vocal cord paralysis

Vocal Cord Vocal Cord Paralysis

Khairallah Aoucar M.D. PGY 3 EntKhairallah Aoucar M.D. PGY 3 EntHoly Spirit UniversityHoly Spirit UniversityENT Grand round Saturday/2/2015ENT Grand round Saturday/2/2015

AnatomyAnatomy

Upper motor neurons from Upper motor neurons from cerebral cortex cerebral cortex nucleus nucleus ambiguus (medulla)ambiguus (medulla)

Lower motor neurons: Lower motor neurons: Vagus nerve exits the Vagus nerve exits the skull base via the jugular skull base via the jugular foramenforamen

SLN:SLN: s:glottis s:glottis

+supraglottis+supraglottis m:CTm:CTRLN:RLN: s:subglottics:subglottic m:PCA/LCA/IA/TAm:PCA/LCA/IA/TA

0.5% non RLN(right)+retroesophageal 0.5% non RLN(right)+retroesophageal right subclavian arteryright subclavian artery

non RLN (left)if situs inversusnon RLN (left)if situs inversus

R is shorther and more oblique than L R is shorther and more oblique than L RLNRLN

Interarytenoid muscle has bilateral Interarytenoid muscle has bilateral innervationinnervation

Where is the lesion ?Where is the lesion ? brain ?brainstem nuclei? vagus nerve? brain ?brainstem nuclei? vagus nerve?

RLN?RLN?

What is the lesion?What is the lesion?

Etiology: NeurologicEtiology: Neurologic

StrokeStroke CNS tumorCNS tumor Diabetic neuropathyDiabetic neuropathy Amyotrophic lateral sclerosis (ALS)Amyotrophic lateral sclerosis (ALS) Parkinson diseaseParkinson disease Myasthenia gravisMyasthenia gravis Guillain-Barre syndromeGuillain-Barre syndrome

Etiology: Tumor infi l tration Etiology: Tumor infi l tration or mass compressionor mass compression Skull baseSkull base ThyroidThyroid EsophagusEsophagus LungLung

Etiology: Systemic Etiology: Systemic diseasedisease Systemic lupus erythematosusSystemic lupus erythematosus SarcoidosisSarcoidosis AmyloidosisAmyloidosis TuberculosisTuberculosis Mitochondrial disordersMitochondrial disorders PorphyriaPorphyria Polyarteritis nodosaPolyarteritis nodosa SilicosisSilicosis

Etiology: MedicationsEtiology: Medications

Vinca alkaloidsVinca alkaloids– Vincristine and vinblastineVincristine and vinblastine– Dose relatedDose related– Resolves with dose adjustment or Resolves with dose adjustment or

cessationcessation

– cisplatincisplatin

Etiology: TraumaticEtiology: Traumatic

Iatrogenic: SurgicalIatrogenic: Surgical– ThyroidectomyThyroidectomy– Anterior cervical spine Anterior cervical spine

proceduresprocedures– EsophagectomyEsophagectomy– ThymectomyThymectomy– Carotid endarterectomyCarotid endarterectomy– Cardiothoracic surgeryCardiothoracic surgery

Aortic surgeryAortic surgery Coronary artery Coronary artery

bypass graftingbypass grafting Pulmonary lobar Pulmonary lobar

resectionresection MediastinoscopyMediastinoscopy

Iatrogenic: Non-surgicalIatrogenic: Non-surgical– Endotracheal intubationEndotracheal intubation

Arytenoid dislocation, Arytenoid dislocation, subluxationsubluxation

Tapia’s syndromeTapia’s syndrome

Non-iatrogenicNon-iatrogenic– Blunt or penetrating trauma Blunt or penetrating trauma

to the neckto the neck

Brousseau et al. A rare but serious entity: nasogastric tube syndrome. Otolaryngol Head Neck Surg. 2006 Nov;135(5): 677-679.

Etiology: IdiopathicEtiology: Idiopathic

Not well understoodNot well understood Possible infectious causePossible infectious cause

– Lyme diseaseLyme disease– Tertiary syphilisTertiary syphilis– Epstein-Barr virusEpstein-Barr virus– Herpes simplex virus Type IHerpes simplex virus Type I

Diagnosis of exclusionDiagnosis of exclusion– Urquhart et al. showed that 26% of patients with Urquhart et al. showed that 26% of patients with

a diagnosis of idiopathic VCP had a preexisting a diagnosis of idiopathic VCP had a preexisting neurologic condition and 20% developed a neurologic condition and 20% developed a subsequent CNS condition.subsequent CNS condition.11

Urquhart et al. Idiopathic vocal cord palsies and associated neurological conditions. Arch Otolaryngol Head Neck Surg. 2005 Dec;131(12):1086-9.

EtiologyEtiology Rosenthal et al. showed Rosenthal et al. showed

that surgical causes of that surgical causes of unilateral vocal cord unilateral vocal cord immobility were the result of immobility were the result of

1.1. Non-thyroid surgeries Non-thyroid surgeries (67%)(67%)• Anterior cervical spine Anterior cervical spine

(15%)(15%)• Carotid endarterectomy Carotid endarterectomy

(11%)(11%)• Cardiac (9%)Cardiac (9%)

1.1. Thyroid surgeries (33%)Thyroid surgeries (33%)• Thyroid (26%)Thyroid (26%)• Parathyroid (6%)Parathyroid (6%)• Thyroid and parathyroid Thyroid and parathyroid

(1%)(1%)

Rosenthal et al. Vocal Fold Immobility: A Longitudinal analysis of Etiology Over 20 Years. Laryngoscope. 2007 Oct;117(10): 1864-1870.

surgery MechanismAnterior cervical spine Retraction; stretch injury of RLN (right more common)

Esophagectomy RLN injury in tracheoesophageal groove

Carotid endarterectomy Vagal injury during dissection

Mediastinoscopy RLN injury, usually left

Coronary artery bypass grafting Retraction or direct injury to vagus or RLN during internal mammary artery harvest for grafting Hypothermic nerve injury form ice cardioplegia

Pulmonary resection Usually left upper lobe or RLN injury

Endotracheal intubation Possible pressure neuropraxia from compression of anterior rami of RLN caused by a high-riding endotracheal cuff in the subglottis

EtiologyEtiology

Rosenthal et al. Rosenthal et al. compared unilateral compared unilateral VCP from 1985-1995 to VCP from 1985-1995 to 1996-20051996-2005– Surgical causes doubledSurgical causes doubled– Malignant causes Malignant causes

decreaseddecreased


EtiologyEtiology

Rosenthal et al. compared their study to previous Rosenthal et al. compared their study to previous studies to evaluate the changing etiology of studies to evaluate the changing etiology of unilateral VCP.unilateral VCP.– Increase in surgical causes, with a greater proportion Increase in surgical causes, with a greater proportion

attributable to non-thyroid surgeriesattributable to non-thyroid surgeries– Decrease in malignant causesDecrease in malignant causes


Evaluation – HistoryEvaluation – History

SymptomsSymptoms– Voice changesVoice changes

Hoarseness to aphoniaHoarseness to aphonia Compensatory voice changesCompensatory voice changes Vocal fatigue, neck painVocal fatigue, neck pain

– AspirationAspiration– Weak, ineffective coughWeak, ineffective cough– Stridor,progressive dyspneaStridor,progressive dyspnea

Past medical and surgical historyPast medical and surgical history Social historySocial history

Evaluation – Physical ExamEvaluation – Physical Exam

Cranial nerve examCranial nerve exam NasopharyngolaryngoscopyNasopharyngolaryngoscopy

– Vocal cord asymmetryVocal cord asymmetry– Horizontal and vertical positionHorizontal and vertical position– Glottic gapGlottic gap– Poooled secretionsPoooled secretions– AspirationAspiration– Maximal phonation time (MPT)Maximal phonation time (MPT)– Supraglottic hyperfunctionSupraglottic hyperfunction

Evaluation – Physical ExamEvaluation – Physical Exam

VideostroboscopyVideostroboscopy– Increased amplitude Increased amplitude

of vibrationof vibration– Vocal fold height Vocal fold height

differencedifference– Vocal process Vocal process

contactcontact

Evaluation – LabsEvaluation – Labs

In a survey of 84 otolaryngologists, In a survey of 84 otolaryngologists, Merati et al. found that Merati et al. found that – 20% found that serum testing was 20% found that serum testing was

necessarynecessary– The most commonly ordered labs were The most commonly ordered labs were

RF, Lyme titer, ESR, ANARF, Lyme titer, ESR, ANA11

Routine labs not supported by the Routine labs not supported by the literature if cause unknown.literature if cause unknown. 2,32,3

1. Merati et al. Diagnostic testing for Vocal Fold Paralysis: Survey of Practice and Evidence-Based Medicine Review. Laryngoscope. 2006 Sept; 116: 1539-1552.

2. Terris et al. Contemporary evaluation of unilatereal vocal cord paralysis. Otolaryngol Head Neck Surg. 1992 Jul;107(1):84-90.

3. MacGregor et al. Vocal Fold palsy: a re-evaluation of investigations. J Laryngol Otol. 1994;108:193-19.

EvaluationEvaluation

Assess swallow function Assess swallow function and aspirationand aspiration– Modified barium swallowModified barium swallow– Functional endoscopic Functional endoscopic

evaluation of swallowing evaluation of swallowing (FEES)(FEES)

No additional work up No additional work up required if clear cut required if clear cut etiologyetiology

Evaluation – ImagingEvaluation – Imaging

ModalitiesModalities– CXR: May be most useful and cost-effective.CXR: May be most useful and cost-effective.– CT with contrast: May evaluate the entire course CT with contrast: May evaluate the entire course

of the RLN.of the RLN.– MRI: May be useful in patients with MRI: May be useful in patients with

polyneuropathypolyneuropathy Literature does not demonstrate superiority Literature does not demonstrate superiority

of any single modalityof any single modality1. Merati et al. Diagnostic testing for Vocal Fold Paralysis: Survey of Practice and Evidence-Based Medicine Review.

Laryngoscope. 2006 Sept; 116: 1539-1552.2. Terris et al. Contemporary evaluation of unilatereal vocal cord paralysis. Otolaryngol Head Neck Surg. 1992

Jul;107(1):84-90.3. Glazer et al. Extralaryngeal causes of vocal cord paralysis: CT evaluation. AJR am J Roentgenol 1983;141:527-531.4. ElBadawey et al. Prospective study to assess vocal cord palsy investigations. Otolaryng Head Neck Surg 2008;

138:78-790.

Evaluation – LEMGEvaluation – LEMG

Munin et al. reported that LEMG obtained 1-6 mo from onset Munin et al. reported that LEMG obtained 1-6 mo from onset may be helpful in determining prognosis.may be helpful in determining prognosis.11

– Prognosis good if there is absent spontaneous activity and Prognosis good if there is absent spontaneous activity and normal recruitment with normal motor unit morphologynormal recruitment with normal motor unit morphology

– Prognosis poor if there is spontaneous activity with absent Prognosis poor if there is spontaneous activity with absent recruitment and presence of fibrillationsrecruitment and presence of fibrillations22

Wang et al. reported that LEMG obtained 2-6 mo from onset Wang et al. reported that LEMG obtained 2-6 mo from onset have a sensitivity and PPV of 93% and accuracy of 87%.have a sensitivity and PPV of 93% and accuracy of 87%. 22

1. Munin et al. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am. 2000 Aug;33(4):759-70.

2. Koufman et al. Diagnostic laryngeal electromyography: The Wake Forest experience 1995-1999. Otolaryngol Head Neck Surg. 2001 Jun;124(6):603-6.

3. Wang et al. Prognostic indicators of unilateral vocal fold paralysis. Arch Otolaryngol Head Neck Surg. 2008 Apr;134(4):380-8.

Differential DiagnosisDifferential Diagnosis

Cricoarytenoid fixation(UVP)Cricoarytenoid fixation(UVP)– Caused byCaused by

Joint subluxation/dislocation with ankylosisJoint subluxation/dislocation with ankylosis Joint fixation by rheumatoid arthritis or goutJoint fixation by rheumatoid arthritis or gout

– Normal EMGNormal EMG– Direct laryngoscopyDirect laryngoscopy

Laryngeal malignancy(UVP)Laryngeal malignancy(UVP) PGS (bilateral VCP)PGS (bilateral VCP)

Trt UVPTrt UVP

Injection Injection FrameworkFramework ArytneoidepexyArytneoidepexy ReinnervationReinnervation

Vocal fold augmentationVocal fold augmentation

1-Temporary correction in cases of unilateral vocal fold paralysis/paresis, 1-Temporary correction in cases of unilateral vocal fold paralysis/paresis, when the prognosis for recovery is uncertainwhen the prognosis for recovery is uncertain

2-Permanent correction of mild-to-moderate glottic insufficiency2-Permanent correction of mild-to-moderate glottic insufficiency a) Vocal fold atrophy (as seen in presbyphonia)a) Vocal fold atrophy (as seen in presbyphonia) b) Vocal fold paralysisb) Vocal fold paralysis c) Vocal fold paresisc) Vocal fold paresis d) Adjunctive augmentation of the vocal fold(s) after prior d) Adjunctive augmentation of the vocal fold(s) after prior laryngeal laryngeal

framework surgery (“touch up”)framework surgery (“touch up”)

Glottic insufficiency due to loss of soft tissue in the vocal fold Ex: of this clinical situation include sulcus vocalis &scarring of the vocal fold

after partial laser cordectomy.

Temporary injection substances Temporary injection substances include:include:

■ Bovine gelatin (Gelfoam™, Surgifoam™) ■ Collagen-based products Zyplast™,

Cosmoplast™/Cosmoderm™, Cymetra™) ■ Carboxymethylcellulose (Radiesse Voice Gel™) ■ Hyaluronic acid gel (Restylane™, Hyalaform™)

Long-lasting injection substances Long-lasting injection substances include:include:

Autologous fatAutologous fat ■ ■ Calcium Hydroxylapatite (Radiesse™)Calcium Hydroxylapatite (Radiesse™) ■ ■ TeflonTeflon

Local anesthesia:Local anesthesia:peroral or percutaneous approach peroral or percutaneous approach Constant feedbackConstant feedback

Augmentation is directed at the posterior and midmembranous vocal fold, along the lateral vocal fold (superior arcuate line),

at a depth of 3–5 mm..

Injection into the superficial lamina propria Injection into the superficial lamina propria (Reinke’s space) is to be avoided.(Reinke’s space) is to be avoided.

Overinjection (15–30%) is recommended he exception to this rule is autologous lipoinjection, which requires substantial overcorrection

Treatment – Medialization Treatment – Medialization thyroplastythyroplasty

Direct medialization of Direct medialization of the vocal cordthe vocal cord

Performed alone or Performed alone or with arytenoid with arytenoid adduction or adduction or reinnervation reinnervation procedureprocedure

Implant materialImplant material– Carved or prefabricated Carved or prefabricated

Silastic implantSilastic implant– Hydroxyapatite implantHydroxyapatite implant– Gore-Tex stripsGore-Tex strips

Indications: Symptomatic (dysphonia-aspiration)glottic insufficiency especially if there is little

change of return to normal neurologic function

Unilateral vocal fold paresis Unilateral or bilateral vocal fold paresis Vocal fold atrophy including age-related

Contraindications: Malignant disease overlying the laryngotracheal complex Poor abduction of the contralateral vocal fold Previous radiation to the larynx

Treatment – Medialization Treatment – Medialization thyroplastythyroplasty

Adv: Local anesthesia, Adv: Local anesthesia, voice feedback, reversible, voice feedback, reversible, vocal fold integrity vocal fold integrity preservedpreserved

Disadv: Open procedure, Disadv: Open procedure, technically difficult, closure technically difficult, closure of posterior gap limitedof posterior gap limited

Complications: Penetration Complications: Penetration of laryngeal mucosa, of laryngeal mucosa, infection, chondritis, infection, chondritis, implant migration, airway implant migration, airway obstruction, obstruction, undercorrectionundercorrection

Treatment – Arytenoid adductionTreatment – Arytenoid adduction

Adjunct to medialization thyroplasty if Adjunct to medialization thyroplasty if large posterior glottic gap or vocal large posterior glottic gap or vocal folds at different levelsfolds at different levels

Kraus et al. showed that when Kraus et al. showed that when combined with a medialization combined with a medialization thyroplasty, there was improvement thyroplasty, there was improvement in symptoms as well as voice in symptoms as well as voice parameters.parameters.11

Mucullough et al. showed that when Mucullough et al. showed that when combined with medialization combined with medialization thyroplasty, functional results thyroplasty, functional results exceeded the improvement attained exceeded the improvement attained with medialization alone.with medialization alone.22

1. Kraus et al. Arytenoid adduction as an adjunct to type I thyroplasty for unilateral vocal cord paralysis. Head Neck. 1999 Jan;21(1):52-9.

2. Mucullouch et al. Arytenoid adduction combined with Gore-Tex medialization thyroplasty. Laryngoscope. 2000 Aug;110(8):1306-11.

arytenoidopexyarytenoidopexy

adjunct ,rarely alone. adjunct ,rarely alone.

consists of the placement of a suture anchoring the muscular process of consists of the placement of a suture anchoring the muscular process of arytenoid to thyroid cartilage. arytenoid to thyroid cartilage.

achieves 3 things with respect to Vocal Process :achieves 3 things with respect to Vocal Process : 1-lowers position 1-lowers position 2-medializes & stabilizes the TVF 2-medializes & stabilizes the TVF 3- rotates the arytenoid cartilage. 3- rotates the arytenoid cartilage. It is typically recommended in patients if Maximum Phonation Time <5 seconds. It is typically recommended in patients if Maximum Phonation Time <5 seconds.

Treatment – Laryngeal reinnervationTreatment – Laryngeal reinnervation

Goal: Increase bulk and toneGoal: Increase bulk and tone Indications: Poor chance of spontaneous recoveryIndications: Poor chance of spontaneous recovery

TypesTypes– Neuromuscular pedicleNeuromuscular pedicle– Nerve-nerve anastamosisNerve-nerve anastamosis

May be combined with temporary injection May be combined with temporary injection laryngoplasty until reinnervationlaryngoplasty until reinnervation

Treatment – Laryngeal ReinnervationTreatment – Laryngeal Reinnervation

Nerve muscle pedicle Nerve muscle pedicle (NMP)(NMP)– Nerve with portion of motor Nerve with portion of motor

units transferred to a units transferred to a denervated muscle.denervated muscle.

– Thyrotomy performed to Thyrotomy performed to place the NMP to the lateral place the NMP to the lateral cricoarytenoid muscle.cricoarytenoid muscle.

– Tucker et al. reported Tucker et al. reported improvement in voice quality improvement in voice quality and restoration of adduction.and restoration of adduction.11

Tucker et al. Long-term results of nerve-muscle pedicle reinnervation for laryngeal paralysis. Ann Otol Rhinol Laryngol 1989;98:674-676.

Treatment – Laryngeal ReinnervationTreatment – Laryngeal Reinnervation

Ansa cervicalis to RLNAnsa cervicalis to RLN– Provides weak tonic innervation to Provides weak tonic innervation to

intrinsic laryngeal musclesintrinsic laryngeal muscles– Adv: Extralaryngeal, no permanent Adv: Extralaryngeal, no permanent

implant material, does not affect implant material, does not affect subsequent proceduressubsequent procedures

– Disadv: Deeper dissection, requires Disadv: Deeper dissection, requires intact nerves , delay in voice intact nerves , delay in voice improvementimprovement

Crumley reported improved vocal Crumley reported improved vocal quality and restoration of the mucosal quality and restoration of the mucosal wave.wave.11

Lorenz et al. reported improved vocal Lorenz et al. reported improved vocal quality as well as glottic closure and quality as well as glottic closure and vocal fold edge straightening.vocal fold edge straightening.22

1. Crumley. Update: ansa cervicalis to recurrent laryngeal nerve anastomosis for unilateral laryngeal paralysis. Laryngoscope. 1991 Apr;101(4 Pt 1):384-388.

2. Lorenz et al. Ansa cervicalis-to-recurrent laryngeal nerve anastomosis for unilateral vocal fold paralysis: experience of a single institution. Ann Otol Rhinol Laryngol. 2008 Jan;117(1):40-5.

Bilateral vocal cord paralysis

step-wise approach to enlarge the glottic airway The least aggressive and safest procedures are:The least aggressive and safest procedures are: the posterior transverse cordotomy (PTC) or medial arytenoidectomythe posterior transverse cordotomy (PTC) or medial arytenoidectomy

(MA).(MA). After these procedures, an extended version of either (or a combination) can After these procedures, an extended version of either (or a combination) can

be performed, or a total arytenoidectomy.be performed, or a total arytenoidectomy.

Which side to operate?

The most important factor for selection is presence of any purposeful motion The most important factor for selection is presence of any purposeful motion either adductory or abductoryeither adductory or abductory

No motion=>do LEMG and operate on the worstNo motion=>do LEMG and operate on the worst

Palpation: Choose the cricoarytenoid joint with the worst range cricoarytenoid joint with the worst range of motion..

Indications:symptomatic airway obstructionsymptomatic airway obstruction

Contraindication:1-Rapidly progressive neurologic disorder2-Unrealist ic patient expectations (improvement in bothairway and voice)

Relative contraindications to treatment include:■ Presence of aspiration■ Compromised pulmonary status■ Diabetes (more true for open procedures than endoscopic)■ Previous radiation therapy to the neck/larynx

Treatment options for BVFP include:Treatment options for BVFP include: ■ ■ TracheotomyTracheotomy ■ ■ Microlaryngoscopy with laser posterior transverseMicrolaryngoscopy with laser posterior transverse cordotomycordotomy ■ ■ Microlaryngoscopy with laser medial arytenoidectomyMicrolaryngoscopy with laser medial arytenoidectomy ■ ■ Microlaryngoscopy with laser total arytenoidectomyMicrolaryngoscopy with laser total arytenoidectomy ■ ■ Endoscopic suture lateralizationEndoscopic suture lateralization ■ ■ Open arytenoidectomyOpen arytenoidectomy

Laser cordotomyLaser cordotomy

Incision is started just anterior to vocal process, being careful not to expose the cartilage, to avoid granulation tissue postoperatively.

A complete cordotomy extends laterally 3–4 mm into the false vocal fold tissue/musculature

Frequently, a branch of the superior laryngeal arteryis encountered, and troublesome bleeding can occur. Suction and bipolar laryngeal cautery are effective in stopping the bleeding.

Laser Medial Laser Medial arytenoidectomyarytenoidectomy

obliterate the medial-most portionof the arytenoid cartilage for approximately 2–3mm in width.

The anterior–posterior dimensions of this area ofobliteration should be posterior to the tip of the vocal Process preserving all or most of the vocal process.

Endoscopic Suture Endoscopic Suture LateralizationLateralization used as a temporizing measure in patients used as a temporizing measure in patients

with early symptomatic BVFP who have an with early symptomatic BVFP who have an uncertain prognosis for recovery.uncertain prognosis for recovery.

Or permanent with partial arytenoidectomyOr permanent with partial arytenoidectomy

should not be carried out if the patient has should not be carried out if the patient has suffered recent trauma to the posterior suffered recent trauma to the posterior glottis from an ETT or is currently intubatedglottis from an ETT or is currently intubated

Open ArytenoidectomyOpen Arytenoidectomy

An anterior laryngofissure or a lateral approach

reserved for cases where endoscopic techniques have failed or are impossible due to anatomic limitations, and thus is rarely required.

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