Download MBBS Final Year ENT Laryngeal paralysis Notes

FUNCTIONS OF VOCAL CORD

• RESPIRATION
• SPEECH

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• PREVENTION OF ASPIRATION AND GENERATION OF COUGH

NERVE SUPPLY

MOTOR

• RECURRENT LARYNGEAL N.
• SUPPLIES ALL MUSCLES EXCEPT CRICOTHYROID

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• CRICOTHYROID IS SUPPLIED BY EXTERNAL LARYNGEAL

SENSORY

• ABOVE VOCAL CORD: INTERNAL LARYNGEAL N
• BELOW VOCAL CORD: RECURRENT LARYNGEAL N

SUPERIOR LARYNGEAL NERVE

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• IT ARISES FROM INFERIOR GANGLION OF VAGUS NERVE, DESCENDS BEHIND INTERNAL CAROTID ARTERY, AND AT THE LEVEL OF GREATER CORNUA OF HYOID BONE DIVIDES INTO EXTERNAL AND INTERNAL LARYNGEAL NERVE.
• THE EXTERNAL BRANCH SUPPLIES CRICOTHYROID MUSCLE WHILE THE INTERNAL BRANCH PIERCES THYROHYOID MEMBRANE AND PROVIDES THE SENSORY SUPPLY OF LARYNX AND HYPOPHARYNX.

RECURRENT LARYNGEAL NERVE

• RT. RECURRENT LARYNGEAL N ARISES FROM THE VAGUS N AT THE LEVEL OF SUBCLAVIAN ARTERY HOOKS ROUND IT AND ASCENDS BETWEEN THE ESOPHAGUS AND TRACHEA.
• LT. RECURRENT LARYNGEAL N ARISES IN THE MEDIASTINUM AT THE LEVEL OF ARCH OF AORTA HOOKS ROUND IT AND ASCENDS UPWARD INTO THE NECK IN THE TRACHEO ESOPHAGEAL GROOVE.

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• LT. RECURRENT LARYNGEAL N HAS A LONG COURSE HENCE MORE PRONE TO PARALYSIS AS COMPARED TO RIGHT.

ADDUCTION OF LARYNX

ABDUCTION OF LARYNX

CAUSES OF LARYNGEAL PARALYSIS

• SUPRANUCLEAR: RARE

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• NUCLEAR: NUCLEUS AMBIGUS IN THE MEDULLA VASCULAR, NEOPLASTIC, MOTOR NEURON DISEASE, POLIO AND SYRINGIOBULBIA
  • THERE WILL BE ASSOCIATED PARALYSIS OF CN AND NEURAL PATHWAYS
• HIGH VAGAL LESION – INTRACRANIALLY – JUGULAR FORAMEN – PARAPHARYNGEAL SPACE
• LOW VAGAL OR RECURRENT LARYNGEAL NERVE
• SYSTEMIC CAUSE: DIABETES, SYPHILIS, DIPHTHERIA, TYPHOID, STREPTOCOCCAL OR VIRAL INFECTION, LEAD POISONING

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THEORIES ON POSITION OF VOCAL CORD IN VOCAL CORD PARALYSIS

• SEMON'S LAW: IN ALL PROGRESSIVE LESIONS, ABDUCTOR FIBRES OF NERVE, WHICH ARE PHYLOGENETICALLY NEWER, ARE MORE SUSCEPTIBLE AND FIRST TO BE PARALYSED COMPARED TO ADDUCTORS.
• WAGNER AND GROSSMAN HYPOTHESIS: COMPLETE PARALYSIS OF RECURRENT LARYNGEAL NERVE VOCAL CORD WILL BE PARAMEDIAN DUE TO INTACT CRICOTHYROID (ADDUCTOR FUNCTION) WHEN SUPERIOR LARYNGEAL NERVE ALSO PARALYSED... CADAVERIC POSITION.

VOCAL CORD POSITION

CLASSIFICATION OF LARYNGEAL PARALYSIS

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• LARYNGEAL PARALYSIS MAY BE UNILATERAL OR BILATERAL AND MAY INVOLVE:
  1. RECURRENT LARYNGEAL N
  2. SUPERIOR LARYNGEAL N
  3. COMBINED OR COMPLETE

A. UNILATERAL PARALYSIS

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IPSILATERAL PARALYSIS OF ALL INTRINSIC MUSCLES EXCEPT THE CRICOTHYROID.

VOCAL CORD THUS ASSUMES MEDIAN OR PARAMEDIAN POSITION.

CLINICAL FEATURES

• ASYMPTOMATIC
• VOICE CHANGE

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• NO ASPIRATION OR AIRWAY OBSTRUCTION
• VOICE IMPROVES DUE TO COMPENSATION BY THE HEALTHY CORD WHICH CROSSES MIDLINE TO MEET PARALYSED ONE.

BILATERAL BILATERAL ABDUCTOR PARALYSIS

• ETIOLOGY: NEURITIS OR SURGICAL TRAUMA (THYROIDECTOMY)
• POSITION OF CORD: ALL THE INTRINSIC MUSCLES OF LARYNX ARE PARALYSED, THE VOCAL CORD LIE IN MEDIAN OR PARAMEDIAN POSITION DUE TO UNOPPOSED ACTION OF CRICOTHYROID MUSCLES.

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• CLINICAL FEATURES:
  1. DYSPNOEA – AS BOTH CORDS LIE MEDIAN OR PARAMEDIAN. AIRWAY IS INADEQUATE.
  2. STRIDOR: BECOMES WORSE ON EXERTION OR ACUTE LARYNGITIS.

PARALYSIS OF SUPERIOR LARYNGEAL N

1. UNILATERAL (RARE COMBINED)

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• PARALYSIS OF CRICOTHYROID MUSCLE AND IPSILATERAL ANAESTHESIA OF LARYNX ABOVE VOCAL CORD.
• ETIOLOGY:
  1. THYROID SURGERY
  2. THYROID TUMOR
  3. DIPHTHERIA

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• CLINICAL FEATURES:
  • WEAK VOICE WITH DECREASED PITCH
  • ANAESTHESIA OF LARYNX ON ONE SIDE
  • ASPIRATION
  • LARYNGEAL FINDINGS:
    • ASKEW POSITION OF GLOTTIS AS ANT COMMISSURE IS ROTATED TO HEALTHY SIDE
    • SHORTENING OF CORD WITH LOSS OF TENSION (WAVY)

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    • FLAPPING OF PARALYSED CORD: CORD SAGS DOWN DURING INSPIRATION AND BULGES UP DURING EXPIRATION.

2. BILATERAL

• UNCOMMON CONDITION

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• BOTH CRICOID MUSCLES ARE PARALYSED WITH ANAESTHESIA OF UPPER LARYNX.
• ETIOLOGY:
  • SURGICAL OR ACCIDENTAL TRAUMA
  • DIPHTHERIA
  • PRESSURE BY CERVICAL NODES
  • NEOPLASTIC DISORDERS

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• CLINICAL FEATURES:
  • PARALYSIS AND BILATERAL ANAESTHESIA
  • COUGH
  • CHOKING FITS

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COMBINED (COMPLETE) PARA LYSIS

• RECURRENT LARYNGEAL AND SUPERIOR LARYNGEAL NERVE PARALYSIS
• 1. UNILATERAL
  • PARALYSIS OF ALL MUSCLES OF LARYNX ON ONE SIDE EXCEPT THE INTERARYTENOID WHICH RECEIVES INNERVATION FROM OPPOSITE SIDE.
  • AETIOLOGY:
    • THYROID SURGERY
    • LESIONS OF NUCLEUS AMBIGUS OR MEDULLA, POST CRANIAL FOSSA, JUGULAR FORAMEN, PARA PHARYNGEAL SPACE.

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  • CLINICAL FEATURES:
    • ALL MUSCLES OF LARYNX ON ONE SIDE ARE PARALYSED (VOCAL CORD IN CADAVERIC POSITION).
    • GLOTTIC INCOMPETENCE (HEALTHY CORD IS UNABLE TO APPROXIMATE THE PARALYSED CORD).
    • HOARSENESS OF VOICE AND ASPIRATION OF LIQUID THROUGH GLOTTIS.

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2. BILATERAL

• BOTH RECURRENT LARYNGEAL N AND SUPERIOR LARYNGEAL NERVE ON BOTH SIDES.
• RARE CONDITION
• CORDS LIE IN CADAVERIC POSITION

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• TOTAL ANAESTHESIA OF LARYNX
• CLINICAL FEATURES:
  • APHONIA AS CORDS DON'T MEET AT ALL.
  • ASPIRATION...INCOMPLETE GLOTTIS AND LARYNX ANAESTHESIA.
  • INABILITY TO COUGH: INABILITY TO MEET....: RETENTION OF SECRETIONS IN CHEST.
  • BRONCHOPNEUMONIA...REPEATED ASPIRATION AND RETENTION OF SECRETION.

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CONGENITAL VOCAL CORD PALSY

• UNILATERAL (MORE COMMON)
  • BIRTH TRAUMA
  • CONGENITAL ANOMALY OF GREAT VESSEL OR HEART

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• BILATERAL
  • HYDROCEPHALUS OR ARNOLD-CHIARI MALFORMATION
  • INTRACEREBRAL HEMORRHAGE DURING BIRTH
  • MENINGOCELE OR CEREBRAL OR NUCLEUS AMBIGUS AGENESIS
  • BILATERAL ABDUCTOR PARALYSIS AND RESPIRATORY

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