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Introduction to Vocal cords paralysis

Causes of vocal cord palsy:
  • Idiopathic (30%)
  • Malignancy:
  1. Bronchial (50%)                              
  2. Oesophageal (20%)
  3. Thyroid (10%)                  
  4. Nasopharyngeal carcinoma (20%)
  5. Glomus, lymphoma
  1. Surgical trauma (Oesophageal, lung, thyroiD. Radical neck dissection)
  2. Non- surgical trauma (road traffic accident, Ottner’s syndrome)
  3. Viral factors: Infectious monouncleosis, influenza
  4. Bacterial causes: T. B., Syphilis
  5. Miscellaneous causes: Hemolytic, anemia, collagen disorder
  6. Diabetes, alcoholism, Gullian Barre
Fig: Recurrent and superior laryngeal nerve

High vagal nerve palsy: Vagus nerve involvement in the skull, at exit from the jugular foramen or in the parapharyngeal space

Table: Causes of combined paralysis (high vagal lesions)
  1. Tumours of posterior fossa
  2. Basal meningitis (tubercular)
Skull base                           
  1. Fracture
  2. Nasopharyngeal cancer
  3. Glomus tumour
  1. Penetrating injury
  2. Parapharyngeal tumours
  3. Metastatic nodes
  4. Lymphoma
  • Normal glottic chink: 8.0 mm
Stridor:    If glottic chink < 3.0 mm
Positions of vocal cords    From the Midline
Median    =   Midline
Paramedian    =  1.5 mm
Intermed  =  3.5 mm
Gentle abduction  =   7.0 mm
Full abduction  =   9.5 mm

Table: Position of the vocal cord in healthy and diseased cases
Position of the cord
Location of the cord from midline
Paramedian 1,5 mm Strong whisper RLN paralysis
Intermediate (cadaveric)  3.5 mm. This is neutral position of
cricoarytenoid joint. Abduction and                   abduction/adduction take place from
this position
RLN paralysis Paralysis of both recurrent and superior laryngeal nerves
Gentle abduction Full 7 mm Quiet respiration
 9.5 mm Deep inspiration Paralysis of adductors

Table: Causes of recurrent laryngeal nerve paralysis (low vagal trunk or recurrent laryngeal nerve)

Right Left Both
A. Neck trauma I. Neck A. Thyroid surgery
B. Benign or malignant thyroid disease A. Accidental trauma B. Carcinoma thyroid
C. Thyroid surgery B. Thyroid disease C. Cervical lymphadenopathy
D. Carcinoma cervical oesophagus C. Thyroid surgery  
e. Cervical lymphadenopathy D. Carcinoma cervical oesophagus  
f. Cancer cervical esophagus e. Cervical lymphadenopathy  
g. Aneurysm of subclavian artery II. Mediastinum  
h. Carcinoma apex right lung A. Bronchogenic cancer  
i. Tuberculosis of cervical p leura B. Carcinoma thoracic oesophagus  
j. Idiopathic C. Aortic aneurysm  
  D. Mediastinal lymphadenopathy  
  e. Enlarged left auricle  
  f. Intrathoracic surgery  
  g. Idiopathic  
Semon’s Law
States that in a gradually advancing organic lesion of recurrent laryngeal nerve abductor fibres of nerve which are phylogeneticaly newer are more susceptible to damage
Wagner and Grossman hypothesis:
States that in the absence of cricoarytenoid joint fixation, the cricothyroid muscle keeps the cord paramedian since it is supplied by the superior laryngeal nerve and is an adductor.
Superior Laryngeal nerve palsy:
U/L: Muscles affected: Cricothyroid
  1. Voice not severely affected and recovers fast
  2. Pitch of the voice cannot be raised
  3. Askew (skewed) position of the larynx
  4. Ipsilateral cord
    • Bowed
    • Floppy
    • ed length
Cords sag down during inspiration and bulge up during expiration.
U/L: Features
  1. Breathy
  2. Weak
High chances of aspiration (Tracheostomy required)   
  1. U/L Abductor Paralysis:
    Affected Cord: Paramedian position
    1. Slightly hoarseness which improves over the days
    2. Voice tries with use
    3. 1/3rd go undetected
  1. Speech therapy
  2. If aspiration Surgery
    * Usually no treatment required
  1. B/L abductor paralysis:
    1. Both cords lie either in the median or in the paramedian position
    2. Voice is good
    3. Dyspnea / stridor: May not be present for months / years (become worse on exertion or during an attack of acute laryngitis)
Emergency tracheostomy (if patient in distress)
If EMG show complete denervation of the muscles then perform lateralization of one of the vocal cords
Lateralization Procedure:
  1. Arytenoidectomy (Woodman’s procedure- Donnie’s procedure or LASER arytenoidectomy)
  2. Vocal cord lateralization through endoscopes (Kirschner’s method)
  3. Cordectomy
  4. Nerve - muscle implant
  1. U/L adductor paralysis:                  
    (both superior and recurrent laryngeal nerve gone)
    - Position of the cord: Cadaveric position
    - Features: Voice produced is weak and husky
    - Cough: Ineffective
    - Chance of aspiration is there
    - Commonest cause: thyroid surgery
Treatment: Cord medialization
Surgery for medialization of the cord:
  1. Intracordal injection (using Burning’s syringe)
    - Teflon
    - Collagen
  2. Arytenoid rotation
  3. Nerve- muscle pedicle reinnervation
  4. Recurrent laryngeal nerve reinnervation
  1. B/L Adductor paralysis:
    Position of the cord: B/L Cadaveric
    1. Aphonia                          
    2. Aspiration      
    3. Inability to cough            
    4. ​Bronchopneumonia
  • Where recovery expected:
  1. Tracheostomy with cuff
  2. Epiglottopexy
  3. Vocal cord plication
  • If neurological lesion progressive: e.g. due to ca oesophagus: Total laryngectomy
Isshiki’s Thyroplasty:
It is an innovative procedure developed to improve the laryngeal mechanics:

Type I: Medialization of the cord
Type II: Lateralization of the cord
Type III: Shortening the cord (Lowering the vocal pitch)
Type IV: Lengthening of the cord (to increase the pitch)

Tumors of the Larynx :
  1. Congenital:
    Most common site;
    1. Ventricular bands
    2. Aryepiglottic fold
      P.S. Most common site of cyst in the larynx: vocal cords : 55%
  2. Retention Cysts:
    • Originate from obstructed sero mucinous salivary glands
    • Lining:
    1. Squamous
    2. Columnar
    • Site: Epiglottis, Vallecula, AE fold
  3. Granulomas:
    Non- specific granuloma: Are nearly always caused by trauma
    Intubation granuloma: Often caused by long-term intubation.
    Site: Ulceration overlying the vocal process area
    Features: Hoarseness, irritation and sometimes pain
    Treatment: Excision by microlaryngeal surgery
  4. Amyloidosis:
    Larynx is rarely involved
    However, the usual site for amyloidosis of the respiratory tract: Larynx
    Age group: 40-60 yrs
    Frequency of involvement: False cords>A.E. Fold> Subglottic                  
    Treatment: Surgery                                
  5. Benign Tumors:
    1. Vascular tumors
    2. Chondroma (most common site: posterior cricoid area)
    3. Myogenic tumors
    4. Lipoma
    5. Fibroma
    6. Papilloma
    7. Adenoma
      - Commonest benign epithelial tumor of the larynx: Papilloma
  1. Papillomatosis of the Larynx
    Juvenile Cause: Viral infection [HPV:-6,11 strains]
    - infant and children                                           
    - Multiple growth                                                
    - SITES : True and false cords                            
Features -             
Glistening - white
warty appearance
Tendency to recur esp juvenile type

Treatment :-
  1. CO2 laser
    - Most preferred treatment (most preferred : micro debridement)
    - Microlaryngeal surgery
  2. Forceps removal
  3. Cryotherapy
    Recurrence after surgery in very common.
    Interferon therapy helps reducing the chance of recurrence.

PS:- 2% of juvenile laryngeal papillomatosis can turn malignant [squamous cell carcinoma] after a period of 15-20 years.

  1. Cancer of the Larynx:
    1. Occurrence: Glottis > supraglottis > Subglottis
      (55-75%) (24-22%) (1-2%)
    2. Age group = 6TH - 7TH decade
    3. Sex = Male : Female =4:6:1

      for glottic C.A.: Male: Female= 9.2:1
      * P.S. Females are more likely to develop supraglottic carcinoma than glottic
  1. Tobacco
  2. Alcohol (Increased risk for supraglottic carcinoma)
  3. Occupational risk factors (Nitrogen, mustard gas. wood worker, diesel, asbestos, cement)
  4. Dietary factors- Deficiency of vit A
  5. Irradiation (Latent period of 40 yrs)
  6. Viral factors (HPV : 6,18,33)
  7. Gastroesophageal reflux

Risk factors associated with laryngeal cancer are smoking, use of alcohol, gastrooesophageal reflux, exposure to wood-dust, asbestos and volatile chemicals, nitrogen mustard and previous ionising radiation. Genetic suscepti­bility also plays a great role.

  1. Leukoplakia                  
  2. Keratosis                       
  3. Papilloma(Juvenile)
  4. Sub mucosal fibrosis
  5. Lichenus planus          
  6. Pachyderma laryngitis
  1. Commonest type: Squamous cell carcinoma
  2. Others: Verrucous type: Ackerman’s Tumor (variant of squamous cell carcinoma) it is well-
  3. differentiated squamous cell variant
  4. Treatment: Partial (Conservation) Laryngectomy/ Total laryngectomy
Table: Classification of sites and various subsites under each site in larynx (AJCC classification 2002)
Site                                         Subsite
  1. Supraglottis                      • Suprahyoid epiglottis (both lingual and laryngeal surfaces)
                                              • Infrahyoid epiglottis
                                              • Aryepiglottic folds (laryngeal aspect only)
                                              • Arytenoids
                                              • Ventricular bands (or false cords)
  2. Glottis                                • True vocal cords including anterior and posterior commissure
  3. Subglottis                          • Subglottis up to lower border of cricoids
  1. Most common site involved: aryepiglottic fold
  2. Presentation : often silent
  3. Other features:
    1. Throat pain,
    2. dysphagia
    3.  lymph nodes mass
iv. Late symptoms
  1. Hoarseness
  2. Dysphagia
  3. Stridor
  4. Weight loss
  1. Most common site : Fee edge Of the vocal cord (junction of ant 1/3 with post2/3)
  1. Circumferential groups
  2. Earliest presentation stridor
  3. Late symptoms hoarseness

Fig.: According to AJCC, glottis extends from the horizontal plane passing through lateral margin of ventricle at its junction with superior surface of the vocal cord to 1 cm below it. Subglottis extends from lower limit of glottis to lower border of cricoids cartilage.

Laryngeal Crepitus: Is the grating sensation experienced while moving the cricoid over the underlying
cervical vertebrA.                           
- Absent in
  1. Post-cricoid carcinoma
  2. Prevertebral abscess
  3. Cold abscess
  4. Retropharyngeal abscess
Hidden Areas of Larynx: Not seen on indirect laryngoscopic examination
  1. Laryngeal surface of epiglottis      
  2. Pyriform sinus apex
  3. Anterior commissure                      
  4. Ventricle
  5. Subglottis                                                        
  6. Post- cricoid area
Areas of laryngeal metastases:
  1. Lung (most common site)              
  2. Mediastinal lymph node
  3. Osseous/ hepatic area
Stages (nodal)
  • No: No regional lymph nodes metastasis
  • N1: Single, I/L £ 3, cm (greatest dimension)
  • N2; N2a: Single, I/L 3-6 cm (greatest dimension)
  • N2b: Multiple. I/L (£ 6cm) (greatest dimension)
  • N2c: H/L or C/L(£ 6 cm (greatest dimension)
  • N3: Lymph node> 6 cm in its greatest dimension
Laryngeal staging:
Tl: One region involved
T2: Two region
T3: Fixity to cord
T4: Outside larynx

T1: Tumor at one subsite – (N)
Vocal cord mobility
T1: Limited vocal cord (cord
T1: Limited to the subglottis
T2: More than one subsite or
glottis with (N) vocal cord
mobility and/ or involvement of
the medial wall of pyriform sinus
mucosa of base tongue and
T2: Extension to vocal cord with impaired vocal cord mobility
T2: Extension to supra/ subglottis   with (N) impaired mobility
 T3: Limited to larynx with vocal
cord fixation and / or invasion of
post – cricoid area, pre-epiglottic
space, deep base tongue
T3: Limited to the larynx with vocal cord fixation
T3: Limited larynx with
vocal cord fixation
T4: Invasion of thyroid cartilage,
tissue neck, oropharynx,
thyroid gland, oesophagus
T4: Limited to the larynx with vocal cord fixation
T4: Limited to the larynx                                 soft
with vocal cord fixation

staging of carcinoma larynx
stage 1: T1N0M0                                                 
stage II: T2N0M0
stage III: T3N0M0 or T1 to T3N1M0                 
stage IV; T4N0M0or T1 to T4 N2    to N3M0 or any T with M1

Fig: Algorithm for treatment of T2N0 glottic cancer

  1. T1 , T2 glottis:
    1. Radiotherapy
    2. Surgery:
  2. T3 T4 glottis: Total laryngectomy followed by radiotherapy
  3. T1 : Surpaglottis: Radiotherapy
  4. T2 supraglottic : Supraglottic laryngectomy
  5. Supraglottic T3 T4: Total laryngectomy
Supraglottic laryngectomy – removal of entire supraglottis (from vallecula to ventrile)
Lower ½ of larynx to base of tongue
Hemilaryngectomy – Removal of ½ thyroid cartilage + true + false vocal cords + part of supraglottis + upper ½ of cricoid cartilage.
Stage wise Rx.
  1. Glottic
    Stage I/II  - Radiotherapy
    Stage III / IV  - Total laryngectomy followed by radiotherapy.
  2. Supraglottic
    Stage I  - Radiotherapy
    Stage II   - Supraglottic laryngectomy
    Stage III / IV  - Total laryngectomy
  3. Subglottic
    Total laryngectomy (with thyroidectomy). 
Subglottic C.A: Total laryngectomy (with thyroidectomy).

Complications of Laryngectomy:
  1. Haemorrhage                                      
  2. Pharyngocutaneous fistula
  3. Hypopharyngeal stricture                
  4. Carotid blow out
  5. Thyroid and parathyroid insufficiency
Vocal Rehabilitation After Total Laryngectomy
After laryngectomy, patient loses his speech completely. Various methods by which communication can be estab­lished are
  1. Oesophageal speech. In this, patient is taught to swallow air and hold it in the upper oesophagus and then slowly eject it from the oesophagus into the pharynx. Patient can speak 6-10 words before re-swallowing air. Voice is rough but loud and understandable.
  2. Artificial larynx. It is used in those who fail to learn oesophageal speech.
    1. Electrolarynx. It is a transistorized, battery operated portable device. Its vibrating disc is held against the soft tissues of the neck and a low pitched sound is produced in the hypopharynx which is further modulated into speech by the tongue, lips, teeth and palate.
    2. Transoral pneumatic device. Another type of artifi­cial larynx is a transoral device. Here vibrations pro­duced in a rubber diaphragm are carried by a plastic tube into the back of the oral cavity where sound is converted into speech by modulators. This is a pneumatic type of device and uses expired air from the tracheostome to vibrate the diaphragm.
  3. Tracheo-oesophageal speech. Here attempt is to carry air from trachea to oesophagus or hypopharynx by the creation of skin-lined fistula or by placement of an artificial prosthesis. The vibrating column of air entering the pharynx is then modulated into speech. This technique has the disadvantage of food entering the tracheA. These days prosthesis (Blom-Singer or Panje) are being used to shunt air from trachea to the oesophagus. They have inbuilt valves which work only in one direction thus preventing problems of aspiration.
LASER treatment in Ca larynx.
It can be used if the tumor is very small. Done under general anaesthesia. Destroys cancer cells.
Laryngeal papillomas can be treated by flash pump dye LASER treatment.
Subglottic stenosis in Ca larynx is treated by CO2 LASER

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