This document discusses vocal cord paralysis, including its causes, symptoms, diagnosis, and treatment options. Some key points: - Vocal cord paralysis can impair breathing, swallowing, and voicing. Common symptoms are breathy voice and difficulty swallowing liquids. - It is usually caused by damage to the recurrent or superior laryngeal nerves, often from medical conditions or surgery. The left cord is more commonly affected due to nerve anatomy. - Diagnosis involves laryngeal exam and sometimes electromyography or MRI. Treatment depends on severity but may include observation, vocal cord injections, framework surgery like medialization thyroplasty, or reinnervation surgery. - Bilateral paralysis can be life-

1. Vocal cord paralysis
Dr Vishnu Premraj

2. Nerve supply of larynx

5. Paralysis of one or both vocal folds may impair the
important physiologic functions of the larynx:
-breathing
-swallowing
-Voicing
The most prominent of these are breathy dysphonia and
dysphagia-particularly to liquids.
INTRODUCTION

6. PATHOPHYSIOLOGY
-Most cases of laryngeal paralysis result from peripheral
nerve damage
-larynx has a strong propensity for re-innervation
-Re-innervation is often dysfunctional and does not
yield physiological function.

7. Laryngeal paralysis may be unilateral or bilateral
and many involve
1. Recurrent laryngeal nerve
2. Superior laryngeal nerve
3.Both recurrent and superior laryngeal nerve

8. AETIOLOGY OF LARYNGEAL PARALYSIS
- More common in Men
- Trauma
- Functional compromise from a range of medical
conditions
-Mechanical damage from surgery
-The left vocal fold is affected more often than the
right
Due to the greater length and more profound descent into the thorax and its greater
vulnerability to disease and surgery

10. Causes of recurrent laryngeal nerve paralysis
Right recurrent laryngeal nerve
 Thyroid disease
 Neck trauma
 malignancy
 Iatrogenic
 Cervical lymphadenopathy
 Aneurysm of subclavian artery
 Carcinoma right lung

11. Left recurrent nerve paralysisis
1.Neck
 Accidental trauma
 Thyroid Disease
 Iatrogenic
 Malignancy
2.In the mediastinum
 Bronchogenic carcinoma
 Carcinoma eosophagus
 Aortic Aneurysm
 mediastinum lymphadenopathy

17. Unilateral laryngeal paralysis :
- unilateral recurrent laryngeal nerve paralysis
Ipsilateral paralysis of all intrinsic muscles except
cricothyroid
Vocal cords will be in median or paramedian
position

18. Theories on vocal cord in vocal cords paralysis
1. Semons law
In all Progressive organic lesions ,abductor fibres
[phylogenetically newer] are more susceptible and
thus first to be paralysed
2. Wagner and Grossman law
Total paralysis of recurrent laryngeal nerve immobilises
vocal fold in paramedian position because of intact
cricothyroid muscle
- Combined paralysis of RLN and SLN causes folds to be
in intermediate position

19. Symptoms
 hoarseness
 hypophonia.
 Dysphagia with possible frank aspiration .
PHYSICAL EXAMINATION
-neck examination
-cranial nerve examination[To rule out jugular
foramen syndromes, after stroke and
after skull base surgeries ]
-Flexible nasolaryngoscopy -

20. Jostle sign
vocal fold motion which may be caused by the
interarytenoid muscles innervated from the contralateral
nerve, by an intact cricothyroid muscle, ,passive lateral
displacement of the arytenoid cartilage on the paralyzed
side or by its pair during adduction.
-Asymmetry of the arytenoids -
prolapsed arytenoid does, profound denervation with
loss of muscular support for the cartilage.

22. Investigations
Laryngeal Electromyography
 measures the integrity of laryngeal innervation
with percutaneous needle electrodes.
 It can provide unambiguous evidence of
denervation and reinnervation.
 offers a reliable way to distinguish neurogenic
from mechanical vocal fold immobility .

23. Suspected high vagal paralysis
MRI may offer a more reliable means of imaging the
skull base or central nervous system

24. Treatment
1)Observation.
Factors favoring observation include
1. no evidence of aspiration
2. certainty that the injured laryngeal
nerve is intact structurally.
3. minimal vocal disability and/or
minimal vocal demand
4. good functional prognosis
5. comorbidites or other medical
factors which discourage or prevent
intervention

25. Injection Augmentation
 temporary relief of their symptoms
accomplished by injection of an absorbable bulking
substance into the paralyzed fold to improve the
glottic insufficiency.
Substances include
collagen and hyaluronic acid preparations, micronized
human dermis, autologous fat,carboxymethylcellulose-
glycerine gel.

26. Factors favouring injection augmentation include
1. Dysphagia,
2. high degree of vocal disability or high vocal demand
3. functional prognosis is good or indeterminate,
4. relatively small glottic gap (<2 to 3 mm),
5. no posterior glottic gap,
6. short life expectancy (less than the expected duration of
the injectate).

27. Technique
- Via direct laryngoscope in operating room
- Peroral / transcutaneously under topical anaesthetic
or superior laryngeal nerve block in the office.
Disadvantages
-Does not effectively reposition the arytenoid cartilage
to rectify posterior glottal gap.
- not ideal for large glottic gaps.

29. Framework Surgery.
Reserved for treatment of glottic insufficiency from
unilateral paralysis which is not expected to improve.
Factors favoring a framework approach are
following-
1. dysphagia,
2. high degree of vocal disability or high
vocal demand,
3. poor functional prognosis,
4. relatively large glottic gap (>2 to 3 mm
5. posterior glottic gap,

30. Medialization thyroplasty.
Consist of insertion of an implant -silicone, formed
polytetrafluoroethylene (formed calcium hydroxylapatite,
or other biologically inert material, into the paraglottic
space to displace the paralyzed vocal fold medially.
- Done under local anaesthesia

32. Complications
 Airway obstruction
 Perforation into laryngeal lumen
 Postoperative edema and hematoma
 The most common “complication,” however, is
suboptimal voice outcome.
Arytenoid cartilage repositioning procedures
-designed to internally rotate and/or suspend the
arytenoid cartilage in physiologic phonatory position
- can be done along with thyroplasty

33. Technique
Muscular process of the arytenoid cartilage is
approached through the inferior constrictor muscle
and around the back of the thyroid lamina.
nonabsorbable suture is passed through the muscular
process and secured to the thyroid lamina so
as to exert anterolateral traction on the muscular
process and thus rotate the vocal process medially
and slightly caudally

34. Reinnervation.
Using nearby nerves [both the ansa cervicalis and the
hypoglossal nerve]
reinnervation generally improves the bulk and
tone of vocal fold muscle but will not restore
physiologic motion
Reinnervation is ideally suited when the vocal fold is
known to be completely denervated.

35. Bilateral recurrent laryngeal berne palsy
- thyroid surgery
- carcinoma thyroid
- Carcinoma eosophagus
-Cervical lymphadenopathy
-Charcot–Marie–Tooth disease is a hereditary motor
and sensory neuropathies that may involve the laryngeal
nerves.
-Amyotrophic lateral sclerosis
- postpolio syndrome
- Arnold Chiari malformation
-Gullain- barre syndrome

36. Symptoms
-dyspnea,
- noisy breathing,
- exercise intolerance.
The severity of these respiratory symptoms is inversely
proportional to the size of the glottic aperture between the
two immobile vocal folds.

37. Acute bilateral vocal cords paralysis
- life threatening condition
The typical situation is unexpected respiratory
distress after extubation from thyroid surgery- securing
airway is consideration

38. Treatment
Treatment is guided by the degree of airway limitation
 Tracheostomy performed emergently .
It provides an adequate airway with
minimal compromise of phonation and deglutition
Other treatment option include
lateralization of one vocal fold or removal of one arytenoid
cartilageor vocal fold tissue to enlarge the glottic aperture

39. VOCAL FOLD PARESIS
Paresis or incomplete paralysis in which some
gross vocal fold mobility is preserved.
Symptoms
 voice difficulty only after speaking for some time or at
high intensity.
 exercise tolerance.

40. Thankyou