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Laryngology > UVFP (Unilateral VF paralysis) > Flashcards

UVFP (Unilateral VF paralysis) Flashcards

1
Q

Etiology of UVFP

A

Dysfnc of either

  • Brainstem nuclei (cortex –> corticobulbar fibers –> internal capsule –> nucleus ambiguus)
  • Vagus nerve
  • RLN
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2
Q

How can a vocal fold have some adduction even when the IPSI RLN is transected

A

-The interarytenoid muscle is unpaired and is innervated by both RLNs. Thus, CONTRA RLN input to the IA can lead to some adduction of the vocal fold even on the paralyzed size

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3
Q

What muscles does the RLN innervate?

A
  • Posterior cricoarytenoid
  • Interarytenoid (unpaired)
  • Lateral cricoarytenoid
  • Thyroarytenoid
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4
Q

Causes of UVFP

A
  • Iatrogenic (nonthyroid 30.6%, thyroid 15.7%)
  • Malignancy (lung 6.6%, nonlung 6.9%)
  • Idiopathic 17.6%
  • Neurologic 7.9% (brainstem stroke)
  • Intubation 4.4%
  • Nonsurgical trauma 2.2%
  • Aortic/cardiac 0.6%
  • Other 12.6%
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5
Q

MCC UVFP

A 
Iatrogenic injury (nonthyroid) > thyroid)
Idiopathic is 2nd mcc
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6
Q

Nonthyroid iatrogenic causes of UVFP

A
  • Anterior cervical spine
  • Esophagectomy
  • CEA
  • Mediastinoscopy
  • CABG
  • Pulm resection
  • Intubation (pressure neuropraxia from compression of ant rami of RLN by high-riding ETT in subglottis)
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7
Q

Why should all unexplained VFP cases be evaluated by an appropriate imaging study that looks at the full course of the cervicothoracic vagus and RLN?

A

Bc of the common association of nonlaryngeal malig with VFP

  • Bronchiogenic carcinoma of the lung
  • Thyroid
  • Esophageal
  • Skull base (paraganglioma)
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8
Q

What is the m/c neuro event a/w UVFP

A

-Brainstem stroke

Almost always see other neuro S/Sx

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9
Q

Other neuro causes of VFP

A
  • Arnold-Chiari malformation
  • ALS
  • Guillain-Barre synd
  • Eaton-Lambert synd
  • PD
  • Shy-Drager synd
  • Progressive bulbar palsy
  • Myasthenia gravis
  • MS
  • Postpolio synd
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10
Q

What is thought to be the cause of idiopathic VFP?

A
  • HSV1 inflammatory neuropathy (like Bells)

- Dx of exclusion (exam and imaging negative)

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11
Q

Spontaneous recovery rate for idiopathic VFP

A

50%

-No evidence that steroids or antivirals help

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12
Q

Medication causes of VFP

A
  • Vinca alkaloids (vincristine & vinblastine)
  • Cisplatinum

Reversible

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13
Q

If VFP results from intubation, what must one rule out?

A
  • Arytenoid cartilage dislocation or subluxation

- Best donw with LEMG (laryngeal electromyography)

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14
Q

Imp elements of Hx

A
  • Voice quality and swallowing
  • Vocal inventory of voice responsibilities (how urgently do they need to be fixed)
  • Often feel breathless while speaking bc of inefficient laryngeal closure and inc effort but not SOB
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15
Q

Imp elements of physical exam

A
  • Neck exam for LAD and thyroid masses
  • Palatal mvmt while phonating (palate and VF paralysis indicate a “high” vagal lesion)
  • CN exam, esp CN XI & XII
  • FNL: “ee-sniff”
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16
Q

How do you distinguish paresis from paralysis on FNL?

A
  • Any ABduction of the affected VF indicates paresis

- Note: a paralyzed cord may still ADduct due to CONTRA RLN IA action

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17
Q

What position can a paralyzed VF be in and does it matter?

A
  • Lateral (cadaveric)
  • Median
  • Paramedian
  • Intermediate

No
The final position is caused entirely by the degree of reinnervation and synkinesis present

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18
Q

Does an anteriorly displaced or overhanging arytenoid cartilage indicate dislocation?

A
  • No, definitely not in nontraumatic cases
  • EMG data from pts w/ VFP + overhanging arytenoid cartilage will almost always show denervation or poor reinnervation of the thyroarytenoid muscle
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19
Q

What is the incidence of arytenoid cartilage subluxation and dislocation?

A
  • Very debated

- Many say exceedingly rare

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20
Q

Signs that should raise suspicion of arytenoid cartilage dislocation when evaluating UVFP

A
  • Arytenoid cartilage edema
  • Difference in VF level (ant dislocation –> IPSI side should be lower)
  • Absence of a “jostle sign”
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21
Q

What is the jostle sign

A

Brief lateral mvmt of the arytenoid cartilage on the immobile side during glottic closure cause by contact from the mobile arytenoid

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22
Q

What is needed to confirm arytenoid dislocation?

A
  • LEMG or

- CA joint palpation

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23
Q

What is plica ventricularis

A
  • compensatory supraglottic contractions

- Some UVFP have this and it can obscure evaluation of VF mvmt

24
Q

How do you evaluate the VF in pts w/ plica ventricularis

A

-“Unloading”: humming or prolonged phonation of “who”

25
Q

What can be seen on videostroboscopy of the paralyzed VF?

A
  • Inc amplitude of vibration bc of the atrophic, “floppy” nature of the denervated vocalis muscle
  • Vocal fold height differences
26
Q

Maximal phonation time (MPT)

A
  • “Say ‘ee’ as long as you can”
  • Nl = 25 sec
  • <= 5 sec
  • MPT should improve after successful medialization

-Time can be affected by poor pulm reserve too though (e.g. COPD pts)

27
Q

What is the main limitation of MPT?

A

Can’t distinguish b/w upper and lower airway sources of dysfnc

28
Q

What is a clinically more useful indicator of glottic incompetence than the MPT?

A

S:Z ratio

  • Duration of z phonation sig dec in glottic insuff while duration of s is unchanged
  • Thus, S:Z ratio increases (>1.4)
29
Q

When is imaging needed in w/u?

A
  • If clearly post-surgical, not needed

- If no cause found, then its essential

30
Q

What imaging should be ordered if warranted?

A
  • Either CT w/ or MRI from skull base to upper chest w/ comment to radiologist that full course of RLN needs to be imaged
  • Some argue CT or MRI of neck + CXR is enough
31
Q

Why is LEMG (laryngeal electromyography) imp in the w/u of UVFP?

A
  • Imp for prognosis
  • Differentiates UVFP and CA joint pathology
  • Diagnoses suspected VF paresis
  • Directs treatment decision making
32
Q

During what time period is LEMG useful for UVFP

A

B/w 1 and 6 months after the onset of paralysis

33
Q

What are the 3 management strategies for UVFP?

A
  1. Obs for 6-12 mo
  2. Refer to SLP for voice strengthening or swallow Rx
  3. Early surg intervention
    - Temporary injxn augmentation
    - Permanent ML +/- AA OR permanent injxn
34
Q

What patient factors favor early treatment?

A
  • Presence of clinical aspiration
  • Nerve transection
  • Paralysis from pulmonary carcinoma or iatrogenic thoracic surgery injury
  • Vocal professional
  • Poor prognosis from LEMG
35
Q

If a nerve is transected, when is the soonest you should go to OR?

A

2-3 months to allow muscular atrophy of the VF (lessens the need for revision surgery)

36
Q

What is the classical teaching for when to pursue permanent treatment of UVFP

A

Watchful waiting period of 9-12 months after onset (bc historically teflon was used to inject and its irreversible)

37
Q

What is the current recommendation for when to pursue permanent treatment of UVFP

A

6-9 mo after onset

38
Q

Does early temporary injection medialization impact the need for permanent intervention later?

A

Yes, decreases the need by encouraging the VF to maintain a more medialized position

39
Q

How long does Radiesse Voice Gel last?

A

2-3 mo

40
Q

How long does Radiesse (CAHA) last?

A

18 mo

41
Q

Why isn’t teflon injected anymore?

A
  • Granuloma

- VF stiffness

42
Q

How much over-injection of fat is required? Why?

A

-Sometimes as much as 100% bc of significant resorption in the first 4-6 wks

43
Q

Where should you inject?

A
  • In the “deep” portion of the vocal fold to avoid disruption of the superficial layer of the lamina propria
  • Intended location is the medial aspect of the TA muscle (vocalis) at the midmembranous and posterior VF
44
Q

What happens if you inject superfically?

A

-You may inject into Reinke space causing permanent loss of vibratory fnc

45
Q

What does framework surgery for UVFP entail

A

Medialization laryngoplasty (ML) and arytenoid adduction (AA)

46
Q

What are implant options for medialization laryngoplasty?

A
  • Gore-Tex strips
  • Montgomery system (pre-formed silicone)
  • Silastic Netterville PhonoForm block
  • Hydroxyapatite VoCoM systems
  • Titanium Kurz implant
  • Adjustable silicone balloon implant
47
Q

What happens to the voice after ML?

A
  • Good to excellent intraop
  • Varying degrees of postop dysphonia 2/2 paraglottic edema or submucosal hemorrhage
  • w/in hrs, voice is rough and breathy
  • Postop dysphonia can last 2-6 wks but is variable
48
Q

Any restriction on future surgery in pt s/p ML?

A
  • Elective procedures should be postponed for 6 mo

- Use 6.0 cuff tube or smaller to avoid laryngeal edema

49
Q

What are the most common mistakes made in ML surgery?

A

Implant placed too anteriorly or superioly

50
Q

What happens if the ML implant is placed too anteriorly?

A

Strained voice quality

51
Q

What does arytenoid adduction simulate?

A

The action of LCA (lateral cricoarytenoid muscle) contraction

52
Q

What does AA entail?

A

Suture from muscular process of arytenoid to an anterior location on the thyroid cartilage

53
Q

What does AA accomplish?

A
  • Lowers the position of the vocal process
  • Medializes and stabilizes the vocal process
  • Rotates the arytenoid cartilage
54
Q

When should one consider AA as an adjunct to ML

A
  • Lack of vocal process contact during phonation (large posterior glottal gap)
  • Vocal folds at different levels
  • Videostroboscopy helps determine need
  • MPT < 5 sec is a predictor of need for AA
55
Q

What have laryngeal reinnervation procedures accomplished?

A
  • Improved vocalis muscle tone rather than purposeful VF motion
  • Increased recruitment

Laryngology (5 decks)

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