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Bilateral Recurrent Laryngeal Nerve Paralysis


Presentation

  • Patients with unilateral vocal fold paralysis present with varied vocal symptoms, ranging from mild to severe dysphonia.[bbivar.com]
  • Cytomegalovirus infection of the laryngeal nerve presenting as hoarseness in patients with acquired immunodeficiency syndrome . The American Journal of Medicine, Vol. 86, Issue. 1, p. 108.[doi.org]
  • Cytomegalovirus infection of the laryngeal nerve presenting as hoarseness in patients with acquired immunodeficiency syndrome. The American Journal of Medicine , Vol. 86, Issue. 1, p. 108.[cambridge.org]
  • She has presented over 70 peer reviewed presentations at national and international conferences on voice and respiratory disorders. Dr.[speechpathology.com]
  • Conclusion: The non-surgical cause of RLN palsy (adductor palsy) presents differently from that of the surgical cause. The presentation and treatment are also different. Tracheostomy is not required and recovery of the nerve is usually the norm.[austinpublishinggroup.com]
Surgical Procedure
  • Bilateral vocal fold paralysis most commonly results from iatrogenic trauma to the recurrent laryngeal nerve during surgical procedures in the anterior neck.[ncbi.nlm.nih.gov]
  • For unilateral paralysis, surgical procedures to move cords closer together For bilateral paralysis, surgical procedures and measures to maintain airway In unilateral paralysis, treatment is directed at improving voice quality through augmentation, medialization[msdmanuals.com]
  • We describe the possible surgical techniques to preserve and not damage the RLN, in the course of a surgical procedure involving the thyroid gland.[scitechnol.com]
  • However, these surgical procedures are often complicated by the necessity to preserve vocal functioning and improve airway functioning.[speechpathology.com]
Fatigue
  • Patients with this pathology often complain of physical fatigue resulting from the increased effort to produce voice and the breathlessness associated with phonation.[bbivar.com]
  • Patients with vocal fold paralysis often complain of vocal fatigue as well as physical fatigue, which is the result of the increased effort to produce voice and the loss of air while voicing due to incomplete glottis closure.[entcolumbia.org]
  • Damage to this nerve can manifest as ipsilateral cricothyroid muscle paralysis, and clinical symptoms may include a hoarse, breathy voice, frequent throat clearing, vocal fatigue or diminished vocal frequency range, especially when rising pitch.[ncbi.nlm.nih.gov]
  • Adaptive measures by the patient may cause a presentation similar to muscle tension dysphonia as compensation with a supraglottic squeezing mechanism may dominate the clinical picture Often complain of rough and breathy voice Voice fatiguable Bilateral[medicine.uiowa.edu]
Pain
  • الصفحة 415 - AD (2000) Cytoarchitectonic and immunohistochemical characterization of a specific pain and temperature relay, the posterior portion of the ventral medial nucleus, in the human thalamus.[books.google.com]
  • The most common symptoms are dysphagia, initially for solid and then for liquid food, ponderal loss and retroesternal pain badly defined. Hoarseness is a less common symptom, but not rare.[arquivosdeorl.org.br]
  • […] what might cause damage to the SLN -trauma -surgery -tumors -stretching -compression -lacerations s/s of tracheal compression -throat clearing -sensations of pain and pressure (extrinsic) -difficulty in swallowing -lowered speaking pitch -inability to[quizlet.com]
  • EVALUATION OF VOCAL CORD PARALYSIS PATIENT • History • Symptoms: (a) Change in voice (b) Hoarseness (c) Aphonia (d) Vocal fatigue (e) Neck pain (f) Aspiration (g) Cough • Past Medical & Surgical History : • Social History : • General Examination : • Local[slideshare.net]
Hoarseness
  • In cases of idiopathic onset of paralysis, patients frequently report that hoarseness began following a viral infection. Patients with unilateral vocal fold paralysis present with varied vocal symptoms, ranging from mild to severe dysphonia.[bbivar.com]
  • Cytomegalovirus infection of the laryngeal nerve presenting as hoarseness in patients with acquired immunodeficiency syndrome . The American Journal of Medicine, Vol. 86, Issue. 1, p. 108.[doi.org]
  • Cytomegalovirus infection of the laryngeal nerve presenting as hoarseness in patients with acquired immunodeficiency syndrome. The American Journal of Medicine , Vol. 86, Issue. 1, p. 108.[cambridge.org]
  • -cricothyroid affected (Pitch raiser) -slackened cord produces hoarse, rough vocal quality (b/c anterior pull from crico isn't there) bilateral superior laryngeal nerve paralysis crico paralyzed on both sides -voice is hoarse, drops in pitch, lacks inflection[quizlet.com]
Hoarseness
  • In cases of idiopathic onset of paralysis, patients frequently report that hoarseness began following a viral infection. Patients with unilateral vocal fold paralysis present with varied vocal symptoms, ranging from mild to severe dysphonia.[bbivar.com]
  • Cytomegalovirus infection of the laryngeal nerve presenting as hoarseness in patients with acquired immunodeficiency syndrome . The American Journal of Medicine, Vol. 86, Issue. 1, p. 108.[doi.org]
  • Cytomegalovirus infection of the laryngeal nerve presenting as hoarseness in patients with acquired immunodeficiency syndrome. The American Journal of Medicine , Vol. 86, Issue. 1, p. 108.[cambridge.org]
  • -cricothyroid affected (Pitch raiser) -slackened cord produces hoarse, rough vocal quality (b/c anterior pull from crico isn't there) bilateral superior laryngeal nerve paralysis crico paralyzed on both sides -voice is hoarse, drops in pitch, lacks inflection[quizlet.com]
Stridor
  • Massive stridor on inspiration is the key symptom. Indirect laryngoscopy confirms the diagnosis. Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytenoid joint.[ncbi.nlm.nih.gov]
  • Hypocalcaemic stridor and infantile nutritional rickets. BMJ 1995;310(6971):48-9. Srivastava A, Ravindran V. Stridor secondary to hypocalcaemia in the elderly: an unusual presentation. Eur J Intern Med 2008;19(3):219-20. Epub 2007 Sep 19.[signavitae.com]
  • Symptoms include respiratory distress with stridor. The situation often necessitates emergent reintubation or tracheostomy. Keyword history 75%/2014 64%/2011 Sources Atlee: Complications in Anesthesia, 2nd ed. 2006. Chapter 204.[openanesthesia.org]
  • . • Clinical features : - Dyspnoea - Stridor 21.[slideshare.net]
  • .- ) tobacco use ( Z72.0 ) Diseases of the respiratory system J38 ICD-10-CM Diagnosis Code J38 Diseases of vocal cords and larynx, not elsewhere classified 2016 2017 2018 2019 Non-Billable/Non-Specific Code Type 1 Excludes congenital laryngeal stridor[icd10data.com]
Stridor
  • Massive stridor on inspiration is the key symptom. Indirect laryngoscopy confirms the diagnosis. Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytenoid joint.[ncbi.nlm.nih.gov]
  • Hypocalcaemic stridor and infantile nutritional rickets. BMJ 1995;310(6971):48-9. Srivastava A, Ravindran V. Stridor secondary to hypocalcaemia in the elderly: an unusual presentation. Eur J Intern Med 2008;19(3):219-20. Epub 2007 Sep 19.[signavitae.com]
  • Symptoms include respiratory distress with stridor. The situation often necessitates emergent reintubation or tracheostomy. Keyword history 75%/2014 64%/2011 Sources Atlee: Complications in Anesthesia, 2nd ed. 2006. Chapter 204.[openanesthesia.org]
  • . • Clinical features : - Dyspnoea - Stridor 21.[slideshare.net]
  • .- ) tobacco use ( Z72.0 ) Diseases of the respiratory system J38 ICD-10-CM Diagnosis Code J38 Diseases of vocal cords and larynx, not elsewhere classified 2016 2017 2018 2019 Non-Billable/Non-Specific Code Type 1 Excludes congenital laryngeal stridor[icd10data.com]
Cough
  • Associated comorbidities: weakness, poor cough (lung function), advanced age Dysphonia (hoarseness) Unilateral vocal cord paralysis may cause 'glottic incompetence' if the paralyzed vocal cord is laterally positioned and lacks sufficient tone to provide[medicine.uiowa.edu]
  • -Inability to cough: due to inability of V.C. to meet which results in retention of secretions in the chest. -Bronchopneumonia- due to repeated aspirations & retention of secretions. 27. Treatment: 1. Tracheostomy 2. Epiglottopexy 3.[slideshare.net]
  • Healthy function of this nerve is needed for breathing, speaking, coughing, and swallowing. The RLN goes into the chest cavity and curves back into the neck until it reaches your voice box.[entnet.org]
  • Three hours post operatively, the patient was noted to have a breathy voice and developed cough on taking oral feeds. She had no breathing difficulty or stridor.[austinpublishinggroup.com]
  • As the vocal cords migrate toward the midline, the voice (and cough) improves, while the airway worsens. Clinicians should not mistake a good voice and cough as signs of a functioning larynx, especially in a patient with stridor.[emedicine.medscape.com]
Orthostatic Hypotension
  • [Article in German] Abstract The Shy-Drager syndrome causes symptoms of multiple nervous atrophy and orthostatic hypotension. This rare disease was diagnosed in a 40-year-old man after he developed an acute bilateral vocal fold paresis.[ncbi.nlm.nih.gov]
Ankylosis
  • Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytenoid joint. Moreover, in many cases, laryngeal electromyography yields reliable prognosis of clinical outcome.[ncbi.nlm.nih.gov]
  • Cricoarytenoid Fixation: caused by joint subluxation or dislocation with ankylosis. - Joint fixation by rheumatoid arthritris or gout. 2. Laryngeal malignancy:[slideshare.net]
  • Palpation of the arytenoids revealed cricoarytenoid (CA) joint ankylosis. Close inspection of the interarytenoid space demonstrated interarytenoid scar. This condition is posterior glottic stenosis (PGS).[emedicine.medscape.com]
Paresis
  • This rare disease was diagnosed in a 40-year-old man after he developed an acute bilateral vocal fold paresis. The respiratory failure required an immediate tracheotomy. The Shy-Drager syndrome can include cranial nerve lesions.[ncbi.nlm.nih.gov]
  • Vocal cord paralysis and paresis can result from abnormal function of the nerves that control your voice box muscles (laryngeal muscles).[entnet.org]
  • . • Vocal cord Paresis : defined as partial interruption of nerve impulse resulting in weak or abnormal movement of laryngeal muscles. 3. • Vocal cord paresis/paralysis can occur at any age or sex. • Effect of VC paralysis may vary & depends on the patient[slideshare.net]
  • We postulate that the cause was attributed to bilateral vocal cord paresis due to the use of the intraoperative nerve monitoring (IONM) whose high setting throughout the surgery was overlooked.[casereports.bmj.com]
  • This is called “paresis”, and because the vocal fold retains some ability to move, can be especially challenging to diagnose. Vocal fold paresis is one of the most commonly overlooked diagnoses in laryngology.[voice.weill.cornell.edu]

Workup

  • Although a small number of conditions account for most cases of vocal cord immobility, this article presents a comprehensive differential diagnosis, followed by the clinical presentations, diagnostic workup, and treatment options.[emedicine.medscape.com]
Polyps
  • Peritonsillar abscess J37 Chronic laryngitis and laryngotracheitis J37.0 Chronic laryngitis J37.1 Chronic laryngotracheitis J38 Diseases of vocal cords and larynx, not elsewhere classified J38.0 Paralysis of vocal cords and larynx J38.00 …… unspecified J38.1 Polyp[icd10data.com]
  • His surgical history included a septal reconstruction with an uvulopalatopharyngoplasty because of obstructive sleep apnoea and a microlaryngoscopy for resection of a single right vocal cord polyp 6 years before.[journals.lww.com]

Treatment

  • Cordectomy was undertaken in one patient for treatment of vocal cord paralysis in adducted position, and no surgical treatment was performed in case of paralysis in abducted position.[jstage.jst.go.jp]
  • Experience of the optic neuritis treatment trial. Neurology 1997:49:1404-1413. ‏[books.google.com]
  • Treatment approaches for unilateral adductor paralysis include a large range of behavioral, surgical, and combination approaches. The most serious form of vocal fold paralysis is a bilateral impairment.[bbivar.com]
  • In most circumstances, your child may need no immediate treatment if she is diagnosed with one-sided vocal cord paralysis.[chop.edu]
  • . • Treatment : Generally no treatment is required. 20.[slideshare.net]

Prognosis

  • Moreover, in many cases, laryngeal electromyography yields reliable prognosis of clinical outcome. While unfavorable results can be predicted with high accuracy, correct prognosis of complete recovery is more difficult.[ncbi.nlm.nih.gov]
  • It has been shown that the cricothyroid muscle does not influence the functional prognosis or the position of the vocal fold in recurrent nerve paralysis ( 6 ).[academic.oup.com]

Etiology

  • Etiologies of the paralyses from both vocal folds are in large number, and sequelae from thyroid gland surgery predominates (3). Tumor diseases of the cervical and mediastinum areas are less common etiologies (3).[arquivosdeorl.org.br]
  • Etiology The etiology of BVFI in the study population, in decreasing order of incidence, included thyroid disease or associated surgery, intubation-related injury, congenital, central neurological disorders, autoimmune disease, and surgery or cancer of[journalotohns.biomedcentral.com]
  • Bilateral vocal fold immobility can be a result of Trauma Unknown etiology Stroke Surgery, including spine, esophagus, or thyroid surgery Treatments for bilateral vocal fold immobility include: Tracheotomy – the narrowed area is bypassed with a tracheotomy[throatdisorder.com]
  • Cricoarytenoid arthritis, which may cause fixation of the cricoarytenoid joint, must be differentiated from a neuromuscular etiology. Fixation is best documented by absence of passive mobility during rigid laryngoscopy under general anesthesia.[msdmanuals.com]

Epidemiology

  • BRLNP is rare, occurring in approx. 0.2% of thyroidectomies for benign thyroid affections. (2) Epidemiological data on late BRLNP after thyroidectomy is spares.[signavitae.com]
  • Epidemiology of vocal fold paralyses after total thyroidectomy for well-differentiated thyroid cancer in a Medicare population. Otolaryngol Head Neck Surg, 150 (2014), pp. 548-557 [29] S. Zheng, Z. Xu, Y. Wei, M. Zeng, J. He.[elsevier.es]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Although a comprehensive discussion of each of the causes is beyond the scope of this article, some principles should be emphasized.[emedicine.medscape.com]
  • Pathophysiology There are several different mechanisms of nerve injury and means of nerve regrowth ( 7 ).[academic.oup.com]
  • The most important aspect of an effective and safe surgical approach is a vast knowledge of surgical anatomy and pathophysiology in combination with meticulous handling and dissection of tissue.[ispub.com]
  • However, the pathophysiology of glottis obstruction is unique in bilateral vocal fold paralysis wherein the inspiratory flow is more adversely affected than the expiratory flow based on the Bernoulli effect [ 28 ].[journalotohns.biomedcentral.com]

Prevention

  • It is important to identify and monitor these patients to prevent confusion with regard to etiology and outcome.[laryngologyandvoice.org]
  • There was one permanent RLN palsy (0.01%) and routine IONM may have prevented one death and altered the outcome in two of the seven patients.[onlinelibrary.wiley.com]
  • Most commonly the vocal folds remain fixed in a ‘near closed’ position, preventing the breathing in and out large amounts of air. Patients complain of shortness of breath with exertion, such as walking up stairs.[throatdisorder.com]
  • The shape enables the electrode to be positioned optimally on the nerve and prevents the electrode from slipping or sliding off.[en.inomed.com]
  • Thyroidectomy: prevention of bilateral recurrent nerve palsy. Results of identification of the nerve over 23 consecutive years (1946–69) with a description of an additional safety measure. Br J Surg, 57 (1970), pp. 1-11 [14] D.H. Rice, B.[elsevier.es]

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