VOCAL FOLD

PARALYSIS
INTRODUCTION

• It is a sign of disease and not a diagnosis

• Potential morbidity and mortality
• A sign of a disease process with multiple etiologies , necessitating thorough
evaluation
• Part of hypo functional neurological disorders
• Most often the result of distal nerve injury in the chest or neck
ANATOMY OF LARYNX
LARYNGEAL CARTILAGES
LARYNGEAL MUSCLES
NERVE SUPPLY OF LARYNX
 NERVE SUPPLY OF LARYNX

MOTOR SENSORY
• All the muscles which moves the vocal folds • Above the vocal folds , larynx is supplied
(abductors , adductors or tensors) are by Internal Laryngeal Nerve a branch of
supplied by the Recurrent Laryngeal Nerve Superior Laryngeal Nerve & below the
except the Cricothyroid muscle , which is vocal folds by Recurrent Laryngeal Nerve .
supplied by Superior Laryngeal Nerve .
• Both of these are branches of Vagus nerve
 FUNCTIONS OF VOCAL FOLDS

Vocal fold mainly has the following movements:

• Adduction: approximation of vocal folds with each other.
• Abduction: movement of vocal folds away from each other.
 PATHOLOGY OF VOCAL FOLD PARALYSIS

• Types:
o Unilateral/Bilateral
o Complete/Incomplete
• Position of Vocal Fold:
o Median - midline
o Paramedian – 1.5 mm from midline
o Cadaveric (intermediate) – 3.5 mm
o Gentle abduction – 7 mm
o Full abduction – 9.5 mm
 PATHOLOGY OF VOCAL FOLD PARALYSIS

• Theories of paralysis:
o Semon ‘s law
States that, in all progressive organic lesions, abductor fibers of the nerve which are phylogenetically
Newer are more susceptible and thus the first to be paralysed as compared to adductor fibers .

o Wagner and Grossman theory

It is the most widely accepted theory. It states that complete paralysis of the RLN results in the vocal
folds being in paramedian because of an intact cricothyroid muscle, which adducts the vocal folds.
When the superior laryngeal nerve is also paralysed, the vocal fold will be in intermediate or
cadaveric position because of loss of this adductive force.
 SITE OF LESION
• Supra nuclear
o Rare
o Bilateral lesions causes paralysis
o Pharyngeal and laryngeal paralysis
• Nuclear
o Lesions of soft palate, pharynx and larynx
• Posterior fossa and jugular foramen
o Vernet’s –lX, X, Xl
o Schmidt’s – X, lX
o Hughling’s jackson – X, lX, Xll
o Collet-Sicard – lX, X, Xl, Xll
o Villaret’s – lX, X, Xl, Xll, Hormers

• Extra cranial
 AETIOLOGY
 Acquired (left- 78%, right- 16%, both- 6% )
 Malignant 25% - Lung (50%), Oesophagus (25%), Thyroid(10%)
 Surgical 20% - Thyroid, Lung, Heart, Oesophagus, mediastinum
 Idiopathic 30% - viral, smokers
 Inflammatory 13% - 95% (Tuberculosis)
 Non surgical trauma 11% - Skull, penetrating injuries, neck, cardiomegaly, aneurysm
 Neurological. 7% - CVA, Parkinson’s disease, Multiple Sclerosis, Alcoholic and .
. diabetic Neuropathy
 Miscellaneous 11% - Haemolytic anaemia, Collagen disease
 AETIOLOGY: MALIGNANCY

• Thyroid
• Oesophagus
• Lung
• Skull base
Temporal lobe malignancies
Posterior fossa tumours
Paraganglioma
 AETIOLOGY: SURGICAL

Rosenthal et.al showed that surgical causes of unilateral vocal fold immobility were the result
of
1. Non thyroid surgeries (67%)
• Anterior cervical spine (15%)
• Carotid endarterectomy (11%)
• Cardiac (9%)
2. Thyroid surgeries (33%)
• Thyroid (26%)
• Parathyroid (6%)
• Thyroid and parathyroid (1%)
 AETIOLOGY: IDIOPATHIC
• Not well understood
• Possible infectious cause
Lyme disease
Tertiary syphilis
Epstein – Barr virus
Herpes simplex virus Type l
• Diagnosis of exclusion
Urquhart et.al showed that 26% of patients with a diagnosis of idiopathic vocal fold paralysis had a pre
existing neurologic condition and 20% developed a subsequent CNS condition
 AETIOLOGY: INFLAMMATORY

• Tuberculosis
This could be due to apical scarring of the mediastinum or enlargememnt of hilar nodes
• Jugular vein thrombophlebitis
• Subacute thyroiditis
• Meningitis both viral and bacterial
 AETIOLOGY: TRAUMATIC
• Iatrogenic : Non – surgical
Endotracheal intubation
 Arytenoid dislocation, subluxation
 Tapia’s Syndrome (combination of recurrent laryngeal and hypoglossal palsy. It has been reported
after interscalene brachial plexus block)
Nasogastric tube placement
• Cardiomegaly, Aneurysm
• Non – iatrogenic
Blunt or penetrating trauma to the neck
 AETIOLOGY: NEUROLOGIC
• Stroke
• CNS tumour
• Diabetic neuropathy
• Amyotrophic Lateral Sclerosis (ALS)
• Arnold chiari malformation
• Myasthenia gravis
• Post polio palsy
 AETIOLOGY: SYSTEMIC DISEASE

• Systemic lupus erythematosus

• Sarcoidosis
• Amyloidosis
• Charcot–Marie–Tooth
• Haemolytic anaemia
• Porphyria
• Polyarteritis nodosa
• Silicosis
 AETIOLOGY: MEDICATIONS

• Vinca alkaloids
Vincristine and vinblastine
Unilateral or bilateral
Dose related neurotoxicity effect
Resolves with dose adjustment or cessation
 CONGENITAL VOCAL FOLD PARALYSIS
• Very common cause of stridor
• Infants with stridor may have congenital paralysis of vocal folds
• Occurs with or without other associated abnormalities – neurologic, laryngeal, cardiac defects
• Most common anomaly is hydrocephalus
• The mechanism of vocal fold paralysis in these children is not clear
 Could be due to stretching of the vagus nerve, due to complicated delivery etc.

• First examination is flexible laryngoscopy

 Nasal or oral
 Video recording

• Laryngeal ultrasound
• Laryngoscopy under Anaesthesia
 SUPERIOR LARYNGEAL NERVE PARALYSIS

Unilateral
• More rarely recognised
• Symmetry maintained during phonation
• Ipsilateral bowed and flabby vocal fold
• Voice not severely affected
• Arytenoid movement unimpaired
• Fails to regain its original strength, though quality returns
 SUPERIOR LARYNGEAL NERVE PARALYSIS
Bilateral
• Rare condition
• Professional voice
• Epiglottis hangs over endolarynx
• Flaccid, bowed and hyperemic vocal folds
• Voice lower, weaker, breathy
• Good compensation; speaking voice returns, but singing voice compromised
 RECURRENT LARYNGEAL NERVE PARALYSIS

Abductor paralysis
1. Unilateral
2. Bilateral
Adductor paralysis
1. Unilateral
2. Bilateral
 UNILATERAL ABDUCTOR PARALYSIS
• Asymptomatic, or only hoarseness-improves with time
• Single paralysed cord in paramedian position
• Compensation occurs
• In some patients, disordered protective mechanism
• Patients with less severe cause, dysphonia persists or voice tires
• Management
 Speech therapy
 Surgical management
 Vocal fold injection
 RLN re innervation
 Arytenoid rotation
 BILATERAL ABDUCTOR PARALYSIS
• Vocal folds in paramedian position
• Voice is good but degree of stridor variable
• Good voice; poor airway
• If after thyroidectomy; reopen
• Management
 Tracheostomy (speaking valve)
 Others
 Cordectomy
 Laterofixation of cord
 Arytenoidectomy and Arytenoidopexy
 Re innervation
 UNILATERAL ADDUCTOR PARALYSIS
• Flaccid paralysed vocal fold sin lateral position
• Weak husky voice, sometimes to more than whisper
• Lesion of vagus or both RLN and SLN
• Aspiration
• Management
Type and timing depends on aetiology
Teflon injection, vocal fold injection
Others
 Speech therapy
 Medialisation laryngoplasty and arytenoid adduction
 BILATERAL ADDUCTOR PARALYSIS
• Rare, CNS disease or neoplasm
• Involving medulla, skull base, or upper neck
• Both vocal folds in lateral position
• Aphonic
• Laryngeal incompetence
• Psychiatric disturbance-Hysterical aphonia
• Management
 Total Laryngectomy
 Epiglottopexy
 Others
 Teflon injection
 Suturing of cords
 EVALUATION

• Assess swallow function and

aspiration
 Modified barium swallow
 Functional Endoscopic Evaluation of
Swallowing (FEES)

• No additional work up required if

clear cut aetiology
 EVALUATION-EXAMINATION
• Complete head and neck examination
 Cranial nerve examination
• Flexible fiberoptic laryngoscopy
(Nasopharyngolaryngoscopy)
 Vocal fold asymmetry
 Horizontal and vertical position
 Glottic gap
 Pooled secretions
 Aspiration
 Supraglottic hyperfunction
• 90 degree Hopkins Rod-lens Telescope
 EVALUATION-VIDEOSTROBOSCOPY
• Demonstrates small mucosal motion
abnormalities
• Video documentation
 EVALUATION-SURGICAL

• Lateral manual compression test

 To determine if patient will benefit from
medialisation thyroplasty
 Pressure applied at the level of vocal
folds
 If quality of speech improves with
pressure, patient will benefit from
procedure
 Limitation: older patients, scarred vocal
folds
 EVALUATION-ELECTROMYOGRAPHY

• Miller et.al in 1982

• Assesses integrity of laryngeal nerves
• Analysis of the electrical activity generated by a motor unit
• It is performed percutaneously, under local anaesthesia
• Electrodes on the cricothyroid muscles and thyroarytenoid muscles
• Miller et.al claims that, laryngeal EMG is the most accurate method of determining
superior laryngeal nerve paralysis
• Differentiates denervation from mechanical obstruction of vocal fold movement
 EVALUATION-ELECTROMYOGRAPHY

• Normal
 Joint fixation
 Posterior scar
• Fibrillation
 Denervation
• Polyphasic
 Synkinesis
 Re innervation
 EVALUATION-IMAGING

• Chest X-ray
 Screen for intrathoracic lesion
• MRI of brain
 Screen for CNS disorders
• CT skull base to Mediastinum
• Direct laryngoscopy
 Palpate arytenoid
 DIFFERENTIAL DIAGNOSIS

• Cricoarytenoid fixation
Caused by
Joint subluxation/dislocation with ankylosis
Joint fixation by rheumatoid arthritis or gout
Normal EMG
Direct laryngoscopy
• Laryngeal malignancy
 TREATMENT-GOAL

• Improves voice and prevent aspiration

• Patient factors affect treatment strategies
Presence of aspiration
Nature of nerve injury
Vocal demands
Medical comorbodities
LEMG findings
 TREATMENT-STRATEGIES

• Observation of 6 to 12 months
• Speech and swallow therapy
 Provides voice therapy
 Teaches vocal hygiene and compensatory strategies
 Identifies and eliminates counterproductive compensatory strategies
 Pre-operative and post-operative assessment
 SURGICAL TREATMENT

• Surgical intervention
 Temporary:
Injection laryngoplasty
 Permanent:
Vocal fold injection with durable material
Medialisation thyroplasty
Arytenoid adduction
Laryngeal reinnervation
THANK YOU