Vocal Cord Paresis:Background and Case Reports The Greater Baltimore Medical Center, The Johns Hopkins Voice Center at GBMC Stroboscopy Grand Rounds
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1 Presented by: David F Smith, MD, PhD March 2, 2012 Vocal Cord Paresis:Background and Case Reports The Greater Baltimore Medical Center, The Johns Hopkins Voice Center at GBMC Stroboscopy Grand Rounds 1
2 Definitions: Paralysis: No movement Paresis: Hypomobility Synkinesis: Aberrant regrowth of the laryngeal nerves. March 2,
3 Anatomy/Nerves: Recurrent Laryngeal Nerves: Different Course -Right-Loops behind R subclavian artery (nonrecurrent possible) -Left-Passes inferoposteriorly to aortic arch March 2,
4 March 2,
5 Anatomy/Nerves: Superior laryngeal nerve: Travels inferiorly, medial to carotid artery. Splits into 2 branches at hyoid. Internal SLN penetrates thyrohyoid membrane with laryngeal a., external division provides motor innervation to cricothyroid m. Note: Find external SLN 1 cm superior to superior pole of thyroid. March 2,
6 Internal b. SLN External b. SLN March 2,
7 Anatomy/Muscles: RLN Innervates 4 muscles Adductors: Thyroarytenoid, lateral cricoarytenoid Abductor: Posterior cricoarytenoid Interarytenoid m-adduction and closure of posterior glottis March 2,
8 March 2,
9 March 2,
10 Occurrence: Highly variable depending on cause: Iatrogenic-seen in thyroid surgery Idiopathic: unknown Large number likely unidentified March 2,
11 Causes: Many causes: iatrogenic, idiopathic, trauma, neurologic ds (MS, ALS, MG, Guillain-Barre, Parkinson ds), local tumor infiltration (thyroid cancer, LN spread, Pancoast tumor), infection (Lyme), collagen-vascular ds, CVA, CNS tumors March 2,
12 Presentation: VC Paresis: VC hypomobility due to neurologic injury Presents as: dysphonia, loss of upper register of voice, hoarseness, breathiness, choking, decreased vocal stamina March 2,
13 Sunderland Classification: First thru Fifth Degrees of Injury First usually with complete recovery, fifth with more permanent changes March 2,
14 Synkinesis: Crumley Classification System: I-normal voice/airway II-spastic VC that twitches w/o control III-tonic adduction of VC, compromised airway IV-tonic abduction of VC, breathy voice and risk of aspiration March 2,
15 Evaluation: History Physical Exam-mirror exam, laryngoscopy, videostroboscopy EMG March 2,
16 EMG: Stimulate cells to produce action potential Innervation ratio (of motor unit) Electrodes placed Measure muscle fiber action potential Inserted into CT, PCA/LCA, Vocalis, TA Insertion, rest, min contract, max contract March 2,
17 EMG: Mild-decrease in recruitment 1-30% Moderate 31-60% Severe 61-99% Paralysis-No observable recruitment March 2,
18 EMG: Abnormal Findings: -increased insertional activity: myopathic and neurogenic -repetitive discharges: neuropathic process March 2,
19 Treatment Voice therapy VC injection Thyroplasty medialization Laryngeal pacing (FES) March 2,
20 Case 1: female vf paresis & presbylarynges 69 yo female R VC paresis and presbylarynges Multiple injections (saline, radiesse gel, and calcium hydroxylapatite) March 2,
21 Case 1 Video: female vf paresis & presbylarynges CLICK HERE for video March 2,
22 Case 2: female, right tvf paresis 56 yo female R VC paresis Also w/ supraglottic hyperfunction and phonotraumatic nodules March 2,
23 Case 2 Video: female, right tvf paresis CLICK HERE for video March 2,
24 Case 2 Video: female, right tvf paresis CLICK HERE for video March 2,
25 Case 2 Video: female, right tvf paresis, injection radiesse CLICK HERE for video March 2,
26 Case 3: male, left tvf paresis 54 yo male L VC paresis *Transcervical injection augmentation March 2,
27 Case 3 Video: male, left tvf paresis CLICK HERE for video March 2,
28 Case 4: female, right tvf paresis & presbylarynges 83 yo female R VC paresis and presbylarynes Previous bilateral Radiesse gel injections March 2,
29 Case 4 Video: female, right tvf paresis & presbylarynges March 2,
30 The END Questions: call The Johns Hopkins Voice Center at The Greater Baltimore Medical Center, Baltimore, Maryland March 2,
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