RECURRENT

LARYNGEAL NERVE
PARALYSIS

By – Sparsh Goel
77
 Right recurrent laryngeal nerve
arises from the vagus at the level of
subclavian artery, hooks around it
and then ascends between the
trachea and oesophagus.

 The left recurrent laryngeal nerve

arises from the vagus in the
mediastinum at the level of arch of
aorta, loops around it and then
ascends into the neck in the
tracheo-oesophageal groove.

 Thus, left recurrent laryngeal nerve

has a much longer course which
makes it more prone to paralysis
compared to the right one
RECURRENT LARYNGEAL NERVE PARALYSIS

UNILATERA
BILATERAL
L
UNILATERAL
 Unilateral injury to recurrent laryngeal nerve results in
ipsilateral paralysis of all the intrinsic muscles except the
cricothyroid.
 The vocal cord thus assumes a median or paramedian
position and does not move laterally on deep inspiration .
THEORIES TO EXPLAIN THE MEDIAN OR
PARAMEDIAN POSITION OF THE CORD :
 One is Semon's law which states that, in all
progressive organic lesions, abductor fibres of the
nerve, which are phylogenetically newer, are
more susceptible and thus the first to be
paralysed compared to adductor fibres.

 The other explanation is Wagner and Grossman

hypothesis which states that cricothyroid muscle
which receives innervation from superior
laryngeal nerve keeps the cord in paramedian
position due to its adductor function.
CLINICAL FEATURES
 Unilateral recurrent laryngeal paralysis may pass
undetected as about one-third of the patients
are asymptomatic.
 Others have some change in voice but no
problems of aspiration or airways obstruction.
 The voice in unilateral paralysis gradually
improves due to compensation by the healthy
cord which crosses the midline to meet the
paralysed one.
TREATMENT
1. Generally no treatment is required as compensation
occurs due to opposite healthy cord. Temporary paralysis
recovers in 6–12 months and it is advisable to wait.

2. Laryngoplasty type I can be used if compensation does

not take place.

3. Laryngoplasty type I with arytenoid adduction is done if

posterior glottis is also incompetent.
BILATERAL
 Aetiology
Neuritis or surgical trauma (thyroidectomy) are the most
important causes. The condition is often acute.
 Position of Cords
As all the intrinsic muscles of larynx are paralysed, the vocal
cords lie in median or paramedian position due to unopposed
action of cricothyroid muscles .
CLINICAL FEATURES

 As both the cords lie in median or paramedian

position, the airway is inadequate causing
dyspnoea and stridor but the voice is good.

 Dyspnoea and stridor become worse on

exertion or during an attack of acute laryngitis.
 TREATMENT
 TRACHEOSTOMY - Many cases of bilateral abductor
paralysis require tracheostomy as an emergency procedure.
 In long-standing cases, the choice is between a permanent
tracheostomy with a speaking valve or a surgical procedure
to lateralize the cord. The former relieves stridor, preserves
good voice but has the disadvantage of a tracheostomy hole in
the neck. The latter relieves airway obstruction but at the
expense of a good voice; however, there is no tracheostomy
hole in the neck.
 Widening the respiratory airway without a permanent
tracheostomy (endoscopic or through external cervical
approach) - Aim is to widen the respiratory airway through
larynx. This can be achieved by (i) arytenoidectomy with
suture, (ii) arytenoidopexy (fixing the arytenoid in lateral
position), (iii) lateralization of vocal cord and (iv) laser
cordectomy removal of one cord).
 These operations have now been replaced by less invasive
techniques such as:

 1. Transverse cordotomy (Kashima operation)

Soft tissue at the junction of membranous cord and vocal process of
arytenoid is excised laterally with laser. This provides good airway. In case
airway is still insufficient more tissue can be removed at subsequent
operation.

 2. Partial arytenoidectomy
Medial part of arytenoid is excised with laser.

 3. Reinnervation procedures
These have been used to innervate paralyzed posterior cricoarytenoid
muscle by implanting a nerve.These procedures have not been very
successful.

 4. Thyroplasty type II
It creates lateral expansion of larynx and is similar to vocal cord
lateralization. Quality of voice may not be good.