 Nerve supply of larynx

 10th cranial nerve

 So called due to its vague course through the

head, neck, thorax and the abdomen.

 Longest nerve of the autonomic nervous

system in the body

 MIXED NERVE: sensory, motor and

parasympathetic
Jugular
Foramen
 Arises from inferior ganglion of the Vagus
 Descends behind the internal carotid artery
 At the level of greater cornua of hyoid bone,
divides into external and internal branches

 External Motor branch: Cricothyroid muscle

 Internal Sensory branch: Pierces thyrohyoid
membrane and supplies sensory innervation to
larynx above vocal cord.
Right
 Arises from the Vagus, at the level of Subclavian artery
 Ascends between the trachea and oesophagus

Left
 Arises from Vagus in mediastinum
 At the level of Arch of Aorta
 Then ascends into the neck in the trachea-oesophageal
groove.

 Thus, Left recurrent laryngeal nerve has a much longer

course which make it more prone to paralysis compared
to the right one. ( About 75%)
Motor Supply
 All intrinsic muscle : Recurrent Laryngeal Nerve
Except, The Cricothyroid Muscle : External
Laryngeal Nerve –the branch of Superior
Laryngeal nerve

Sensory Supply
 Above the vocal cords: Internal Laryngeal
Nerve –the branch of Superior Laryngeal Nerve
 Below the vocal cords: Recurrent Laryngeal
Nerve
 RIGHT
(15%)

LEFT
RLN
(75%)

Partial/ B/L (10%)

Nerve Incomplete
involved Combined / U/L
Complete SLN
Laryngeal
Palsy B/L
Combined
High Vagal
palsy
location
Low Vagal RLN Palsy
Right Left Both
Neck trauma Neck trauma Thyroid surgery

Benign or malignant Benign or malignant Carcinoma thyroid

thyroid ds. thyroid ds.
Ca cervical esophagus Ca cervical esophagus Ca cervical esophagus

Cervical LAP Cervical LAP Cervical LAP

Aneurysm of Bronchogenic ca.

subclavian A.
Ca apex right lung Ca thoracic
oseophagus
Mediastinal LAP

TB of cervical pleura Aortic aneurysm

Intrathoracic sx
Common Recurrent laryngeal
nerve palsy = Left

MCC of RLN Palsy-

Bronchogenic carcinoma

Common Recurrent Laryngeal

Nerve Palsy during
Thyroidectomy= Right
 U/L paralysis of all muscles except cricothyroid
C/F :
 Asymptomatic - one third
 Change in voice which gradually improves due to
compensation by healthy cord.
 Tiring voice
 Diplophonia
O/E
 Affected VC in median/paramedian position.
 Wagner and Grossman
Semon’s Law hypothesis
 In isolated paralysis of
 “In all progressive organic recurrent laryngeal nerve,
lesions, abductor fibres of cricothyroid muscle (which
recurrent laryngeal nerve, receives innervation from
which are phylogenetically superior laryngeal nerve)
newer, are more susceptible keeps vocal cord in
and thus first to be paramedian position due to
paralyzed compared to adductor function
adductor fibres.”
 In superior laryngeal nerve
palsy, cord lies in
intermediate (cadaveric)
position
Position of Location Health Disease
cord from midline

Median midline Phonation

Paramedian 1.5 mm Strong RLN

whisper paralysis

Intermediate 3.5 mm Neutral Both RLN

(cadaveric) position and SLN
nerves
Gentle 7 mm Quite Paralysis
abduction respiration of
adductors
Full 9.5 mm Deep
abduction inspiration
Treatment
 Asymptomatic – spontaneous recovery
 Speech therapy
 Intracordal inj of teflon paste
 Medialization thyroplasty
 Abductor paralysis. There is unopposed action of
cricothyroid muscle
Etiology – thyroidectomy (mc), trauma, neoplasm
C/F
 Acute onset
 Dyspnoea and inspiratory stridor which becomes
worst on exertion or infection
 Aspiration in elderly
 Patient may retain good voice
O/E
 Both VC in median or paramedian position, immobile,
flabby, flickers on phonation
 Diagnosis – CT, MRI ,Chest X Ray,
Panendoscopy, Stroboscopy, Barium swallow

Treatment
 Intubation/emergency tracheostomy
 Permanent tracheostomy with a speaking
valve – to retain good voice
 Lateralisation of VC – VC is moved and fixed in
lateral position which improves airway. Not
preferred in patients with good voice as voice is
lost
 Arytenoidectomy – removal of arytenoid by external
approach (woodman’s operation), by endoscopic approach
(thornell operation)
 Endoscopic CO2 LASER cordotomy ( Kashima Operation)
Soft tissue at the junction of membranous cord and vocal
process of arytenoid is excised laterally with laser, which
provides good airway.
 Endoscopic CO2 LASER cordectomy
 Laterialisation thyroplasty Type 2
 Nerve muscle implant – sternohyoid muscle with nerve
supply is transplanted into post cricoarytenoid
 Arytenoidopexy ( fixing the arytenoid in lateral position)
 Rare
 Paralysis of unilateral cricothyroid muscle
 Unilateral supraglottic anaesthesia
Etiology – thyroid surgery, tumours, trauma, neuritis
C/F
 Weak and low pitch voice (loss of tension)
 Occasional aspiration (anaesthesia)
O/E
 I/L VC flabby and bowed, wavy appearance
 Oblique laryngeal inlet
 Post commissure deviated medially towards
affected side
Prognosis
 Voice recovered by compensation from healthy
cord
 Singers cant produce high pitch voice

Treatment
 Speech therapy

During ligation of Superior thyroid vessels in thyroid

surgeries, the dissection should stay close to the
thyroid to avoid nerve damage.
External branch of superior laryngeal nerve lies
posteromedial to the thyroid vessels and should be
identified and preserved.
 Electromyography
of the cricoithyroid
muscle helps to
 Least common diagnose the
 Both cricothyroid paralysed
condition.
 Anaesthesia of supraglottic larynx
Etiology – surgical trauma, RTA, neoplasm
C/F
 Coughing and choking during swallowing due to
aspiration
 Weak and husky/breathy voice
 Short phonation time
O/E
 B/L flaccid and bowed VC
Treatment
 Ryle’s/NG tube feed

 Tracheostomy with cuffed tube

 Thyroplasty Type 1

 Injection teflon/collagen for medialization

 Epiglottoplexy – reversible procedure where

in laryngeal inlet is closed to protect the lungs
from aspiration. Epiglottis is fixed to
arytenoids
Intracranial :
 Intracranial Tumors of posterior fossa
 Basal meningitis(tubercular)

Skull base:
 Nasopharyngeal cancer
 Glomus tumour
 Skull base Fractures

Neck :
 Parapharyngeal tumours
 Metastatic nodes
 Lymphoma
 Neck Penetrating injury
 Paralysis of all unilateral muscles except interarytenoid
which receive innervation from other side

Etiology – high vagal lesions, thyroid surgery

C/F
 Hoarseness of voice
 Aspiration of fluids
 Inadequate cough (d/t air wastage)

O/E
 Unilateral paralysed VC in cadaveric position
Prognosis
 No compensation by healthy cord

Treatment
 Speech therapy
 Medialisation of paralysed vc by teflon
injection or thyroplasty
 Rare
 Total anaesthesia of larynx
 All laryngeal muscles paralysed

Etiology
 Neoplasm in skull base, medulla, upper neck
 CNS disorder

C/F
 Aphonia – VC dont approximate
 Aspiration – laryngeal anaesthesia
 Inability to cough leading to collection of secretions
 Bronchopneumonia due to aspiration and secretions
O/E
 Both VC in cadaveric position

Treatment
 Ryle’s tube feed
 Reversible
 Tracheostomy with cuffed tube
 Epiglottoplexy
 VC plication – approximation of VC with sutures
 Irreversible
 Total laryngectomy – for progessive and irreversible
disease, when voice is lost- to protect lungs
 Second mc cause of stridor in neonates (1st laryngomalacia)
 Unilateral mc, Right VC

Etiology
 Idiopathic
 U/L – birth trauma, congenital anomaly of heart or vessel
 B/L – anomalies of CNS, hydrocephalus, meningitis

C/F
 Weak or hoarse cry
 Inspiratory or biphasic stridor
 Difficulty in feeding

Prognosis – 70% U/L and 50% B/L recover

spontaneously within six months
Diagnosis
 Awake flexible laryngoscopy
 MRI
 X Ray Neck/Chest

Treatment-
 NG tube feed
 U/L (if severe aspiration or dyspnoea)
 Inj teflon/thyroplasty
 B/L (after 5 yrs of age if recovery has not
happened)
 Arytenoidectomy (endoscopic/external)
 Endoscopic lateral cordotomy
“any surgery designed primarily for the
improvement or restoration of the voice”
 Microlaryngoscopic Surgery
 Vocal Fold Injection
 Laryngeal Framework Surgery
 Nerve Grafting / Rennervation Surgery
 Manual Compression Test
Type of Anesthesia
Local - allows patient to phonate
 Careful administration of IV sedation
 Internal br. of superior laryngeal nerve is blocked
at the thyrohyoid membrane
 Glossopharyngeal nerve block at the inferior pole
of the tonsils
 Flexible endoscope allows visualization
 Pt sitting and injecting through cricothyroid
membrane
General
 Visualizaation problems d/t ETT
 Abnormal anatomical position of neck
 Lack of pt feedback
 Adds fullness to the vocal cord to help it
better oppose the other side
 Injection technique is similar regardless of
material used
 Injection into thyroarytenoid/vocalis
 Injection can be done endoscopically or
percutaneously
 External landmarks –
several mm anterior
to oblique line
horizontally,
midpoint between
thyroid notch and
inferior thyroid
border vertically
 Teflon
 Fat
 Glycerine
 Collagen
 Siliconegel
 Hyaluronic Acid
 Calcium Hydroxyapatite gel
Teflon
 Polymer of Tetrafluroethylene
 Produces localised inflammatory response
 Irreversible
 Used in persons with short life expectancy
 Poor long term voice results
 High density & injected deep into
thyroarytenoid muscle
 Risk of granuloma formation
Fat
 Autogenous material
 Easily harvested, readily available, no FB reaction
 Overcorrection is necessary – about 50%
 Resorption in months to years
Glycerine
 Completely reversible
 Absorbed in 2-6 wks
 Injected deep within vocal fold

Collagen
 Natural constituent of lamina propria
 Bovine collage used
 Skin testing required
 Over injection
 Airway compromise
 Under injection
 Misplacement & migration (silicon)
 Granuloma (teflon)
First described by Payr and reintroduced by Ishiki
in 1974
Variety of materials used for implants:
 Autologous Cartilage
 Silastic
 Hydroxyapatite
 Gortex
 Titanium

Useful for anterior glottic gap

 Type I thyroplasty- medialization of VC.
 Type II thyroplasty- lateralization of VC.
 Type III thyroplasty- shortening or relaxation of VC.
It lowers pitch of voice, done in mutational falsetto or
in those who have gone gender transformation from
female to male
 Type IV thyroplasty- lengthening of VC to elevate
pitch. It is also used when vocal cord is lax and bowing
due to aging process on trauma.
Advantages:
 Permanent, but surgically reversible
 No need to remove implant if vocal function
returns
 Excellent at closing anterior gap

Disadvantages:
 More invasive
 Poor closure of posterior glottic gap
Complications
 Extrusion/Displacement (Intraoperative or Postop)
 Misplacement – most often superior
 Infection
 Undercorrection – important to overcorrect by 1-2mm

Controversies
 Location of graft placement
 Status of inner perichondrium
 Many series have shown low extrusion rate with
sacrificed perichondrium
 First described by Ishiki with modifications by
Zeitels and others
 Addresses posterior glottic gap by pulling
arytenoid into adducted position
 Difficult to predict which patients will benefit
preoperatively.
 Most advocate use in combination with anterior
medialization
Endoscopic Approaches:
Suture Placed to Cricoid Cartilage
 Simulates action of lateral cricoarytenoid

Zeitels Modification – Arytenopexy

 Presumably allows a more physiologic positioning of the
arytenoid
 Involves suturing the arytenoid in a more posterior and
medial position to allow more tension on flaccid cord
 Cricothyroid subluxation mimics action of cricothyroid muscle
 Modifications should be used selectively
Complications
 Sutures too tight – may displace arytenoid
complex anteriorly, adversely affecting voice
 Entry in pyriform sinus
 Open method – lateral / Median approach

 Vocal fold abduction

- Suture technique
- Thyroarytenoid myectomy
 RLN anastomosis first described by Horsely in
1909

 Crumly showed Ansa cervicalis to RLN

anastomosis
 Results in synkynetic
tone of vocal cord

 Ansa to Recurrent
Laryngeal Nerve

 Ansa to Omohyoid to
Thyroarytenoid
 Hypoglossal to recurrent laryngeal nerve

 Crossed nerve grafts or wire conduction

prostheses from one muscle to its paralyzed
counterpart are being researched
THANK YOU