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Overview
Anatomy of the Larynx Function of the Larynx Causes of Vocal Cord Paralysis Evaluation of Vocal Cord Paralysis Treatment for unilateral & Bilateral Vocal Cord Paralysis
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Function of Larynx
Passage for Respiration Prevents Aspiration Allows Phonation Allows Stabilization of Thorax
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Respiration
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Phonation
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Etiology:
Thyroid
Tumors Surgery
Thoracic
Tumors:
Skull base:
Nasopharyneal
metastasis Surgery
carcinoma, Cervical
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Cervical surgery:thyroid and parathyroid surgery, anterior approach to cx. Spine, carotid endarterectomy, cricopharyneal myotomy Thoracic surgery: pneumonectomy, repair of crotid aneurysm, aortic valve replacement, CAPG, esophageal surgery, tracheal surgery, ligation of PDA, cardiac transplant. Neurosurgery: skull base surgery, brain stem surgery Endotracheal intubation & central venous line 18
Etiology: in adults
Cause Surgery Idiopathic Malignancy Trauma Neurologic Intubation Other Unilateral % 24 20 25 11 8 8 5 Bilateral % 26 13 17 11 13 18 5
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Etiology in children
Meningoencephalocele Arnold Chiari malformation Patent ductus arteriosus Encephalitis Guillain-Barre syndrome Diphtheria Neurotoxicity e.g. Vincristine
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Clinical symptoms
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Tobacco Usage Voice Abuse URI Reflux Neurologic Disorders History of Trauma or Surgery Systemic Illness Rheumatoid Duration Affects Prognosis
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Complete Head and Neck examination Cranial nerves examination Mirror laryngoscopy Telescopic laryngoscopy Flexible transnasal Laryngoscopy 23
Mirror laryngoscopy
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Evaluation - Imaging
Chest X-ray
Screen
MRI of Brain
Screen
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Evaluation
Barium swallow Thyroid scan Respiratory function tests Lab studies: VDRL, glucose tolerance test, lumbar puncture, ESR, Monospot test, arsenic , lead and mercury levels.
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Evaluation - Electromyography
Assesses integrity of laryngeal nerves Differentiates denervation from mechanical fixation of vocal cord movement
Electrode
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Evaluation - Electromyography
Normal
Fibrillation
Denervation
Polyphasic
Synkinesis Reinnervation
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Evaluation- DL
arytenoids with a laryngeal spatula esp. if no L-EMG Exclude laryngeal tumors Bronchoscopy & esophagoscopy
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Primary cause Assess patients vocal requirements Adequacy of Airway and laryngeal competence
Assess extent of posterior glottic gap Position of Cords: Median, Paramedian, Lateral Surgery often not necessary in paramedian position
Duration of problem:
Do not perform irreversible interventions in patients with possibility of functional return for 6-12 months
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administration of IV sedation Internal superior laryngeal nerve block at the thyrohyoid membrane Glossopharyngeal nerve block at the inferior pole of the tonsils Flexible endoscope allows visualization
General
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In unilateral paralysis Adds fullness to the vocal cord to help it better appose the other side Into thyro-arytenoid/vocalis
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Hyaluronic Acid
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Injector
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Different materials: cartilage, silastic Surgically reversible Excellent at closing anterior gap More invasive Misplacement Under-correction Infection 45
Manual compression
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Patients exhibit lack of abduction during inspiration, but good phonation Maintenance of airway is the primary goal Airway preservation often damages an otherwise good voice
Inspiration
Expiration
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Tracheostomy
Emergency procedure Most adults will require this Speaking valves aid in phonation
Laser Cordectomy/Cordotomy
Widening posterior glottis for respiration and leaving anterior glottis for phonation
Laser Microlaryngosurgery
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Recent procedures:
Reinnervation:
Ansa
Electrical Pacing
Timed
to inspiration with electrode placed on posterior cricoarytenoid Long-term efficacy not yet shown
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Acute laryngitis Acute epiglottitis Viral laryngotracheobronchitis Bacterial laryngotracheobronchitis Spasmodic croup Diphtheria
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Acute laryngitis
Viral/bacterial, irritant fumes, allergy Presentation: common cold, sore throat, rough deep voice, aphonia Laryngoscopy: erythema, edema of vocal cords, excess secretions Management: voice rest, steam
inhalation, excess fluids mucolytics, antibiotics only when there is evidence of bacterial infection, steroids in professional voice users
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Acute laryngitis
Age 3-6 years Toxic feverish child Acute sore throat and drooling Tachypenia, muffled voice and inspiratory stridor: rapidly progressive Typical posture: sitting upright, extending the neck
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Changing:
Hemophilus
influenzae type B: is decreasing due to immunization (by 90%) Meningococci Hemophilus parainfluenzae Beta hemolytic streptococci Staphylococcus aureus
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Pharyngeal examination should not be attempted Patient taken to OR or pediatric ICU X-ray soft tissue lateral film for the neck: thumb sign and blunting of vallecula.
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Acute epiglottitis
Confirm diagnosis in controlled setting with direct laryngoscopy Secure the airway with endotracheal intubation or tracheostomy
Depending
experience
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Age : 6 months -3years Boys more More in winter Airway inflammation Edema of subglottic area (Poiseilles law)
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Croup: diagnosis
and malaise, Symptoms of cold Inspiratory or biphasic stridor Hoarseness barking cough.
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None
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Audible with stethoscope Mild Decreased
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Audible without stethoscope Moderate Severely decreased
severe
With agitation
At rest altered
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Croup Scoring:
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Croup: Treatment
Reassurance Observation/admission Oxygen and hydration Nebulized epinephrine: 1ml 1/1000 in 3ml saline) Steroids:
Improve
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Bacterial laryngotracheobronchitis
There is sloughing of respiratory mucosa (subglottic and trachea) and profuse mucopururlent secretions Less common than croup
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Age is older than croup Child is feverish & toxic Clinically, radiologically similar to croup No response to steroids Diagnosis confirmed on endoscopy: pseudomembrane in the subglottis and trachea, thick mucopus
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Endoscopy: Confirm diagnosis, remove of secretions Secure airway: IT intubation Nursing care/ suction Oxygen and hydration Antibiotics: staphylococcus aureus commonly isolated from tracheal culture
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Spasmodic croup:
Similar to croup Recurrent Not infection:?allergy, atopy, ?reflux Typically at night and resolve within hours Management: assurance, single dose of dexamethasone Endoscopy should be done in persistent cases to exclude stenosis
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Diphtheria
Rare now due immunization Corynebacterium diphtheriae: toxic strains Pharyngeal diphtheria: sore throat, malaise, feve, pharyngeal pseudomembrane, huge neck lymph nodes. Laryngeal diphtheria: inspiratory stridor becomes evident and cough Myocarditis : slow to resolve Neuropathy: soft palate paralysis Management: early diagnosis, antitoxin, high dose penicillin, secure the airway 73
Thank You
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