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Neurological voice disorders (Recurrent laryngeal nerve paralysis…
Neurological voice disorders
Superior laryngeal nerve paralysis
Innervates cricothyroid muscle. Tenses VF to increase pitch. VF adduction
Symptoms: Vocal fatigue, hoarseness, loss of vocal range, breathiness
Mgm: Wait, see. Surgical fusion of thyroid, cricoid cartilages
Recurrent laryngeal nerve paralysis
Aetiology
Congenital - in children w spina bifida
Intrathoracic neoplasms/tumours-cancers in course of RLN
Thryoidectomy-remove thyroid gland
Aneurysms- swelling in blood vessels
Mitral valve stenosis (left auricle enlarge, stretch RLN)
Neck trauma, penetrating injuries
Radiation-cancer in head, neck region
Systemic disease
Idiopathic
Notes
Left RLN lesions 10x more freq cf. right RLN eg. car accident, lung, heart surgery, LRLN more prone to damage
RLN innervates all intrinsic muscles of larynx EXCEPT cricothyroid (SLN)
Lesion may be bilateral (Xphonate) , unilateral
2 types: adductor (affect muscles of adduction), abductor (affect muscles of abduction)
RRLN only in neck region, LRLN goes deep into chest
Types
Unilateral adductor paralysis: One VF X move to midline
Bilateral adductor paralysis: Both VF X move to midline
Unilateral abductor paralysis: VF remains in fixed adductor position
Bilateral abductor paralysis: both VFs remain in adducted position-respiratory difficulty, X open to allow air into lungs
Perceptual, physiological signs
Highly variable presentation bcos of 1) location of paralysed VF wrt non-paralysed VF
2) Ability of indv to compensate for paralysis, 3) Degrees of paralysis determines if we can get voice/not.
Unilateral RLN
AB- phonatory capability may be preserved. Dysphonia may be present. Change to vocal quality
AD-Excessively breathy, weak voice. Increased airflow, decreased subglottal pressure
Bilateral RLN
AB-inhalatory stridor, voice quite good bcos both VF weakly adducted. Some patient's airway can be obstructed. Tracheostomy might be required.
AD-Aphonia, dysphonia depending on fixed location of VF
Mgm
Wait and see approach BUT depends on aetiology. Wait 6-9 months to allow for functional recovery which may occur as result of nerve regeneration.
Behavioural voice therapy
Voice Tx 2-6 weeks post diagnosis can improve phonatory stability w/o surgery
Can be used in addition to surgery to improve outcomes
Vocal fn exercises, resonant voice Tx
Surgery
Injection of fat, collagen etc to plump up paralysed VF. Better chance of touching free VF
Injection into lateral to thyroarytenoid muscle, lamina propria
Usually done under endoscopic guidance
Implantation
Insert gore-tex hard material medial to thyroid cartilage at VF level-type 1 thyroplasty
Serves as wedge to move paralysed VF to midline
Arytenoid adduction
Rotation of arytenoid cartilages so that tip of vocal processes moves to midline
Voice usually excellent immediately post-op. Deteriorates as swelling subsides. Impv in 1-2 weeks
Surgical Tx for bilateral paralysis
Tracheostomy
Arytenoidectomy
Cordectomy
Spasmodic dysphonia
Aetiology
Psychologically based-conversion rxn. Musculoskeletal tension
+++Neurologically based-organic, essential tremor, dystonia+++
Idiopathic
Onset: 40-50 y/o
More common in women
Often associated w URTI, emotional stress, gradual
What?
Strained, choked, effortful voice pattern
Relatively rare
Resistant to traditional voice Tx
Types
Adductor
Approx 80% of cases
Phonation: true, false VF hyperadduct, intermittent, irregular spasms. Too hard, too fast
Attribute to organic pathology-psychological factors co-exist
Abrupt, staccato, vocal explosions, strained-strangled, intermittent vocal arests on vowels
Larynx normal at rest
Abductor
Severe breathy aphonia-intermittent arrests on voiceless consonants
Hypokinetic dysphonia