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APPROACH TO A PATIENT WITH VOCAL CORD PARALYSIS
- 1. APPROACH TO A PATIENT WITH VOCAL CORD PARALYSIS
- 2. EPIDEMIOLOGY • Acquired and congenital • Asymptomatic: 30-50% • Incidence increases with age. • left recurrent laryngeal nerve is more frequently involved: lung ca, esophageal ca, aortic aneurysm, tuberculosis, sarcoidosis, lymphoma, mediastinal Tm etc. • Surgical etiology more frequent than tumors.
- 3. Unilateral vocal fold palsy • Iatrogenic: Nonthyroid thyroid • Malignancy : Lung Non lung • Idiopathic • Neurogenic • Intubation • Trauma • Aortic/cardic • other • 30.6% • 15.7% • 6.6% • 6.9% • 17.6% • 7.9% • 4.4% • 2.2% • .6% • 12.6%
- 4. Bilateral vocal cord palsy • Iatrogenic: Thyroid Non thyroid • Malignancy • Intubation • Neurological • Trauma • others • 55.5% • 48.6% • 6.9% • 9.7% • 8.3% • 6.9% • 1.4% • 8.4%
- 5. Vagus nerve
- 7. Causes of laryngeal palsy • Supranuclear • Nuclear: vascular, neoplastic, motor, neuron disease, polio and syringomyelia. • High vagal lesion: skull, jugular foramen or in parapharyngeal space • Low vagal • Systemic causes • Idiopathic: 30%
- 8. Causes of combined palsy • Intracranial: Tumors of posterior fossa, basal meningitis . • Skull base: fracture, nasopharyngeal Tumors and glomus Tumors • Neck: penetrating injury, parapharyngeal Tumors, metastatic nodes and lymphoma.
- 9. Causes of RLN paralysis RIGHT(15%) • Neck trauma • Thyroid surgery • Ca cx esophagus • Cx LAP • Subclavian artery aneurysm • Ca apex of lung • idiopathic LEFT(75%) • Neck Mediastinal • Bronchogenic Ca • Ca thoracic esophagus • Aortic aneurysm • Mediastinal LAP • Enlarged left auricle(oatner’s syndrome) • idiopathic
- 11. Approach to patient with vocal cord palsy Voice change • Mode of onset • Duration • Progressive, intermittent or constant. • Aggravating and relieving factors. • Effortful phonation • Vocal fatigue acute insidious
- 12. • H/o preceding URI, trauma, vocal abuse, surgery. Associated Throat symptoms • Throat pain • Discomfort, dryness or soreness, frequent clearing, burning sensation. Cough • With or without sputum or blood • Diurnal variation • Aggravating factors : after meals or on lying down.
- 13. • relieving factors Breathing difficulty • Duration • Mode of onset • Progressive • Noisy breathing • Chocking
- 14. Difficult swallowing • Duration • Onset • For liquids/solids • Pain • Progressive or non progressive
- 15. H/o: • trauma • Fever with evening rise • Weight loss • Decrease appetite • Swelling neck or other sites of body • Symptoms of hyper/hypothyroidism • Chest pain • Weakness & numbness
- 16. Past history • Trauma • Viral infection or URI • Previous surgery • Prolonged intubation • Drug intake • DM/ Tuberculosis/ HT • radiation
- 17. Family history • DM , HT, tuberculosis • Heart disease • Carcinoma • Neurogenic disorders Personal history • Tobacco chewing • Smoking • Alcohol intake • Sleep habits Professional history
- 18. EXAMINATION General physical examination. • Build and nourishment • Vitals • Pallor, ictreus, anemia, clubbing, LAP,JVP • Cranial nerve examination. • Chest examination • CVS examination • GIT examination
- 19. LOCAL EXAMINATION Voice evaluation(perceptual) Quality: - normal( 50% Pt with u/l RLN or SLN palsy) - mild to moderately breathy( u/l SLN) - mod to severe breathy (u/l RLN) - hoarse - mild to moderate or severe hypernasality - strained
- 21. • loudness: Soft • Pitch • Reduced • High ( paralytic falsetto ) • Pitch breaks • Diplophonia ( u/l palsy) • Weak cough
- 22. Quantitative analysis • Magneting tape recording • Performance assesment: MFT & range of speech frequencies • Phonetogram: pitch vs. intensity • Spectogram: time, frequency and amplitude • Aerodynamics analysis: phonatory airflow rate, subglottic air pressure & air volume.
- 23. Fourier’s spectral analysis: • Fundamental frequency: sustaining a single tone at fundamental frequency. • Shimmer: avg cycle to cycle difference in amplitude of sound • Jitter: avg cycle to cycle difference in pitch of sound.
- 24. ENT examination Nose and PNS Lips, vestibule, oral cavity and oropharynx Palatopharyngeal gag reflex reduced or absent, inability to elevate soft palate.
- 25. Neck examination Inspection: -laryngeal framework - swelling Palpation: - laryngeal crepitus - swelling - lymph nodes
- 26. Indirect laryngoscopy • BOT, Vallecula, epiglottis, vocal cord, arytenoids, pyriform fossa. • Vocal cords: appearance, position at rest, in relation to each other, symmetry, glottic closure, movements in quite breathing and vocalization. • ee sniff test : maximum adduction and abduction.
- 27. Features • U/L SLN palsy: during phonation. • Usually normal and difficult to appreciate • Floppy, lower level of paralysed cord. • Askew position of glottis • Short, bowed and bulky cords • hyperemia of hemilarynx ( loss of sympathetic nerve supply)
- 28. • B/L SLN palsy: difficult to detect. • Epiglottis hangs over due to anterior tilt of larynx. • Cords are flaccid, bowed and hyperemic. • Guttmann’s test: frontal pressure on the thyroid cartilage will normally lower voice pitch by counteracting cricothyroid, whereas lateral pressure has opposite effect.
- 30. • RLN palsy ( abductor palsy): • Cord is not mobile • Floppy • Flickers on phonation • Paralysed cord balloons out on phonation • Arytenoid crosses midline • B/L : cord in median position - tends to limit activity - URTI precipitates laryngeal obstruction
- 34. Combined paralysis U/L: healthy cord not able to approximate paralysed cord • Glottic incompetence. Bilateral combined: • Cords lie in cadaveric position • Aphonia & aspiration.
- 35. Adavntages: simple opd procedure, max information. Disadvantages: brief duration, anterior glottic not seen, depth perception handicapped, ventricles , post cricoid, apex of pyriform sinus not seen and mucosal waves cannot be seen
- 36. • Vocal cord position: 6 positions not valid anymore • Semon’s law • Wager & grossman hypothesis
- 37. • Modern theory: final position not static depends on – degree of muscle atrophy & fibrosis - degree of reinnervation -Extent of synkinesis of muscles Three positions: abduction, adduction and midline
- 38. Specific investigations of cord movement • Rigid 70° video- telescopy. • Fiberoptic video laryngoscopy. • Laryngostroboscopic: glottic closure pattern evaluation - mucosal wave in response - of pitch and loudness - Lesion - Vocal fold opening and closing pattern - Supraglottic appearance - Symmetry of arytenoids
- 40. LARYNGEAL ELECTROMYOGRAPHY Gold standard • Degree of paralysis & prognosis • Differiating from mechanical fixation of CA joint • Neurological diagnosis • Site of lesion • Synkinesis & dysfunction reinnervation • Intaoperative nerve monitoring • Therapeutic inspection • Biofeedback in speech & swallowing disorder.
- 41. INVESTIGATIONS Vocal cord palsy is not a disease per se, it’s just a sign of underlying disease. 57% of cases can be diagnosed by taking proper history and detailed examination Routine : CBC , RBS, SE, VDRL and LFT, barium swallow & thyroid scan. low diagnostic yield ( usually not recommended)
- 42. Radiological chest xray:- secondaries, primary carcinoma, apiration pneumonia, metastatic lymph nodes, aortic arch aneurysm and TB. (54% diagnostic yield) No other detectable lesion: contrast CT ( skull base to aortic arch) No mass lesion – idiopathic. Palatal & pharyngeal paralysis and other neuropathies: gadolinium enhanched MRI skull base and neck. If negative- HRCT temporal bone for bony mets
- 43. • Flexible or rigid esophagoscopy with biopsy.
- 44. Treatment Unilateral vocal fold palsy Known permanent etiology/ unknown etiology > 9 months Healthy pt, no aspiration Healthy pt, with aspiration sick pt, with or w/o aspiration VOICE THERAPY PHONOSURGERY
- 45. Temporary or unknown etiology < 9 months Healthy pt,no aspiration Healthy pt,with aspiration & strong need of voice sick pt, with or w/o aspiration VOICE THERAPY TEMPORARY AUGMENTATION after 9 months DEFINITE PHONOSURGERY
- 46. • Educational information regarding phonation • Vocal hygiene: voice rest, avoid shouting, talking loudly, clearing throat - adequate hydration - steam inhalation - smoking cessation, reducing alcohol, - Diet and reflux reduction
- 47. VOICE THERAPY • Vocal exercise : strengthening the muscle groups, improving glottic closure and efficiency. • Reducing excessive tension in muscles around larynx, neck and shoulders. • Advice on posture and breathing during speech • Laryngeal massage • General relaxation exercise • Psychological counseling.
- 48. Bilateral vocal cord paralysis • Tracheostomy • Posterior transverse cordotomy( CO2 laser)
- 49. • Medial arytenoidectomy • Total arytenoidectomy
- 50. • Endo-extralaryngeal suture. • Laryngeal pacing.
- 51. In cases of contraindication • Epiglottopexy • Vocal cord plication • Total laryngectomy: cause is progressive, irreversible and speech is unservicable. • Diversion procedures: intractable aspiration
- 52. PHONOSURGERY TYPES : • Microlaryngosurgery • Laryngeal injection • Laryngeal framework surgery • Nerve pedicle rinnervation
- 53. • Laryngeal injection techniques:- for phonatory gap in u/l abductor or adductor palsy • Teflon, fat, collagen, gelfoam, silicone etc
- 55. Laryngeal framework surgery • THYROPLASTY: type 1( medial displacement)
- 57. • Arytenoid adduction: large posterior glottic gap. • Laryngeal reinnervation: nerve muscle pedicle graft technique. • Anterior belly of omohyoid with ansa hypoglossi and vessels.
- 58. THANK YOU