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Devashish Kamra Roll no.

45/09

SENSORY SUPPLY SUPRAGLOTTIC PART –internal branch of superior laryngeal nerve

GLOTTIC & INFRAGLOTTIC PART –Recurrent Laryngeal Nerve

 MOTOR

SUPPLY All the muscles of larynx are supplied by recurrent laryngeal nerve except the cricothyroid which is supplied by external branch of superior laryngeal nerve.  Motor cortex has a b/l representation of both vocal cords.

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ADDUCTORS • Lateral cricoarytenoid • Transverse arytenoid • Oblique arytenoid ABDUCTOR • Posterior cricoarytenoid TENSOR • Thyroarytenoid (including vocalis muscle) • Cricothyroid .

iii. PROTECTION & MAINTENANCE OF AIRWAYS Sphincteric closure of laryngeal opening Cessation of respiration Cough reflex i. ii.    PHONATION(aerodynamic myeloelastic theory of voice production) REGULATION OF RESPIRATORY FLOW FIXATION OF CHEST .

It leads to complete motor paralysis without sensory involvement. HIGH VAGAL LESION(leading to combined SLN & RLN paralysis)-Vagus nerve involved in skull. exit from jugular foramen or parapharyngeal space. Vocal cord is flaccid.ass. with lesion of cranial nerves. NUCLEAR-Nucleus Ambiguous involved.they are ass.SUPRANUCLEAR-rare as only b/l cortical lesions will produce paralysis. When present . Laryngeal paralysis is b/l & after short period of flaccidity becomes spastic. with other neurological defects. LOW VAGAL LESION-RLN paralysis .

diabetes.syringobulbia.Poliomyelitis.Shy-Dragger Syndrome .Arnold Chiari Malformation.  Supranuclear and nuclear lesions are caused due to neurological defects like Amyotrophic Lateral sclerosis. HIGH VAGAL LESIONS CAUSESINTRACRANIAL Tumors of posterior fossa Basal meningitis SKULL BASE Fractures Nasopharyngeal cancers Glomus tumor NECK Penetrating injury Parapharyngeal tumors Metastatic nodes Lymphoma .vascular & neoplastic disorders.

MOST COMMON CAUSE IS TOTAL THYROIDECTOMY    NECK CAUSES Thyroid surgery Benign or malignant thyroid disease Carcinoma cervical esophagus Neck trauma Cervical lymphadenopathy •MEDIASTINAL CAUSES RIGHT Aneurysm of subclavian artery Carcinoma apex right lung TB of cervical pleura Idiopathic LEFT Bronchogenic cancer Carcinoma thoracic esophagus Aortic aneurysm Mediastinal LAP Enlarged left auricle Intrathoracic surgery idiopathic    .

& potential of recovery. neck & mediastinum can be done Glucose tolerance done to rule out diabetes Serology Stroboscopy. Associated nerve deficits esp. cranial nerves is seen to determine the cause of lesion.       Early detection requires thorough evaluation of any paralysis with no apparent cause. electromyography & transmural stimulation laryngeal muscles gives more info. . Radiologic evaluation (CAT. Complete ENT examination exam with endoscopy is the baseline.MRI) of skull .

cricothyroid spared causing adduction But vocal cords can tense.UNILATERAL PARALYSIS  Vocal cord –median or paramedian position generally but not always  Semon’s law.  .  Wagner and Grossman Hypothesis.abductor fibres more susceptible than adductor as they are phylogenetically new. move slightly.

It could be done by vocal cord injection or by surgical procedures like thyroplasty. ACUTE ONSET PARALYSIS-weak voice but later gets compensated .  If the paralyzed cord is unable to bridge the gap leading to hoarseness of voice then medialisation of cord is done.  TREATMENT  Depends on the final position of vocal cord. CLINICAL FEATURES-  Asymptomatic in 1/3rd patients.  .  GRADUAL ONSET PARALYSIS-compensation occurs progressively & symptoms are minimal.

neuritis. Cricothyroid spared  CLINICAL FEATURES voice is good as vocal cords are adducted  airway is inadequate causing dyspnoea and stridor  Dyspnoea worsened on ac. laryngitis .upper esophageal Ca. BILATERAL  Thyroidectomy. POSITION OF CORDS-median or paramedian .

 Techniques that widen posterior commissure are most likely to achieve this without too much compromise with voice. with respiratory tract infection.  Long standing cases-either permanent tracheostomy with a speaking valve is done or surgical lateralization of the cord is done to secure the airway. .  Tracheostomy –relieves stridor & preserve good voice with disadvantage of a tracheostomy hole in neck.TREATMENT TRACHEOSTOMY Emergency tracheostomy done in acute cases or in ass. SURGICAL LATERALISATION OF CORD Aims to improve the airway at the expense of voice.

Various procedures for surgical lateralization are –  Endoscopic techniques without arytenoidectomy(Kirchner 1979) Use of microcautery or laser  Temporary sutures exiting through neck.  Without sutures relying on scar contracture  Now done by CO2 laser by vaporizing laryngeal tissue  Requires a mobile arytenoid  Complete laser cordectomy considered rarely. .

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 Complications–   granuloma formation at site of incision web formation in posterior commissure  It was simplified by Laser . Endoscopic techniques with arytenoidectomy(Thornell 1948) Mucosal incision made on top of arytenoid and the cartilage dissected & extracted.

 Implantable devices  Midline thyrotomy Induced Paralysis to SLN Motor  Reinnervation  Practically obsolete . This is a difficult approach mastered by few operators. Extralaryngeal approach –arytenoids are removed by an external approach.

Clinical Features Weak voice  Pitch can’t be raised  Occasional aspiration  Anterior comm.UNILATERAL PARALYSIS Isolated lesions of this nerve rare. rotated to healthy side  Flapping of paralyzed cord .  Leads to supraglottic anaesthesia and cricothyroid paralysis.

neuritis patients recover spontaneously.  Patients with repeated aspiration require tracheostomy with a cuffed tube & an esophageal feeding tube.  Paralysis + anaesthesia b/l leads to repeated aspiration  Voice weak and husky TREATMENT Depends upon cause.  Epiglottopexy done to close laryngeal inlet to protect lungs from aspiration.BILATERAL PARALYSIS Leads to paralysis of both cricothyroid muscles along with anaesthesia of upper larynx. .

 UNILATERAL  PARALYSIS- Paralysis of all the muscles of larynx on one side except interarytenoid CLINICAL FEATURES All the muscles of one side are paralyzed  vocal cord lie in intermediate position(earlier known as cadaveric position) i. . therefore leads to hoarseness of voice and aspiration of liquids through glottis.  Cough ineffective due to improper adduction.5 mm from midline. 3.e.  Healthy cord is unable to reach paralyzed cord.

TREATMENT – • Speech Therapy-helps in compensating the function of paralyzed cord due to movement of healthy cord across the midline. Materials used for injection Paraffin initially  Gelfoam  Fat  Teflon(with glycerine as a base)  Bovine collagen • . If necessary then lateral midportion of cord is injected. PROCEDURES TO MEDIALISE THE PARALYSED CORDa) Vocal cord injectionPrinciple-lateral side of vocal process is injected with an inert material so as to push the cord to medial side.

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pushing the cord medially.Requirements for injection Cricoarytenoid joint should be mobile.  Cord should not be more than 3-4 mm away from midline.  Cord should be totally paralyzed otherwise the material will migrate result is poor. Done in the presence of a very large gap >3-4mm at posterior commissure can be done in severely scarred larynx where vocal cord injection is not possible. Procedure. .  Surgical  medialisation-   Muscle graft or piece of cartilage is inserted between thyroid cartilage and its inner perichondrium lateral to vocal cord.it is done with direct laryngoscopy under local anaesthesia.

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arytenoid cartilage rotated medially and fixed with a screw. Both cords lie in intermediate position with total anaesthesia of larynx. .  BILATERAL PARALYSISBoth RLN & SLN of both sides are paralyzed. CLINICAL FEATURES Aphonia  Aspiration  Inability to cough  Bronchopneumonia due to repeated aspiration and retention of secretions. It is a rare condition.Vocal cord reinnervation –selective reinnervation of adductors is done to bring cords to midline.  Arthrodesis of cricoarytenoid joint-Larynx is opened by a laryngofissure.

TREATMENT Tracheostomy  Epiglottopexy  Vocal Cord plication-mucosa of true and false cords is removed & then they are approximated with sutures.  Diversion Procedures .  Total laryngectomy done when cause is progressive and speech is unserviceable. It helps prevent aspiration and can be reversed when required.

5 mm) • Paralysis of both RLN & SLN • cadaver • Quiet respiration • Paralysis of adductors Gentle abduction(7mm) Full abduction (9.Median • Phonation • RLN paralysis Paramedian (1.5mm) • Strong whisper • RLN paralysis Intermediate (3.5mm) • Deep inspiration .

May be unilateral or bilateral. intra-cerebral hemorrhage during birth.  . meningocoele or cerebral or nucleus ambiguous agenesis.  Cause of B/L –hydrocephalus . Unilateral paralysis more common  Cause of U/L-birth trauma or a congenital anomaly of a great vessel or heart.Arnold Chiari malformation.

It is done in mutational falsetto or in those who have undergone gender transformation from female to male. This procedure lowers the pitch. Also used when vocal cord is lax due to ageing process or trauma. Type IV-It lengthens(tightens) the vocal cord & elevate the pitch. Vocal Cord Injection THYROPLASTY-Ishikki divided thyroplasty procedures into 4 categoriesType I-medial displacement of vocal cord Type II-lateral displacement of vocal cord Type III-it shortens(Relax) the vocal cord. It converts male character of voice to female and thus used in gender transformation. REINNERVATION .   a) b) c) d)  Excision of benign & malignant lesions by laser or microsurgery.

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