Vocal Fold Palsy

44 Vocal Fold Palsy


44.1 Anatomy of Vagus/Recurrent Laryngeal Nerve


• Brainstem—medulla nucleus ambiguus


• Carotid sheath—between internal jugular vein and internal carotid artery


• Left vagus crossing arch of aorta gives rise to left recurrent laryngeal nerve (RLN), which ascends in tracheoesophageal groove and then enters larynx at cricothyroid joint


• Right vagus loops around subclavian artery to ascend to the larynx


• RLN supplies motor fibres to all the muscles of the larynx except the cricothyroid muscle (which adducts the vocal cords) and sensation to the glottis/subglottis and trachea


• The interarytenoid muscle (contraction causes approximation of the arytenoid muscles closing the posterior portion of the glottis) is the only muscle with bilateral innervation


• A paralysed vocal fold (VF) may assume three positions:


figure Adducted


figure Abducted


figure Paramedian


• Theories that attempt to explain this:


figure Semon law: recurrent laryngeal nerve palsy the abductors are affected before the adductors


figure Wagner and Grossman hypothesis relates to cricothyroid activity


figure Movement may be present of arytenoids despite VF palsy due to bilateral innervation of interarytenoid muscles


44.2 Unilateral Vocal Fold Palsy


44.2.1 Clinical Features (Fig. 44.1)


• Presentation


figure Hoarse voice


figure Breathy voice


figure Weak cough


figure Difficulty in breathing


figure Pain


figure Choking with liquids—aspiration


• Aetiology


figure Congenital: hydrocephalus


• Acquired:


figure Iatrogenic surgery


– Head and neck including thyroid


– Vascular: carotid, cardiothoracic


– Cervical spine and mediastinal operations


• Intubation


figure Malignancy: thyroid, laryngeal, lung, skull base or oesophageal cancers


figure Trauma


figure Idiopathic


44.2.2 Diagnosis


• Investigations


figure Unknown aetiology:


– Chest X-ray


– CT skull base to mediastinum


• Prognosis on recovery:


figure Electromyelography—percutaneous placement of needle


44.2.3 Treatment


• Medical


figure Better outcomes if VF is medialized


• Surgical


figure VF injection


figure Laryngeal framework surgery


44.2.4 Surgical Treatment Options


• Injection laryngoplasty


figure One-way procedure


figure Can consider injection for patients with lung malignancy prior to treatment of cancer


figure Local anaesthetic injection dependent on material type and respiratory status


figure Present injectables:


– Collagen: bovine extract decreasing use, check allergy status with intradermal injection before use


– Hyaluronic acid: can inject percutaneously with 24/25-G needle; may last 4 months


– Fat: requires abdominal fat harvest ± centrifuging, variable survival



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Jul 4, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Vocal Fold Palsy

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