A study on neurological diseases of larynx

1. Dr Manpreet Singh Nanda
Associate Professor ENT
MMMC&H Solan

2.  Supranuclear – tumours, trauma, stroke
 Nuclear – tumours, stroke
 High vagal – above inferior ganglion
 A – intracranial – tumours, meningitis, head
injury
 B – jugular foramen – fractures, NP Cancer,
glomus tumour
 C – parapharyngeal space – tumours, surgery,
glomus
 Low vagal
 1 – SLN – neck trauma, thyroid surgery
 2 – RLN – Neck trauma, thyroid surgery, tumours,
mediastinal lesions (left)

3.  Systemic
 Diabetes
 Diptheria
 Typhoid
 OP/Lead poisoning
 Viral
 Syphilis
 IDIOPATHIC , MALIGNANCY (MC) AND
SURGICAL TRAUMA (30% EACH)

4.  Semon’s law – fibres supplying the abductors get
affected much earlier than adductors and
reverse for recovery in RLN paralysis result in vc
earlier in paramedian position
 Wagner’s and Grossman hypothesis – In absence
of cricoarytenoid fixation vocal cords are in
median and paramedian position in RLN paralysis
due to continued function of cricothyroid
muscle.
 Negus – Supported Semon law. Since post
cricoarytenoid is a only abductor supplied by RLN
so abductors are more vulnerable in RLN
paralysis..

5.  Median (midline) – phonation, RLN paralysis
 Paramedian – vc 1.5 mm away from midline –
strong whisper, RLN paralysis
 Intermediate/cadaveric/lateral – vc 3.5 mm
away from midline – combined paralysis
 Gentle/slight abduction – vc 7mm away from
midline – quiet respiration, adductor
paralysis
 Full abduction – vc 9.5 mm away from
midline – deep inspiration

6.  U/L paralysis of all muscles except cricothyroid
 Etiology – Bronchogenic carcinoma, thyroid
surgery (mc)
 C/F
 Asymptomatic - one third
 Change in voice which gradually improves due to
compensation by healthy cord..
 Tiring voice
 Diplophonia
 O/E
 Affected VC in median/paramedian position

7.  Treatment
 Asymptomatic – spontaneous recovery
 Speech therapy
 Intracordal inj of teflon paste
 Medialization thyroplasty

8.  Abductor paralysis. There is unopposed action of
cricothyroid muscle
 Etiology – thyroidectomy (mc), trauma,
neoplasm
 C/F
 Acute onset
 Dyspnoea and inspiratory stridor which becomes
worst on exertion or infection..
 Aspiration in elderly
 Patient may retain good voice
 O/E – both vc in median or paramedian position
 Diagnosis – CT, MRI ,Chest X Ray, Panendoscopy..

9.  Intubation/emergency tracheostomy
 Permanent tracheostomy with a speaking
valve – to retain good voice
 Lateralisation of vc – vc is moved and fixed in
lateral position which improves airway. Not
preferred in patients with good voice as good
voice is lost

10.  Arytenoidectomy – removal of arytenoid by
external approach (woodman’s operation), by
endoscopic approach (thornell operation)
 Endoscopic CO2 LASER cordectomy
 Laterialisation thyroplasty
 Nerve muscle implant – sternohyoid muscle
with nerve supply is transplanted into post
cricoarytenoid

11.  Rare
 Paralysis of unilateral cricothyroid muscle
 Unilateral supraglottic anaesthesia
 Etiology – thyroid surgery, tumours, trauma,
neuritis
 C/F
 Weak and low pitch voice (loss of tension)
 Occasional aspiration (anaesthesia)
 O/E
 I/L VC flabby and bowed, wavy appearance
 Oblique laryngeal inlet
 Post commissure deviated medially towards
affected side

12.  Prognosis
 Voice recovered by compensation from
healthy cord
 Singers cant produce high pitch voice
 Treatment
 Speech therapy

13.  Least common
 Both cricothyroid paralysed
 Anaesthesia of supraglottic larynx
 Etiology – surgical trauma, RTA, neoplasm
 C/F
 Coughing and choking during swallowing due
to aspiration
 Weak and husky/breathy voice
 Short phonation time
 O/E
 B/L flaccid and bowed vc

14.  Treatment
 Ryle’s/NG tube feed
 Tracheostomy with cuffed tube
 Thyroplasty
 Injection teflon/collagen for medialization
 Epiglottoplexy – reversible procedure where
in laryngeal inlet is closed to protect the
lungs from aspiration. Epiglottis is fixed to
arytenoids

15.  Paralysis of all unilateral muscles except
interarytenoid which receive innervation from
other side
 Etiology – high vagal lesions, thyroid surgery
 C/F
 Hoarseness of voice
 Aspiration of fluids
 Inadequate cough
 O/E
 Unilateral paralysed vc in cadaveric position
 Prognosis
 No compensation by healthy cord

16.  Treatment
 Speech therapy
 Medialisation of paralysed vc by teflon
injection or thyroplasty

17.  Rare
 Total anaesthesia of larynx
 All laryngeal muscles paralysed
 Etiology
 Neoplasm in skull base, medulla, upper neck
 CNS disorder
 C/F
 Aphonia – vc dont approximate
 Aspiration – laryngeal anaesthesia
 Inability to cough leading to collection of
secretions
 Bronchopneumonia due to aspiration and
secretions

18.  O/E
 Both vc in cadaveric position
 Treatment
 Ryle’s tube feed
 Reversible
 Tracheostomy with cuffed tube
 Epiglottoplexy
 VC plication – approximation of vc with sutures
 Irreversible
 Total laryngectomy – for progessive and
irreversible disease, when voice is lost- to
protect lungs

19.  Second mc cause of stridor in neonates (1st
laryngomalacia)
 Unilateral mc, Right VC
 Etiology
 Idiopathic
 U/L – birth trauma, congenital anomaly of heart or
vessel
 B/L – anomalies of CNS, hydrocephalus, meningitis
 C/F
 Weak or hoarse cry
 Inspiratory or biphasic stridor
 Difficulty in feeding
 Prognosis – 70% U/L and 50% B/L recover
spontaneously within six months

20.  Diagnosis
 Awake flexible laryngoscopy
 MRI
 X Ray Neck/Chest
 Treatment-
 NG tube feed
 U/L (if severe aspiration or dyspnoea)
 Inj teflon/thyroplasty
 B/L (after 5 yrs of age if recovery has not
happened)
 Arytenoidectomy (endoscopic/external)
 Endoscopic lateral cordotomy

21.  Microlaryngeal surgery
 Excision of vc lesion under operating microscope
using LASER, microdebrider, forceps
 Local intralesional injections ..
 To medialize the vocal cords
 Done percutaneously/transorally under operating
microscope using
 Teflon paste (PTFE)
 Gelfoam
 Collagen
 Autologous fat
 Collagen derivatives

22.  Thyroplasty (laryngeal framework surgery)
 Isshiki’s thyroplasty
 I – Medial displacement of vc to improve
quality of life (Medialisation thyroplasty) –
window created below thyroid notch and
silastic block fitted through window
 II – Lateral displacement of vc to improve
airway (Lateralisation thyroplasty)
 III – Relaxation or shortening of vc
 To produce male low pitched voice
 Puberphonia/gender transformation

23.  IV – Tension or lengthening of vc
 To produce female high pitched voice
 Cricothyroid palsy
 Gender transformation
 Laryngeal innervation procedure
 Window made in thyroid cartilage and
segment of superior belly of omohyoid with
its nerve supply is implanted into vocalis
muscle
 To innervate paralysed vocalis muscle

24.  Etiology
 Malignancy
 Adhesions/mass
 Cricoarytenoid joint arthritis
 Diagnosis
 Swelling around cricoarytenoid joint
 Straight or shortened vc – no bowing
 No deviation of arytenoid cartilage
 On phonation no flicker
 Probe test – press the arytenoid with a large
probe. No vibration of vc or change in position