the vocal cord paralysis seminar presentation.pptx

vocal cord paralysis

1. DEPARTMENT OF E.N.T. G.R. MEDICAL COLLEGE, GWALIOR Guided by Dr. V.P. Narvey (M.S.), Professor & Head Vocal cord paralysis Presented by Dr. MEENAKSHI GARG, P.G. STUDENT Seminar on

2. Course of vagus The vagus nerve arises from three nuclei located in the medulla of brain. They are (DAT) Nucleus ambiguous (Motor) Nucleus dorsalis Nucleus of tractus solitaries 1. Nucleus ambiguus : Is the motor nucleus of the vagus nerve (upper part give fibres to 9th nerve and lower to 10th ). The efferent fibers of the dorsal nucleus innervates the involuntary muscles of bronchi, esophagus, heart, stomach, small intestine, and part of the large intestine. The efferent fibers of the nucleus of the tractus solitarius carry sensory fibers from the pharynx, larynx, and esophagus .

3. The vagus nerve (wanderer) takes a tortuous path after emerging from the jugular foramen. It has two ganglions. The smaller superior ganglion and a larger inferior or nodose ganglion. Neck it runs in carotid sheath Supplies most muscles of pharynx and palate. Rt Vagus – 32cm whereas Left is 43cm long The vagus gives two branches to the larynx, superior laryngeal nerve and recurrent laryngeal nerve Superior laryngeal nerve After arising from the inferior ganglion of vagus just below the base of skull, descends down and in the neck at the level of greater cornu of hyoid gives two branches: a) External laryngoal nerve b) Internal laryngeal nerve

4. The external laryngeal nerve, lies externally deep to the superior thyroid artery and supplies the cricothyroid muscle which is the only intrinsic muscle of the larynx lying externally Internal laryngeal nerve The internal laryngeal nerve pierces the thyrohyoid membrane along with the superior laryngeal artery (a branch of superior thyroid artery), passes between the middle and inferior constrictor and gives sensory supply to the larynx and hypo pharynx above the level of true vocal cord. This nerve ends by anastomosing with an ascending branch of recurrent laryngeal nerve. This anastomosis is called Galen's anastomosis and is purely sensory.

5. 2) Recurrent laryngeal nerve (RILN): The inferior branch of vagus is the recurrent laryngeal nerve which has a different course on the right and left side. On the right side the recurrent laryngeal is given at the level of subclavian artery. loops around it and enters the neck where it lies in between the branches of inferior thyroid vessels and sometimes either anterior or posterior to it. This makes it more prone to injury during thyroid and other neck surgeries. It then enters the larynx behind the cricothyroid joint. On the left side the recurrent laryngeal nerve is given further down at the level of arch of aorta. It then loops around it, ascends up in the tracheo-oesophageal groove reaching the neck where it lies mostly posterior to the inferior thyroid vessels and sometimes in between or anterior to them. It then enters the larynx behind the cricothyroid joint. The recurrent laryngeal nerves give sensory supply to the larynx and hypo pharynx below the level of True vocal cord and motor supply to all the muscles of larynx except cricothyroid .

6. 3. Nerve supply of larynx :- Motor supply of intrinsic muscles:- Cricothyroid muscle: superlor laryngeal nerve All other muscles: recurrent laryngeal nerve Sensory:-Above vocal cord: superlor laryngeal nerve- Below vocal cord: recurrent laryngeal nerve

7. Muscles of larynx

8. Aetiology Congenital :- Very common cause of stridor Infants Occurs with or without other associated abnormalities neurologic, laryngeal and cardiac defectsMost common anomaly is hydrocephalus.The mechanism of vocal cord palsy - could be due to stretching of the vagus nerve, due to complicated delivery etc ) Acquired (Lt-78%, Rt-16%, Both-6%)(Male: Female 8-10:1) Malignant25% - Lung(50%), oesophagus (25%),Thyroid (10%),Others Surgical20%- Thyroid, Lung, Heart,Oesophagus , Mediastinum Idiopathic 13% - Viral, Smokers Inflammatory13%- Tuberculosis (95%)( This could be due to apical scarring of the mediastinum or enlargement of hilar nodes) Non Surgical trauma 11%-# skull, penetrating injuries neck, cardiomegaly, aneurysm. Neurological7%- CVA, Parkinson's, MS, Alcoholic and diabetic neuropathy. Miscellaneous11%- Haemolytic anaemia , RA, Collagen disease

9. Positions of vocal cord

10. Type of palsy Position of VC Speech Aspiration Respiration Coughing Position during phonation Manegement Remark U/L RLN Mostly midline/paramedian Mostly normal, sometimes – hoarseness Absent Normal Normal Conservative Palsy with least consequences B/L RLN Median Mostly normal , sometimes – mild hoarseness Absent Stridor And dyspnea on exertion Normal Immediate tracheostomy f/by vc lateralization by cordectomy Type 2 thyroplasty Laryngeal re- innervation procedure Most life threatening palsy

11. Type of palsy Position of VC Speech Aspiration Respiration Coughing Position during phonation Manegement Remark U/L SLN Normally moving curved vc Weak voice and voice fatigue Occasionally Normal Normal Conservative Loss of timber of voice B/L SLN Normally moving b/l curved vc Husky voice Present Normal Weak cough Tracheostomy & epiglottopexy( to prevent aspiration) U/L complete Cadaveric Initially dysphonea or aphonia Subsequently hoarseness Sometimes Normal Cough is ineffective due to air wastage MedialiSation of vc ( teflon / fat injection Type 1 thyroplasty Laryngeal reinnervation B/L complete Both vc in cadaveric position Aphonia Severe aspiration episodes Normal Inability to cough Tracheo - oesophageal diversion, Epiglittopexy , Vc plication with tracheostomy

12. Specific Investigations Analysis of vocal cord movement Rigid 700 video - telescopy Fibreoptic video-laryngoscopy − stroboscopy : Intermittent flashlight focussed on vocal cords during phonation Frequency of light made 2 m sec slower to cord frequency Produces slow motion movement of vocal cords for better analysis of cord movement

13. • Laryngeal electromyography (LEMG)• Measures electric activity of larynx muscle via thin percutaneous needle electrodes •Allows better differentiation between neural lesion and other cause . • Provide evidence of re-innervation and denervation • Localization of lesion along nerve EVALUATION OF LEMG• Normal- joint fixation,post scar • Fibrillation – denervation • Polyphasic - reinnervationsynkineses

14. Manual compression test   Improvement in voice : thyroplasty (anterior medialization procedure) No improvement in voice : arytenoid adduction (posterior medialization procedure)

15. Isshiki’s Thyroplasty Type 1 (Medial Displacement) Type 2 (Lateral Displacement) Type 3 (Shortening Or Relaxation) Type 4 (Lengthening Or Tensioning) Thyroplasty is reversible, does not invade vocal folds nor alter their mass or stiffness unlike vocal fold injection

16. Treatment for phonatory gap in U/L palsy 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

17. MATERIALS USED • Paraffin• Teflon• Autologous fat• .Collagen• Calcium hydroxyapatite• Gelfoam paste• Hyaluronic acid formulations. TEFLON Polymer of tetrafluoroethylene• Contain 50% glycerine .Glycerine absorbed in few weeks• Length of effect - permanent• DisadvantageInflammatory reaction encapsulation of remaining teflon(granuloma) • If placed superficially - erosion of overlying mucosa AUTOLOGOUS FAT• Insertion deep into VF (High density).30-50% - absorbed within 1st monthGood immediate voice qualityLength of effect - permanent• Advantages:.. Easily harvested• Readily available (lower abdomen and inner thigh)No foreign body reaction COLLAGEN • Protein - natural constituent of lamina propria of VF• Popularized by ford et al. for use in larynxInjected superficially into vocal ligamentLength of effect-3-4 AdvantagemonthsBetter stability. Reduces rate of hypersensitivity, which is < 1% Vocal cord injection

18. METHODS •Percutaneous injection • Transoral injection • Laryngoscopic injection • Complication • Under injection - requires repeat procedures • Over injection - airway compromise • Improper placement -subglottal extension and potential stenosis• •Granuloma formation •Migration of materials (Teflon) SILICONE Silicon gelInjected deep in body of VF to prevent migration• Length of effect - permanent • Inflammatory reaction-fibrous capsule CALCIUM HYDROXYAPATITE• Widespread usageInjected deep in VFotherwise lead to long-term hoarseness Length of effect-2-5 years

19. MEDIALIZATION THYROPLASTY Medialization of VF by an implant placedthrough a window in thyroid cartilage • Insertion of prosthesis -lateral to inner perichondrium IMPLANTS USED • Silastic implants (montgomery)Carved or prefabricated • Dense hydroxyapatite (vocom) implants • Gore-tex strip • Advantages •performed with local anesthesia. • potentially reversible .• better assessment of voice during procedure • structural integrity of VF-preserved. Disadvantages •open procedure •procedure is technically more difficult • closure of posterior glottis may be limited

20. Laryngeal re-innervation Neuromuscular pedicle of superior belly of omohyoid (or sternohyoid ) + ansa hypoglossi nerve transferred into thyro -arytenoid for vocal fold medialization Neural anastomosis of ansa hypoglossi nerve directly to recurrent laryngeal nerve ( crumley ) laryngeal re-innervation

21. Treatment of stridor in B/L abductor paralysis Tracheostomy: temporary / permanent Vocal cord lateralization: endoscopic, external (king) Lateralization thyroplasty ( isshiki type II) Endoscopic vocal cordotomy : knife, cautery, laser Vocal cordectomy : endoscopic Arytenoidectomy : endoscopic, external (woodman) Laryngeal re-innervation: ansa hypoglossi-omohyoid pedicle transfer into posterior crico -arytenoid

22. LARYNGOTRACHEAL SEPARATION (LTS) • Division of trachea horizontallybetween 2nd and 3rd tracheal rings orat level of an existing tracheotomy • Proximal tracheal edges closed antero-posterioas blind pouch • Distal tracheal segment - used to createtracheostoma TRACHEOESOPHAGEAL DIVERSION (TED) • Lindeman (1975) •Horizontal division at 4th and 5th tracheal rings Proximal tracheal segment -end anastomosed to anterior esophagus Distal tracheal segmentused to create a tracheostoma ENDOLARYNGEAL STENT S olid stent • Weisberger and huebsch Solid silicone laryngeal stentplaced endoscopically• Secured transcervically with sutures• Tracheotomy tube necessary

23. MANAGEMENT OF BILATERAL ADDUCTOR PARALYSIS (CHRONIC ASPIRATION) Non surgical management• All oral intake is discontinued. • Alternative route of alimentation - nasogastric feeding tubes, . gastrostomy, and jejunostomy • Appropriate antibiotics for infectious complications • Aggressive pulmonary therapy • Vented stent.Eliachar. Vented silicone laryngeal stentsinserted through tracheotomy• Secured by flexible strap of silicone thatextends from tracheotomy tract above tracheotomytube• DisadvantageDiscomfort to patient• Dislodgement of implant

24. RECENT ADVANCES • In recent years, botulinum toxin (botox) injection - used in laryngealsynkinesis• Currently being investigated include• Gene therapy. Stem cell therapyLaryngeal pacing BOTULINUM TOXIN • Neurotoxin- by clostridium botulinum• Prevents - release of acetylcholine from axon terminals - causes flaccid paralysis• In case of BVFP.• Used to block aberrant reinnervation of adductor muscles by inspiratory motoneurons• Thus, abductor inspiratory motoneurons would gain advantageand become more effective in producing glottal opening• Marie et al. First described botox injection into bilateral adductormuscles as a treatment for BVFP GENE THERAPY • Delivering genes by vector to injured neurons and/or denervated muscles• After genes are transduced into nucleus of target cells .Produce peptidesPromote a) RLN regeneration, synaptic formationb) muscle growth • Patients with 8VFP caused by neurodegenerative diseases -benefited STEM CELL THERAPY Improve healing potential in degenerative tissue by tissueregeneration• Autologous stem cells - isolated from small samples of tissue frompatients - cultured to a critical mass - re-implanted• May promote a) regrowth of atrophic muscle massb) provide better platform for reinnervation• Halum et al. (2007) - introduced use of autologous muscle-derivedstem cell for treatment of VFP

25. THANK YOU