department of ent, head and neck surgeryoer.unimed.edu.ng/lecture...
TRANSCRIPT
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VOCAL CORD PALSY
Department of ENT, Head and
Neck Surgery
DR OSEGHALE
DR AKPALABA
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Case Presentation
• M /70 years
• Pensioner
• Christain
• Bini
• Resides in Benin
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• Had total thyroidectomy.
Follicular Ca of thyroid
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• Post-op developed inspiratory stridour and
respiratory difficulty on extubation
• DL in theatre by anaesthetists- vocal cords
apposed with slit-like opening
• Ass- ?neuropraxic injury to recurrent
laryngeal nerve
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• 3rd day post op
• Extubation attempted but failed
• Had tracheostomy under LA by ENT TOC
• Fibre-optic laryngoscopy
• Pooling of saliva around the supra-glottis and
over the cords. Cords are centrally placed and
immobile.
• Ass- bilateral abductor paralysis
• Plan- retain tracheostomy tube
• Being followed-up in ENT clinic
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Introduction
• Vocal fold paralysis can have a profound
impact on a patient's quality of life.
• Bilateral vocal fold paralysis is life
threatening because of airway
compromise, and unilateral vocal fold
paralysis is potentially life threatening.
• The surgical armamentarium available has
significantly expanded over the last 15
years.
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ANATOMY OF LARYNX
• The larynx lies in front of the hypopharynx
opposite the third to sixth cervical
vertebrae
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• Larynx has 3 unpaired and 3 paired
cartilages.
• Unpaired: Thyroid, cricoid, epiglottis.
• Paired: Arytenoid, corniculate, cuneiform
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Muscles of Larynx
• They are of two types,
• intrinsic, which attach laryngeal cartilages
to each other, and
• extrinsic, which attach larynx to the
surrounding structures
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Intrinsic muscles.
(a) Acting on vocal cords
• Abductors: Posterior cricoarytenoid
• Adductors: Lateral cricoarytenoid lnterarytenoid, Thyroarytenoid (external part)
• Tensors: Cricothyroid, Vocalis
(b) Acting on laryngeal inlet
• Openers of laryngeal inlet: Thyroepiglottic
• Closers of laringeal inlet: Interarytenoid (oblique part), Aryepiglottic
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Extrinsic muscles.
• (a) Elevators. Primary elevators-
stylopharyngeus, salpingopharyngeus,
palatopharyngeusand thyrohyoid.
• Secondary elevators- digastric, stylohyoid,
geniohyoid.
• (b) Depressors. They include sternohyoid,
sternothyroid and omohyoid.
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• Nerve supply- Vagus nerve (X CN)
a. Superior laryngeal
b. Recurrent laryngeal
• Arterial supply
a. Laryngeal branches of supr & infr
thyroid arteries
b. Cricothyroid branch of supr thyroid
artery
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Neuro anatomy
• Centrally- Nucleus ambiguus and Nucleus
tractus solitarus from upper medulla and
lower pons.
• Vagus- Superior laryngeal nerve at
nodose ganglion
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Superior Laryngeal Nerve
• 2nd branch of the Vagus
• Deep to int carotid
• Divides into internal and external superior
laryngeal nerve
• Internal branch- mainly sensory» Enters larynx through thyrohyoid membrane
» Divides into superior, middle and inferior branches
» Anastomoses with recurrent laryngeal nv
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External branch of SLN
• Seperates at greater cornu of hyoid
• Runs posterior to superior thyroid artery
• Ramifies into two to supply oblique and
rectus bellies of cricothyroid
• May anastomose with recurrent laryngeal
nerve
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Recurrent Laryngeal nerve
• Vagus travels in carotid sheath
• On the right the vagus runs anterior to
subclavian
• Gives of right recurrent laryngeal nerve
• Runs ant to post and cephalad
• Lat to medial till the tracheo-oesophageal
groove
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• Left branches at the level of the aortic arch
• Cranially and medially till the tracheo-
oesophageal groove
• Runs deep to the thyroid gland
• Branches to the deep cardiac plexus,
trachea and oesophagus.
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• Enters the larynx at inf. Cornu of thyroid
cartilage
• Divides into anterior adductor and
posterior abductor branches
• Sensory to the sub-glottis
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• Epithelium of the mucous membrane is
ciliated columnar
• type except over the vocal cords and
upper part of
• the vestibule where it is stratified
squamous type.
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Physiology
• The larynx performs the following
important functions:
• Protection of lower airways
• Phonation
• Respiration
• Fixation of the chest.
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View in phonation position
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View in respiratory position
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Causes of Vocal Cord Palsy
• Surgery
• Other medical interventions
• Medical diseases
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EtiologyCause Unilateral % Bilateral %
Surgery 24 26
Idiopathic/Viral 20 13
Malignancy 25 17
Trauma 11 11
Neurologic 8 13
Intubation 8 18
Other 5 5
Benninger et al., Evaluation and Treatment of the Unilateral Paralyzed Vocal Fold.
Otolaryngol Head Neck Surg 1994;111-497-508
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Surgery
• Cevical- thyroidectomy, carotid
endarterectomy, cricopharyngeal myotomy
• Thoracic- pneumonectomy, coronary
artery bypass graft, aortic valve
replacement, tracheal surgeries,
oesophageal surgeries
• Skull base surgery, brainstem surgery,
neurosurgery requiring brainstem
retraction.
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Other Medical Interventions
• Endotracheal intubation
• Central venous catheterisation
• Radiation
• Drugs and other toxicities
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Medical Diseases
• Malignancy
• Mediastinal lymphadenopathy
• Aortic aneurysm
• Stroke
• Neurological diseases-Arnold-chiari
malformation, Charcot-Marie-Tooth
disease
• Viral- EBV, herpes simplex e.t.c
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• Spontaneous recovery of unsevered nerve
within 12months.
• Aim of treatment –to resolve glottic
insufficiecy and improve swallowing and
voice production.
• Interventions are generally safe and
reversible.
TREATMENT OF UNILATERAL
VOCAL CORD PALSY
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• Observation.
• Voice therapy
• Injection laryngoplasty
• Medialization laryngoplasty
• Laryngeal reinnervation.
MANAGEMENT OPTIONS FOR
UVCP.
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• For voice strenghtening or swallow
therapy as indicated..
• Can augment effectiveness of surgical
treatment.
• Allows patients time to consider surgical
options.
VOICE THERAPY
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• Aspiration
• Severe denervation injury
• High level vocal demand.
Determining the need for early
intervention.
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• Temporary procedure
• Indicated when prognosis for recovery is
uncertain.
• Improves voice quality and swallowing
while allowing a period of recovery of
vocal cord function.
INJECTION LARYNGOPLASTY.
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• Teflon
• Autologous fat.
• Autologous collagen
• Bioplastique
• Hyaluronic acid.
• gelfoam
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• Goal-to improve glottal closure by shifting the vocal cord to the midline by use of prosthesis
Advantages-permanent but surgically reversible.
No need to remove implant if vocal function returns.
Materials-silastic,titanium,cartilage,goretex,Hydroxyapatite.
Advantage-permanent but surgically reversible
Disavantage-more invasive.
Complications-airway obstruction,implant extrusion.
MEDIALIZATION
LARYNGOPLASTY.
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• Ansa to RLN
• Ansa to omohyoid to
Thyroartenoid.
• Significant risk of synki
nesis but also a good
Chance of reasonable
result.
LARYNGEAL REINNERVATION
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• Hypoglossal to recurrent nerve.
• Use of crossed nerve grafts from one
muscle to its paralysed counterpart are
being researched.
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• Procedures are devised to improve the airway while minimizing the detrimental effect on phonation and swallow.
• Reversible etiologies should be treated prior to destructive surgeries.ss
Options-
Tracheostomy.
Posterior cordotomy
Arytenoidectomy
Suture lateralization
BILATERAL VOCAL CORD PALSYBILATERAL ABDUCTOR PARALYSIS.
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• Most common treatment to provide an
airway without detrimental effect to the
voice.
• Not a good long term stategy as most
patients are unhappy with permanent
tracheostomy.
TRACHEOSTOMY
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• May be performed alone or in combination with other procedures
• A viable option for temporising the patients airway..
• VC is lateralized by placing a suture from skin to larynx.
• Complications-altered voice quality
-loss of airway protection.
-granuloma formation.
-chondritis of arytenoids.
SUTURE LATERALIZATION
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• The most widely used surgical procedure
in BVCP.
• An incision is made in the post vocal cord
at the vocal process resulting in a wedge
shaped defect.
• Effective
• Complications are rare.
POSTERIOR CORDOTOMY
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Posterior cordectomy
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-the laryngeal inlet is widened in its
tranverse diameter producing a larger
airway by partial or complete excision of
the aytenoid.
-can be approached endoscopically or an
external framework approach can be
utilized.
ARYTENOIDECTOMY
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• Goal-to prevent aspiration and improve
phonation while preserving the airway.
• Aforementioned medialization techniques
can be applied.
BILATERAL ADDUCTOR
PARALYSIS
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• Complications-altered voice quality
-loss of airway protection.
-granuloma formation.
-chondritis of arytenoids.
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• Complications-altered voice quality
-loss of airway protection.
-granuloma formation.
-chondritis of arytenoids.
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• Complications-altered voice quality
-loss of airway protection.
-granuloma formation.
-chondritis of arytenoids.
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• Most promising treatment for BVCP.
• A pulse generator implanted beneath the
skin delivers electrical stimulation to the
PCA during inspiration.
LARYNGEAL PACING
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CONCLUSION