisation of VC Surgery Interarytenoid
- 24. • Observation • Normalor near normal function within one year without VF Motion • Injection Augmentation • Laryngeal Framework Surgery • Re-innervation Of Larynx • Voice Therapy • May relief symptoms Rx of U/L VF Palsy
- 25. Rx of U/LVF Palsy Injection Augmentation • Adding bulk to the free edge of VF • Temporary Solution • Absorbable material • Transcutaneous(transthyroid / cricothyroid approach) under Local • Per-oral approach under GA • Short term 2 months– Gelfoam , Carboxymethylecellulose • Intermediate 2-12 months – Hyaluronic Acid Derivaties, Collagen Derivatives • Long term 1-2 years – Calcium Hydroxylapatite , Autologous Facia(Facia lata >> temporalis sheath > Rectus sheath) • Permanent – Teflon , Silicon, Autologous Fat(thigh > periumbilical) • Laryngospasm , Laryngeal oedema , allergy to material • Other Use -Sulcus vocalis,Vocal fold scar, phonatory gap due to NM disease
- 26. • Pressure appliedat the level of vocal cord • If speech improves from the compression then patient will benefit from the medialization. • Limitation of test – older patient, scar over vocal cord.
- 27. Laryngeal Framework Surgery MedializationThyroplasty • Type I thyroplasty • Long term solution for glottic insufficiency, dysphonia & aspiration risk due to U/L VFP • Insertion of an implant in Para glottic space • Implant material – silastic, hydroxyl apatite, polytetrafluorethylene ribbon, titanium • Sedation, prefer propofol as it can be reversed easily • Flexible nasolaryngoscopy with simultaneously + LA infiltration in skin overlying thyroid cartilage • Skin crease incision -- > subplatysmal flap and strap muscles divided • External perichondrium flap incised and elevated. • Identify the inferior border of the thyroid cartilage • Make a window 5-7 mm posterior to the midline and 2-3 mm superior to the inferior border of thyroid cartilage
- 29. Medialization Thyroplasty • Inciseinternal perichondrium PARAGLOTTIC SPACE • Ask anesthetist for reversal to check the voice • Fix the implant with nonabsorbable suture. • Drain as per requirement • Overnight stay in hospital to avoid airway compromise • Additional dose of injectable steroids • Voice rest + Physical exercise avoid for 5-7 days. • Complication- 1) Airway compromise 2) Implant extrusion – due to intraoperatively injured laryngeal mucosa lead to infection and then extrusion • Unsatisfactory result -- > malpositioning 1. Superior – most common – diplophonic 2. Anterior – strained voice
- 30. Arytenoid Repositioning • Ifmedialization alone will not improve the condition. • In palsy , vocal process will remain lateralized and there will be posterior gap with height mismatch. • Arytenoid repositioning aims to mimic the arytenoid physiological phonatary position – medial rotation of arytenoid, lower vocal process, stabilize and medialize the vocal process. • Arytenoid adduction is the most common procedure in this technique. • Removal some part of posterior part of thyroid cartilage • Suturing with nonabsorbable material in anterolateral direction. • It will mimic the TA-LCA muscle complex. • Risk – injury to the laryngeal mucosa.
- 33. Rx of B/LVF Palsy No intervention with regular follow-up • In initial stage of the palsy patient due to any neurological conditions. • Rarely require surgical intervention. Medical Treatment • Systemic steroids can reduce edema. But short term benefit only. Intubation • Emergency Tracheostomy • Gold standard in Emergency, preventing aspiration, temporary till definitive management
- 34. Surgery • Aim –any static procedure which enlarge the laryngeal airway • There are multiple options but it will deteriorate the quality of voice • Resection of anatomical structure 1. Endoscopic transvers cordectomy 2. Medial arytenoidectomy 3. Total arytenoidectomy (external or endoscopic LASER)
- 35. Endoscopic Transverse Cordotomy:LASER • Less time, better result and reduced postoperative risk • Vocal fold tissue is not significantly excised -- > only frees the vocal ligament and vocalis muscle from the vocal process -- > tissue retraction occurs -- > enlarge the airway • Microscope with 400 mm lens with CO2 LASER • Intubated or Tracheostomised whatever the condition always confirm that tube is LASER Resistant. • Saline soaked cotton in subglottis • Incision line = 2-3 mm long with 10-12 Watt. • Lateral extent of cordotomy site should be flush with lateral subglottic wall.
- 36. Endoscopic Medial Arytenoidectomy:LASER • Medial Part of arytenoid body resection. • Preservation of lateral, posterior part and vocal process also. • Allows the posterior third of glottis widened and keep phonatory glottis(membranous) preserved.
- 37. Endoscopic Total Arytenoidectomy: LASER •Initially it was done by trans-thyroid or posterolateral approach. • Nowadays Endoscopic procedure • Carried out under temporary tracheostomy. • Complete ablation of arytenoid cartilage. • Procedure should be flush with the cricoid ring both posteriorly and laterally.
- 38. Retailoring and displacingthe existing structure : Endoscopic VF Lateralization Indication:- B/L VCP for approx 30 years as a measure of definative airway management. Contraindication:- ET trauma to posterior glottis
- 39. Reinnervation of LaryngealMusculature • Posterior Cricoarytenoid • Ansa hypoglossi with omohyoid or sternohyoid Botulinum Toxin • Injecting into adductor muscle -thyroarytenoid and lateral cricoarytenoid. • It will eliminate the synkinsis. • Permit unopposed action of PCA to abduct VF.
- 40. Laryngeal Innervation Surgery •Neuromuscular Pedicle • Ansa cervicalis RLN anastomosis.
- 41. Thyroplasty Repair of thyroidcartilage to change the position of vocal cord Type Isshiki Classification Indication Contraindication I Medialistion U/L VF Palsy -Malignancy -h/o Radiation -Poor Abduction Of C/L VF II Lateralistion RLN Palsy III Shortening/Pushing/Relax Decrease Pitch: Puberphonia, Spastic Dysphonia IV Lengthening/Pull Anteriorly/Tensoning Increase Pitch:- Androphonia, Presbyphonia, Transsexualism(M to F)