Recurrent laryngeal nerve paralysis

ppt on RLNP, defn, causes, clinical features and management

1. RECURRENT
LARYNGEAL NERVE
PARALYSIS
BY:
NILUFER

2. For normal voice production:
•VOCAL CORDS must :
•1. be able to approximate with each
other
•2. have proper size and stiffness
•3. have an ability to vibrate reg. in
response to air column

3. •in vocal cord palsy ;
•
• - loss of approximation of vc
• - decreased stiffness of vc

4. ANATOMY OF LARYNX

LOCATION :
in the middle and ant.part of
the neck , opp. C3 - C6
CARTILAGES :
1. paired

2.unpaired

5. Unpaired :
• *epiglottis
* thyroid
*cricoid
Paired :
* arytenoid
* corniculate
* cuneiform

8. 1. ABDUCTORS :
Post. cricoarytenoid
2. ADDUCTORS:
Lat.cricoarytenoid
interarytenoid
Thyroarytenoid
3.TENSORS:
Cricothyroid
4.RELAXERS :

9. Vocalis
Thyroarytenoid (int part)
Acting on l.inlet:
1.OPENERS
Thyroepiglottic
2.CLOSERS
Interarytenoid
(oblique p.)

Aryepiglottic
(post. ob. p.)

10. Extrinsic muscles :
•1. elevators
•2. depressors

11. NERVE SUPPLY OF LARYNX
1. sensory :
* above vocal cords - SLN (ILN)
* below vocal cords - RLN
2.motor:
* all intrinsic muscles - RLN
# except . cricothyroid ( SLN -
external)

12. VOCAL CORDS
•*DEFN : are pearly white mucous memb.
infoldings that stretch horizontally across
mid.laryngeal cavity.
•ATTACHMENTS: Ant : thyroid cartilage
Post : arytenoid cartilage (
vocal process)
EDGES: Outer - attached to muscle in larynx
Inner - free ( form rima glottidis)
•TYPES:
• 1. TRUE : formed from conus
elasticus (inf layer of
infolded membrane)

14. 2. FALSE : formed from quadrangular
membrane ( sup. layer of
infol.mem )
•ant. 2/3 -
membranous
•post 1/3 -
cartilagenous

17. position of vocal cords
normally :
breathing -
abducted

phonation -
adducted
swallowing -
add.

18. COURSE OF RLN

20. vagus - tenth. CN
Cranial part ; 2 nuclei
vagus descends down
exits skull via jugular.f
sup. ganglion
inf.ganglion

descends down and enters
carotid sheath

21. below inf.gang.
• gives SLN
• at level of hyoid bone it
divides into
external internal

23. at level of SCA - GIVES RIGHT RLN
•at thr level of arch of aorta - gives LEFT
• RLN
•GALEN 'ANASTOMOSIS: btw SLN &
RLN
•NON RECURRENT LARYNGEAL N.
•WHY LEFT RLN more prone for
paralysis?

25. CLASSIFICATION
•1. RLN
•2. SLN
•3. COMBINED
•* 1. CONGENITAL/ ACQUIRED
• 2. U/L or B/L
• 3. COMPLETE/ INCOMPLETE
•4. ABDUCTOR / ADDUCTOR/ BOTH

26. 5. SENSORY / MOTOR
•* ETIOLOGY :
•1. supranuclear
• 2. nuclear
•3. vagus nerve ( high vagal )
•4. low vagal trunk
• - right RLN
• - left RLN
• - both
•5. systemic causes

27. CAUSES OF RLNP
•RIGHT : neck
• - neck trauma
• - thyroid disease
• -malignancy
• - iatrogenic
• - cer. lymphadenopathy
• - aneurysm of SCA
• - CA.apex rt.lung
• - TBofcer.pleura
• - idiopathic

28. LEFT : 1. in the NECK;
• - acc.trauma
• - thy. disease
• - iatrogenic
• - malignancy
• - c.lymph.
•in the MEDIASTINUM ;
• - Bronchogenic.CA
• - CA.tho.eso
• - aortic aneurysm
• - M. lymph
• - ortner s syn.
• - intrathoracic surgry

29. BOTH ;

•thy.surgry
•CA.thyroid
•CAcer. oeso
•cer. lymphadenopathy

30. TYPES OF RLNP
1. UNILATERAL
2. BILATERAL
1.UNILATERAL RLNP :
DEFN: Condition which leads to ipsilateral
paralysis of all intrinsic laryngeal muscles
except cricothyroid .
INCIDENCE :
usually affects adults
SEX : both males n females

31. •clinical
• features

33. THEORIES TO EXPLAIN THE POSITION
OF VOCAL CORDS IN PARALYSIS
•1. SEMON 'S LAW :
• "in all the prog. org. lesions,
abd.fibres of nerve which are
phylogenetically newer, are more
susceptible & are first to be paralysed
compared to adductors.
•2. WAGNER AND GROSSMAN 'S LAW

34. " cricothyroid muscle ( supplied by SLN)
which has adductor function, keeps cord in
paramedian position."
VOCAL
CORDS
PM pure
RLNP
C comb.palsy

35. •ETIO :
• - BRONCHOGENIC CA.
• - THYROID SURGERY
C/F :
- VOICE
- POSITION OF VOCAL CORDS
- RESPIRATION ( stridor)
- SWALLOWING ( aspiration )

36. •1. VOICE :
- asympotomatic in 1/3 cases
- left sided; hoarseness
-no change
- improves gradually by
compensation
2. POSITION OF VC : median or paramedian
- aff. vc may lie at a lower
level
3. no prob. of aspiration or breathing

38. INVESTIGATIONS :
•1. Chest X-Ray
•2. biopsy
•3. radiography of barium swallow
•4. panendoscopy - dir.laryngoscopy,
bronchoscopy, esophagoscopy
•5. blood sugar
•6. VDRL
•7. ESR
•8. neurological invest.
•9. CVS
•10. CT- SCAN and MRI

40. MANAGEMENT :
- if asymptomatic - no trtmnt reqd,.
- temporary paralysis recovers in 6 to 12
months
- advisable to wait
- voice improvement during waiting period
- 1. speech therapy
-

41. •if paralysis persists for 9 to 12 months,
then following procedures performed:
• 1. laryngoplasty type 1 with vc inj.
• 2. laryngoplasty type 2 with arytenoid
adduction
• 3. thyroplasty type 1 - medialization of vc
• - make window through
thy.cartilage
•then implant silastic prosthesis

46. BILATERAL RLNP
( ABDUCTOR PARALYSIS)
DEFN: condition in which al the intrinsic
muscles of larynx are paralysed
bilaterally. except cricothyroid
ETIO : neuritis
thyroid surgery
C/F :
- Acute in onset
- dyspnea
- stridor

48. •- becomes worse during exertion and
infection
•voice : good
•position of vc: median / paramedian
INVESTIGATIONS
MANAGEMENT :
1. Surgical treatmnt

49. 2 modalities;
1. permanent tracheostomy
with speaking valve
2. lateralization of cord

50. •by endoscopy or ext.cervical approach
•1.arytenoidectomy
•2. arytenoidopexy
•3.transverse cordotomy ( kashima op.)
•4. thyroplasty type 2
•5. reinnervation

52. thyroplasty
•type 1. - medialization
•type 2 . - lateralization
type 3. - vc. are relaxed (shortening)
type 4 . - vc. are tensed

54. reinnervation
•innervate the paralysed post.
cricoarytenoid muscle by
•implanting nerve muscle pedicle from
sternohyoid or omohyoid with its n.s.
from ansa cervicalis.