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Khalid H Al Malki, MD Khalid H Al Malki, MD, PhD Consultant, Associate Professor Phoniatrics (Voice, Communication and Swallowing Disorders) Head, Communication and Swallowing Disorders Unit (CSDU) Deputy chairman, ENT Department King Abdulaziz University Hospital King Saud University, Riyadh, Saudi Arabia. Head, Communication and Swallowing Division (CSDD) ORL/HNS Department Riyadh Military Hospital, Riyadh, Saudi Arabia http://faculty.ksu.edu.sa/kmalky/default.aspx Vocal Fold Paralysis Khalid H Al Malki, MD, PhD Khalid H Al Malki, MD, PhD Joints and Vocal Fold Movements Khalid H Al Malki, MD, PhD True vocal fold movements: (1) Gross movements: Adduction (phonation) and Abduction (breathing). (2) Fine movements: Mucosal waves during adduction. Khalid H Al Malki, MD, PhD I. Gross movements During breathing During phonation (Abduction) (Adduction) Khalid H Al Malki, MD, PhD II. Fine movements During phonation (Adduction) Khalid H Al Malki, MD, PhD Important laryngeal joints: (1) Cricoarytenoid joint. (2) Cricothyroid joint. Khalid H Al Malki, MD, PhD Khalid H Al Malki, MD, PhD Cricoarytenoid joint Khalid H Al Malki, MD, PhD Cricothyroid joint Khalid H Al Malki, MD, PhD Muscles Khalid H Al Malki, MD, PhD I. Intrinsic muscles: (1) Posterior cricoarytenoid muscle (2) Lateral cricoarytenoid muscle (3) Interarytenoid muscle (4) Cricothyroid muscle (5) Thyroarytenoid muscle II. Extrinsic muscles: (1) Suprahyoid muscles. (2) Infrahyoid muscles. Khalid H Al Malki, MD, PhD Khalid H Al Malki, MD, PhD Khalid H Al Malki, MD, PhD Khalid H Al Malki, MD, PhD Thyroarytenoid muscle Khalid H Al Malki, MD, PhD Cricothyroid muscle Khalid H Al Malki, MD, PhD Khalid H Al Malki, MD, PhD Nerve supply Khalid H Al Malki, MD, PhD Khalid H Al Malki, MD, PhD All intrinsic muscles of the larynx are supplied by the recurrent laryngeal nerve except cricothyroid muscle, which is supplied by superior laryngeal nerve. Khalid H Al Malki, MD, PhD Sensation above true vocal folds is carried by superior laryngeal nerve, whereas below true vocal folds is by recurrent laryngeal nerve. Khalid H Al Malki, MD, PhD Neurologic Voice Disorders Khalid H Al Malki, MD, PhD (1) Vocal fold paralysis (unilateral, bilateral, superior laryngeal). (2) Spasmodic dysphonia. (3) Essential voice tremer. (4) Myesthenia gravis. (5) Dysarthrophonia and Parkinson’s disease. Khalid H Al Malki, MD, PhD Vocal Fold Paralysis Khalid H Al Malki, MD, PhD Terminology: Vocal fold immobility is a more accurate term until the etiology of the motion impairment has been determined. Vocal fold paralysis: loss of vocal fold mobility due to loss of motor innervations. Vocal fold paresis: vocal fold retains some mobility despite partial dysfunction. Khalid H Al Malki, MD, PhD Laryngeal Nerves: Recurrent laryngeal nerve. Superior laryngeal nerve. Khalid H Al Malki, MD, PhD Etiology (Causes) of immobility: I. Neurogenic (paralysis, paresis). II. Mechanical (fixation). Khalid H Al Malki, MD, PhD Etiology (Causes): I. Neurogenic: 1. Neoplastic (cervical, thoracic). 2. Trauma (surgical and nonsurgical trauma). 3. Medical disease (eg CVA). 4. Idiopathic. Khalid H Al Malki, MD, PhD Etiology (Causes): II. Mechanical: 1. Fixation of the joint from fibrosis or arthritis. 2. Posterior glottic stenosis. 3. Neoplastic invasion of the vocal fold muscle. 4. Arytenoid dislocation. Khalid H Al Malki, MD, PhD Evaluation: (1) Workup of the etiology of the vocal fold immobility: Neoplasms (tumors). (2) Management of the patient’s symptoms: - Airway. - Voice. - Swallowing. Voice Sheet Khalid H Al Malki, MD, PhD Management: A clinical consensus has arisen, which states that prognosis is poor for return of vocal fold movement after a prescribed time interval of 6 to 12 months. Khalid H Al Malki, MD, PhD Management: Severity of voice, Expectations for swallowing, and spontaneous recovery airway symptoms vs. (mild symptoms) Surgical - Wait and see Intervention - Voice therapy Khalid H Al Malki, MD, PhD Surgical Management: (1) Vocal fold augmentation (injection). (2) Medialization laryngoplasty. (3) Arytenoid adduction. (4) Laryngeal reinervation. Khalid H Al Malki, MD, PhD Surgical Management: (1) Vocal fold augmentation (injection): It improve glottic closure by augmentation of the paraglottic space with a biocompatible of substance, thereby adding bulk of the vocal fold and medializing the free edge. Khalid H Al Malki, MD, PhD Khalid H Al Malki, MD, PhD Surgical Management: (1) Vocal fold augmentation (injection): - Human collagen preparations (Cymetra). - Fat. - Hyaluronic acid. - Calcium hydroxylapitie paste (Radiesse). - Collagen. - Teflon. Khalid H Al Malki, MD, PhD Surgical Management: (1) Vocal fold augmentation (injection): May be performed: A. Under topical or local anesthetic in office: 1. per-orally, or 2. transcutaenously. B. Suspension laryngoscopy in OR. Khalid H Al Malki, MD, PhD Per-oral in Office Transcutaenous in Office Suspension laryngoscopy in OR Khalid H Al Malki, MD, PhD Surgical Management: (1) Vocal fold augmentation (injection): It is generally felt to be more suitable in cases where: 1. the glottic gap is small, and 2. the glottic gap predominantly affecting the membranous vocal fold. Khalid H Al Malki, MD, PhD Surgical Management: (2) Medialization laryngoplasty: It involves creation of a window in the thyroid cartilage through which the paraglottic space can be accessed. An implant is then placed into the paraglottic space displacing the true vocal fold medially. Khalid H Al Malki, MD, PhD Khalid H Al Malki, MD, PhD Surgical Management: (2) Medialization laryngoplasty: Performed under local anesthesia. Allows fine-tuning of the position, shape, and size of the implant guided by the immediate feedback of the patient’s voice with each repositioning maneuver. Khalid H Al Malki, MD, PhD Surgical Management: (2) Medialization laryngoplasty: It is generally felt to be more suitable in cases where: 1. the glottic gap is medium to large, and 2. the glottic gap predominantly affecting the membranous vocal fold. Khalid H Al Malki, MD, PhD Surgical Management: (3) Arytenoid adduction: It is used in cases where the glottic gap is posterior. This procedure rotates the arytenoid cartilage medially, displaces the vocal process caudally and medially, and stabilizes the vocal process. Khalid H Al Malki, MD, PhD Khalid H Al Malki, MD, PhD Surgical Management: (4) Laryngeal reinervation: Include: 1. neuromuscular transfer. 2. neural anastomosis. 3. direct nerve implantation. Reliable restoration of physiologic function has not been realized to date. Khalid H Al Malki, MD, PhD Bilateral Vocal Fold Paralysis: * Causes: Bilateral thyroidectomy accounting for the majority of cases. The voice: usually close to normal. Breathing: airway compromise from inability to abduct the vocal folds. Management: Tracheostomy, Laser arytenoidectomy. Khalid H Al Malki, MD, PhD Thank You Khalid H Al Malki, MD, PhD.
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