Vocal cord palsy & evaluation of hoarseness Dr. Vishal Sharma.
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Transcript of Vocal cord palsy & evaluation of hoarseness Dr. Vishal Sharma.
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Vocal cord palsy & evaluation of
hoarsenessDr. Vishal Sharma
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Nerve supply of larynx
Motor supply of intrinsic muscles:
Cricothyroid muscle: superior laryngeal nerve
All other muscles: recurrent laryngeal nerve
Sensory:
Above vocal cord: superior laryngeal nerve
Below vocal cord: recurrent laryngeal nerve
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Recurrent laryngeal nerve
Right:
Arises from vagus at level of right subclavian
artery & hooks around it
Left:
Arises from vagus in mediastinum at level of
arch of aorta & loops around it
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Development of arterial arches
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Final position of B/L RLN
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Superior laryngeal nerve
Arises from inferior ganglion of vagus
Descends behind internal carotid artery at level
of greater cornu of hyoid bone divides into
external & internal branches
External motor branch: to cricothyroid muscle
Internal sensory branch: pierces thyrohyoid
membrane to enter
larynx
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Dual innervation of inter-arytenoid muscles
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ClassificationA. Incomplete paralysis
1. Recurrent laryngeal nerve palsy
a. Left (75% ), Right (15%), B/L (10%)
b. Abductor, Adductor
2. Superior laryngeal nerve palsy
B. Combined paralysis / complete paralysis
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Causes of laryngeal paralysis
Supra-nuclear
Nuclear: nucleus ambiguus
High vagal lesions: combined palsy
Low vagal lesions: recurrent laryngeal nerve palsy
Systemic causes
Idiopathic
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Causes of combined paralysis
Intracranial Neck
Tumors of posterior fossa Penetrating injury
Basal meningitis (TB) Parapharyngeal
tumors
Skull base Metastatic neck
nodes
Fractures Lymphoma
Nasopharyngeal cancer Thyroid surgery
Glomus tumour
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Etiology of recurrent laryngeal nerve palsy
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Malignancy (25%): lung (>50%), thyroid, esophageal,
nasopharyngeal, metastatic neck
node
Surgical trauma (20%): during surgeries of lung,
heart, thyroid, esophagus,
mediastinum
Inflammatory (13%): tuberculosis, syphilis
Idiopathic (13%): viral neuritis
Non-surgical trauma (11%): accidental neck trauma,
left atrial enlargement (Ortner), aortic aneurysm
Neurological (7%): CVA, head injury, Parkinsonism,
multiple sclerosis, alcoholic / diabetic neuropathy
Others (11%): rheumatoid arthritis, haemolytic anemia
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Causes of left RLN palsy (75%)
Neck
Accidental trauma
Thyroid disease
Thyroid surgery
Ca esophagus
Lymphadenopathy
Mediastinum
Bronchogenic ca
Ca esophagus
Aortic aneurysm
Lymphadenopathy
Enlarged left atrium
Intra-thoracic surgery
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Causes of right RLN palsy (15%)
• Neck trauma
• Thyroid disease
• Thyroid surgery
• Ca cervical esophagus
• Cervical lymphadenopathy
• Aneurysm of subclavian artery
• Ca apex right lung
• TB of cervical pleura
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Causes of B/L RLN palsy (10%)
• Thyroid surgery
• Ca thyroid
• Cancer cervical esophagus
• Cervical lymphadenopathy
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Congenital vocal cord paralysis
Unilateral: birth trauma, congenital anomaly of
great vessel or heart
Bilateral:
Hydrocephalus Meningocoele
Arnold-Chiari malformation Cerebral agenesis
Intra-cerebral hemorrhage Nucleus ambiguus
agenesis
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Thyroid surgery
Joll’s sterno-thyro-laryngeal triangle for S.L.N.:
Lateral = superior thyroid vessels & upper thyroid
pole; superior = attachment of strap muscles to
thyroid cartilage; medially = midline
Beahr’s triangle for recurrent laryngeal nerve:
Lateral = common carotid artery; superior = inferior
thyroid artery; medial = tracheo-esophageal
groove + recurrent laryngeal nerve
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Joll’s triangle for SLN
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Beahr’s triangle for RLN
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Why right RLN commonly damaged in thyroid surgery?
Right recurrent laryngeal nerve more superficial
Right nerves enters thyroid at 450 angle but left
lies in tracheo-esophageal groove
Right nerve mostly passes superior to or b/w
branches of inferior thyroid artery; left nerve
mostly passes deep to inferior thyroid artery
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Position of vocal cord
Distance from centre
Healthy Diseased
Median Midline Phonation RLN paralysis
Paramedian 1.5 mm Strong whisper
RLN paralysis
Intermediate(Cadaveric)
3.5 mm (neutral position)
Paralysis of both RLN &
SLN
Gentle abduction
7 mm Quiet respiration
Paralysis of adductors
Full abduction
9.5 mm Deep inspiration
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Position of vocal cords
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Semon’s Law
Rosenbach (1880) & Semon (1881)
“In all progressive organic lesions, abductor
fibres of recurrent laryngeal nerve, which are
phylogenetically newer, are more susceptible
and thus first to be paralyzed compared to
adductor fibres.”
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1st stage: only abductor fibres damaged; vocal
folds approximate in midline; adduction still
possible (paramedian position)
2nd stage: contracture of adductors; vocal folds
immobilized in median position
3rd stage: adductors become paralyzed; vocal fold
assumes cadaveric position
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Why abductors affected first ?
Nerve fibres supplying abductors are in
periphery of recurrent laryngeal nerve
Muscle bulk for the abductors is less, more
susceptible
Phylogenetically, larynx’s main function is
protection, so adductor functions are maintained
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Wagner & Grossman Theory
In isolated paralysis of recurrent laryngeal nerve,
cricothyroid muscle (which receives innervation
from superior laryngeal nerve) keeps vocal cord
in paramedian position due to adductor function
In superior laryngeal nerve palsy, cord lies in
intermediate (cadaveric) position
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Final position of paralyses vocal cord is not
static & is decided by:
Degree of paralyzed muscle atrophy & fibrosis
Degree of re-innervation following injury
Extent of synkinesis (mass movement) of all
intrinsic muscles
Fibrosis & ankylosis of crico-arytenoid joint
Modern theory
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Retrograde atrophy of vagus nerve occurs up to
nucleus ambiguus
Stretching of RLN by enlarged intra-thoracic
lesions pulls vagus nerve down from skull base,
injuring superior laryngeal nerve
Intermediate position of vocal cords in RLN palsy ?
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Vocal cord paralysisCricoarytenoid
joint fixation
1. Floppy, vocal cords with bowing
2. Arytenoids falls antero-medially
3. Vocal cord at a higher level
4. Tilting of larynx paralysed side
5. Flickering of cord on phonation
6. Shallow pyriform fossa
7. Fixed in specific position
8. Arytenoids can be moved
1. Absent
2. In position
3. Same level
4. Absent
5. Absent
6. Normal
7. Any position
8. Arytenoids fixed
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Clinical Features
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Lesion above pharyngeal branch
Inability to elevate soft palate, nasal intonation,
nasal regurgitation & nasal emissions
Gag reflex reduced or absent due to palsy of
internal branch of superior laryngeal nerve
Hoarseness due to palsy of intrinsic muscles of
larynx
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Asymptomatic (1/3rd unilateral paralysis)
Faint whisper Functional adductor paralysis
Forced whisper Organic adductor paralysis
Voice tires with use Unilateral abductor paralysis
Stridor & aspiration Bilateral abductor paralysis
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U/L S.L.N. palsy B/L S.L.N. palsy
• Disability in professional
voice user only
• Voice weak, breathy,
inability to raise pitch
• Anterior commissural tilt
to healthy side
• Short & flabby vocal fold
• Flapping cord during
respiration
• Professional voice
compromised
• Voice weak, breathy,
inability to raise pitch
• Absence of anterior
commissural tilt
• Cough & choking due
to aspiration
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U/L combined palsy B/L combined palsy
• Cord in cadaveric
position hoarseness
• Glottic incompetence
ineffective cough
• Partial anesthesia of
larynx aspiration
• B/L cords in cadaveric
position aphonia
• Glottic incompetence
ineffective cough
• Total anesthesia of
larynx aspiration +
bronchopneumonia
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Specific Investigations
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Voice assessment
1. Magnetic tape recording: for self assessment
2. Performance assessment by examiner: maximum
phonation time & range of speech frequencies
3. Phonetogram: plot of pitch vs. intensity of voice
4. Aerodynamic analysis: phonatory airflow rate,
subglottic pressure & laryngeal resistance
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Phonetogram
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Aerodynamic analysis
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5. Fourier’s Spectral analysis (Spectrogram)
Fundamental frequency: lowest speech
frequency
Shimmer: average cycle to cycle difference in
amplitude of sound
Jitter: average cycle to cycle difference in
duration of glottal cycle
In hoarseness there is increased shimmers & jitters
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Spectrogram
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Shimmer & Jitter
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Analysis of cord movement
1. Rigid 700 video-telescopy ↓LA
2. Fibreoptic video-laryngoscopy
3. Stroboscopy: Intermittent flash light focussed
on vocal cords during phonation. Frequency of
light made 2 msec slower to cord frequency.
Produces slow motion movement of vocal cords
for better analysis of cord movement
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Video-stroboscopy
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4. Electro-glottography: 2 electrodes placed on both
sides of thyroid cartilage & current passed b/w them.
Recorded waveform shows impedance across larynx
& is highest during contact b/w vocal cords. Records
closing phase of glottal cycle.
5. Photo-glottography: fibreoptic light source passes
light via glottis & is received by photo-sensor on neck
skin. Light received glottic chink. Records opening
phase of glottal cycle.
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Electroglottography
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Photoglottography
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Radiological Submento-vertical skull base view
X-ray neck AP & lateral view
Chest X-ray PA view
Barium swallow AP & lateral oblique view
High resolution CT scan with contrast from skull
base to mid thorax: gold standard
M.R.I.: ideal for skull base lesions
Thyroid scan
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Endoscopy1. Rigid 700 Telescopy ↓ LA
2. Fibreoptic Laryngoscopy ↓ LA
3. Pan-endoscopy ↓ GA (for metastatic node):
a. Nasopharyngoscopy
b. Micro-laryngoscopy: probe test on arytenoids
c. Bronchoscopy & bronchial washings
d. Hypopharyngoscopy
e. Oesophagoscopy
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Fibre-optic laryngoscopy
paralyzed vocal fold is foreshortened, lateralized & flaccid
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B/L abductor palsy
Inspiration Expiration
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Biopsy for suspected malignancy
1. F.N.A.B. from enlarged lymph nodes
2. Punch biopsy from visible growth
3. Blind biopsy from (if metastatic node present):
Fossa of Rosenmuller
Base of tongue
Pyriform fossa
Laryngeal ventricles
Bronchial carina
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Respiratory function test
1. Conventional spirometry
2. Flow-Volume Loop analysis
Variable extra-thoracic obstruction:
↓ed inspiratory flow
Intra-thoracic obstruction: ↓ed expiratory flow
Fixed obstruction: ↓ed inspiratory + expiratory flow
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Flow volume loop analysis
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Other investigations
Blood: ESR, serology for syphilis
Electromyography of intrinsic laryngeal muscles:
a. Normal: Joint fixation, post - scarring
b. Fibrillation: Denervation (bad prognosis)
c. Polyphasic: Synkinesis, Re-innervation (good
prognosis)
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Electromyography
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Treatment for phonatory
gap in U/L abductor or
adductor palsy
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Speech therapy: for 2-12 months (usual
treatment)
Vocal cord injection: with Teflon / fat / collagen
Medialization thyroplasty (Isshiki type I)
Arytenoid adduction: for posterior approximation
Arytenoidopexy: medial rotation + fixation
Laryngeal re-innervation
Combination of above
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Indications for immediate surgical intervention
Electromyography shows fibrillation (complete
loss of function with no signs of recovery)
Vocal cord palsy due to nerve entrapment in
thyroid / bronchial malignancy where recovery
is not expected
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Per-oral Teflon injection Kleinsasser’s microlaryngoscope introduced
Bruning’s syringe loaded with Teflon paste
Needle pushed lateral to thyroarytenoid muscle
First injection at postero-lateral angle of middle
third of vocal cord, 2.5 mm lateral to cord margin
Second injection (0.2 ml) made at antero-lateral
angle till both cords approximate in phonation
I.V. Dexamethasone given for 24 hours
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Per-oral Teflon injection
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Vocal fold Teflon injection
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Percutaneous Teflon injection
Needle introduced in midline through crico-
thyroid membrane angled 300 - 450 upward &
laterally into vocal cord
Direct lateral penetration of larynx through
thyroid ala is alternate route of injection
Vocal cord entered under endoscopic control
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Percutaneous Teflon injection
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Midline & lateral routes
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Vocal fold fat injection
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Vocal fold collagen injection
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Isshiki’s Thyroplasty Type 1 (medial displacement)
Type 2 (lateral displacement)
Type 3 (shortening or relaxation)
Type 4 (elongation of tensioning)
Thyroplasty is reversible, does not invade vocal
folds nor alters their mass or stiffness unlike
vocal fold injection
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Thyroplasty type I
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Thyroplasty type I
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Thyroplasty type I
Horizontal skin incision made over mid-point of
thyroid cartilage lamina (from a point 2 cm lateral
to midline on opposite side to posterior margin of
thyroid cartilage on affected side)
Subplatysmal flaps elevated & strap muscles
retracted laterally to expose thyroid cartilage
Window made in thyroid lamina with scalpel or 1
mm cutting burr, as per Koufman’s formula
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Window’s superior border lies at level with vocal
cords (midpoint b/w thyroid notch & inferior
margin of thyroid cartilage) & its anterior border
situated 8 mm posterior to midline
Cartilage removal started postero-inferiorly
Inner perichondrium elevated off thyroid
cartilage & silastic prosthesis inserted
Patient asked to phonate while moving silastic
prosthesis into its optimal position under
flexible laryngoscopy guidance
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Type I thyroplasty
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Koufman’s formula
Window height (mm) = thyroid alar height (mm) – 4 ------------------------------------- 4
Window width (mm) = thyroid alar height (mm) – 4 ------------------------------------ 2
Average = 12 X 6 mm (male); 10 X 5 mm (female)
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Insertion of prosthesis
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Insertion of silastic prosthesis
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Silastic implant
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Arytenoid adduction Portion of posterior thyroid cartilage margin cut
to expose muscular process of arytenoid
Two 4-0 Prolene sutures passed through
muscular process & through thyroid cartilage
Sutures pulled parallel to lateral cricoarytenoid
After optimal medialization of vocal fold, sutures
tied on external aspect of thyroid lamina
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Arytenoid adduction
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Arytenoid adduction
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Laryngeal re-innervation
Neuromuscular pedicle of superior belly of
omohyoid (or sternohyoid) + ansa hypoglossi
nerve transferred into thyro-arytenoideus for
vocal fold medialization; or posterior crico-
arytenoideus for lateralization (Tucker)
Neural anastomosis of ansa hypoglossi nerve
directly to recurrent laryngeal nerve (Crumley)
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Neuromuscular pedicle
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Neuromuscular pedicle
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Neuromuscular pedicle
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Ansa-R.L.N. anastomosis
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Combination surgeries
Neuromuscular pedicle re-innervation +
Thyroplasty type 1
Thyroplasty type 1 + arytenoid adduction
Arytenoid adduction has advantage of posterior
glottic approximation unlike thyroplasty
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Treatment of stridor
in B/L abductor
paralysis
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Tracheostomy: temporary / permanent in acute stridor
Vocal cord lateralization: endoscopic, external (King)
Vocal cordectomy: external, endoscopic
Endoscopic vocal cordotomy: knife, cautery, laser
Arytenoidectomy: endoscopic, external (Woodman)
Lateralization thyroplasty (Isshiki type II)
Laryngeal re-innervation: ansa hypoglossi-omohyoid
pedicle transfer into posterior crico-
arytenoideus
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Vocal cord lateralization (laterofixation / cordopexy)
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Vocal cord lateralization
Thyroid cartilage exposed via horizontal incision
16-gauge IV cannula inserted through thyroid
cartilage 4 mm anterior & 2 mm below mid-point
of oblique line, into laryngeal lumen, just above
tip of vocal process, under M.L.S. guidance
Another 16-gauge IV cannula inserted 5 mm
below 1st cannula, just below tip of vocal process
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Vocal cord lateralization 1-0 Prolene suture threaded through inferior
cannula into laryngeal lumen
Suture thread brought out with forceps into
laryngeal lumen & inserted into superior cannula
External traction put on both suture ends to pull
vocal cord laterally to give a 5 mm airway
Threads tied over thyroid lamina 8 times
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Cordectomy
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Cordectomy + lateralization
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Posterior cordotomy
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Arytenoidectomy
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Cordotomy + arytenoidectomy
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Thyroplasty type II (lateralization)
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Treatment for bilateral adductor paralysis
causing chronic aspiration
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• Endolaryngeal stenting (solid & vented)
• Epiglottic flap closure
• Epiglottopexy to posterior pharyngeal wall
• Epiglottic tube laryngoplasty
• Glottic closure
• Sub-perichondrial cricoidectomy
• Tracheo-esophageal diversion
• Laryngo-tracheal separation
• Narrow field laryngectomy
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Endolaryngeal stent
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Epiglottic flap closure
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Epiglottopexy
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Epiglottic tube laryngoplasty
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Glottic closure
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Subperichondrial cricoidectomy
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Tracheo-esophageal diversion
Proximal trachea
anastomosed with
esophagus
Distal trachea opens
into permanent
tracheostomy
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Laryngo-tracheal separation
Proximal trachea
closed
Distal trachea
opens into
permanent
tracheostomy
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Narrow field laryngectomy
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Other procedures for aspiration• Double cuff tracheostomy
• Laryngeal suspension
• Feeding Gastrostomy
• Feeding Jejunostomy
• Vocal cord injection
• Medialization thyroplasty
• Laryngeal re-innervation
• Tympanic / Chorda tympani neurectomy
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Laryngeal suspension
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Other vocal cord surgeries
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Thyroplasty type III (shortening)
Used for mutational falsetto
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Thyroplasty type IV (elongation)
Used for raising vocal pitch & ing vocal tension
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Evaluation of Hoarseness (dysphonia)
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Causes of Hoarseness
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Mechanism of hoarseness Loss of approximation of vocal cords: in
paralysis, fixation or intervening tumor / lesions
Alteration of size of vocal cord: ed in edema,
tumor; ed in partial surgical excision, fibrosis
Alteration of stiffness of vocal cord: ed in
spasmodic dysphonia, fibrosis; ed in paralysis
Improper vibration of vocal cord: hyperemia,
vocal nodule, vocal polyp
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10 organic dysphonia 20 organic dysphonia
1. Congenital * 1. Laryngitis *
2. Laryngeal tumor * 2. Vocal nodule
3. Vocal cord palsy 3. Vocal polyp
4. Spasmodic 4. Reinke’s edema
5. Muscular * Functional dysphonia
6. Neurological * 1. Psychogenic
7. Endocrine * 2. Habitual
8. Senile 3. Puberphonia
9. Fixation by arthritis 4. Ventricular *
10. Traumatic * 5. Malingering
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Congenital: laryngomalacia, laryngocoele,
haemangioma, web
Laryngeal tumor: papilloma, malignancy
Muscular: myasthenia gravis
Neurological: Parkinsonism, Multiple sclerosis,
cerebro-vascular accident, bulbar palsy
Endocrine: hypothyroidism, inter-sex, pregnancy
Traumatic: accidental, foreign body, intubation
Laryngitis: bacterial, viral, TB, allergic, GERD
Ventricular: dysphonia plica ventricularis
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1. Duration: > 3 weeks in pt > 40 years is laryngeal
malignancy until proven otherwise
2. Progression: due to mass effect or malignancy
3. Voice quality:
a. Forced whisper: Organic adductor paralysis
b. Faint whisper: Functional adductor paralysis
c. Tires with use: U/L abductor paralysis, myasthenia
History taking
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4. Associated symptoms:
a. Stridor: B/L abductor paralysis
b. Aspiration: B/L adductor paralysis
c. Dysphagia + exertion dyspnea: Ortner’s syndrome
d. Hemoptysis: lung malignancy, tuberculosis
e. Nasal regurgitation & intonation: high vagal lesion
5. Past history:
a. Trauma: accidental, foreign body, intubation
b. Surgery: thyroid, intra-thoracic
c. Viral upper respiratory tract infection, smoking
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Physical Examination Listening to patient’s voice: for hoarseness
Indirect laryngoscopy: laryngeal lesions
Otoscopy: rule out glomus tumor
Neck: lymph node enlargement, thyroid disease
Chest: lung malignancy, tuberculosis
Cardiovascular: mitral stenosis
Neurological: Parkinsonism, multiple sclerosis
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Manual compression testImprovement in voice = do thyroplasty (anterior
medialization procedure). No improvement in voice = do
arytenoid adduction (posterior medialization procedure)
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Routine investigations Fibre-optic laryngoscopy
Microlaryngoscopy: crico-arytenoid joint mobility
CT scan skull base to diaphragm: best
X-ray chest: for hemoptysis
Ba swallow: for dysphagia
Thyroid scan: for thyroid enlargement
Panendoscopy: in presence of hard neck node
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Thank You