Recurrent laryngeal nerve paralysis
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ppt on RLNP, defn, causes, clinical features and management
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Recurrent laryngeal nerve paralysis
- 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
- 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.