Management of Laryngeal Nerve Injuries · Management of Laryngeal Nerve Injuries Mark S. Courey,...

10/24/2008

1

OHNS Website: http://ohns.ucsf.edu

Management of Management of Laryngeal Nerve InjuriesLaryngeal Nerve Injuries

Mark S. Courey, M.D. Mark S. Courey, M.D. Professor, Otolaryngology/HNSProfessor, Otolaryngology/HNS

Director, Division of LaryngologyDirector, Division of LaryngologyOHNS Website: http://ohns.ucsf.edu

Type of Laryngeal Nerve InjuriesType of Laryngeal Nerve Injuries

1.1. Recurrent laryngeal nerve (RLN)Recurrent laryngeal nerve (RLN)−− Motor supply Motor supply

�� Vocal foldVocal fold�� Pharyngeal wallPharyngeal wall

−− Sensory supply to pharynx and larynxSensory supply to pharynx and larynx

2.2. Superior laryngeal nerve (SLN)Superior laryngeal nerve (SLN)−− Motor supply cricothyroid muscleMotor supply cricothyroid muscle

�� External branch (pitch control)External branch (pitch control)−− Sensory to larynx above the vocal foldSensory to larynx above the vocal fold


Intrinsic Laryngeal MusculatureIntrinsic Laryngeal Musculature

Controls VF MovementControls VF Movement

●●Adduction Adduction –– ClosureClosure−− ThyroarytenoidThyroarytenoid−− Lateral cricoarytenoidLateral cricoarytenoid−− InterarytenoidiusInterarytenoidius

●●Abduction Abduction –– OpeningOpening−− Posterior cricoarytenoidPosterior cricoarytenoid

●●TensionTension−− CricothyroidCricothyroid


Intrinsic Laryngeal AnatomyIntrinsic Laryngeal Anatomy

Vallecula Epiglottis

Aryepiglotticfold

Arytenoidcomplex

Lateral pharyngeal wall

Pyriform sinus

Esophageal inlet

False vocal fold

True vocal fold

Interarytenoidregion

10/24/2008

2


Laryngeal Function Laryngeal Function -- VoiceVoice●● Intrinsic laryngeal muscles approximate vocal foldsIntrinsic laryngeal muscles approximate vocal folds

●● Exhaled air from lungs creates vocal fold vibrationExhaled air from lungs creates vocal fold vibration−− Ability of vocal folds to achieve “preAbility of vocal folds to achieve “pre--phonatory configuration”phonatory configuration”−− Pliability of vocal fold mucosa Pliability of vocal fold mucosa –– “cover”“cover”


Laryngeal Function Laryngeal Function -- SwallowingSwallowing

●● Extrinsic laryngeal muscles provide laryngeal elevationExtrinsic laryngeal muscles provide laryngeal elevation−− Pharyngeal constrictorsPharyngeal constrictors−− Cervical strap musclesCervical strap muscles




●● Larynx is pulled up and forward as food bolus is directed Larynx is pulled up and forward as food bolus is directed through the pyriform sinus through the pyriform sinus -- “lateral channels”“lateral channels”




●● Larynx is pulled up and forward as food bolus is directed Larynx is pulled up and forward as food bolus is directed through the pyriform sinus through the pyriform sinus -- “lateral channels”“lateral channels”

●● Vocal fold closure occurs late during swallowVocal fold closure occurs late during swallow−− EMG findingEMG finding−− Lessens aspiration of retained food particlesLessens aspiration of retained food particles

10/24/2008

3


Types of InjuryTypes of Injury

●● VoiceVoice−− Acute Acute –– often not noticed and thought secondary to often not noticed and thought secondary to

intubation traumaintubation trauma−− ChronicChronic

�� Mild breathy voiceMild breathy voice�� Vocal Fatigue Vocal Fatigue –– voice wears out with usevoice wears out with use

�� Slight reduction in vocal range noted in singing voiceSlight reduction in vocal range noted in singing voice

●● Physical findingsPhysical findings−− Vocal fold mobileVocal fold mobile−− Larynx may “tilt” to side of injuryLarynx may “tilt” to side of injury

Unilateral SLN



●● VoiceVoice−− Acute Acute –– breathy dysphonia and loss of rangebreathy dysphonia and loss of range−− Chronic Chronic –– low pitched speaking voice with inability low pitched speaking voice with inability

to elevate pitch and cannot singto elevate pitch and cannot sing

●● Physical findingsPhysical findings−− Vocal folds do not elongateVocal folds do not elongate−− Abduction/adduction normalAbduction/adduction normal

Bilateral SLN


Endoscopy Endoscopy –– Bilateral SLN InjuryBilateral SLN Injury

Acute Chronic


Mechanism of SLN InjuryMechanism of SLN Injury

●● Transection during dissection of superior pole vesselsTransection during dissection of superior pole vessels1.1. Skeletonize superior pole vessels by dissecting on glandSkeletonize superior pole vessels by dissecting on gland2.2. Identify nerve prior to taking superior vesselsIdentify nerve prior to taking superior vessels

10/24/2008

4


Mechanism of SLN InjuryMechanism of SLN Injury

●● Transection during dissection of superior pole vessels Transection during dissection of superior pole vessels 1.1. Skeletonize superior pole vessels by dissecting on glandSkeletonize superior pole vessels by dissecting on gland2.2. Identify nerve prior to taking superior vesselsIdentify nerve prior to taking superior vessels

●● Minimally invasive surgical techniquesMinimally invasive surgical techniques−− Superior pole vessels taken in larger groupsSuperior pole vessels taken in larger groups−− May be associated with a higher incidence of SLN injuryMay be associated with a higher incidence of SLN injury−− SLN should be visualizedSLN should be visualized



●● VoiceVoice−− Acute Acute –– breathy voice with fatiguebreathy voice with fatigue−− ChronicChronic

�� Significant voice change Significant voice change –– high or low pitch increased high or low pitch increased roughness and breathinessroughness and breathiness

�� Near normal Near normal –– 30%30%

●● Physical findingsPhysical findings−− Abduction/adduction absent one vocal foldAbduction/adduction absent one vocal fold

Unilateral RLN


Endoscopy Endoscopy –– Unilateral RLN InjuryUnilateral RLN Injury

Acute Chronic



●● VoiceVoice−− Acute Acute –– breathy voice, loss of range and vocal fatiguebreathy voice, loss of range and vocal fatigue−− Chronic Chronic –– strain to near normal voicestrain to near normal voice

●● Airway considerationsAirway considerations−− Acute Acute –– flaccid paralysis may allow adequate respirationflaccid paralysis may allow adequate respiration−− Chronic Chronic –– patients adapt lifestyle to marginal airwaypatients adapt lifestyle to marginal airway

●● PhysicalPhysical−− Bilateral loss of abductionBilateral loss of abduction

Bilateral RLN

10/24/2008

5


Endoscopy Endoscopy –– Bilateral RLN InjuryBilateral RLN Injury

Acute Chronic


Mechanism of RLN InjuryMechanism of RLN Injury

●● Dissection of inferior thyroid arteryDissection of inferior thyroid artery−− TransectionTransection−− Pressure/stretchPressure/stretch


Management StrategiesManagement Strategies

●● Best avoidedBest avoided−− Incidence of RLN injury 0.3Incidence of RLN injury 0.3-- 3%3%−− Incidence of SLN injury unkownIncidence of SLN injury unkown

Acute Injuries



●● Noted nerve injury in ORNoted nerve injury in OR−− Suture ends together Suture ends together –– increases likelihood of increases likelihood of

developing vocal tone and voluntary EMG activity developing vocal tone and voluntary EMG activity

Acute Injuries

10/24/2008

6



●● Noted nerve injury in ORNoted nerve injury in OR−− Suture ends together Suture ends together –– increases likelihood of increases likelihood of

developing vocal tone and voluntary EMG activity developing vocal tone and voluntary EMG activity −− Crumley R, Repair of the recurrent laryngeal nerve, Crumley R, Repair of the recurrent laryngeal nerve,

Otolaryngol Clin North Am. 1990 Jun;Otolaryngol Clin North Am. 1990 Jun;2323((33):):553553--6363..−− Green DC, Ward PH, The management of the Green DC, Ward PH, The management of the

divided laryngeal nerve, Laryngoscope. 1990 divided laryngeal nerve, Laryngoscope. 1990 Jul;Jul;100100((77):):779779--8282. .

Acute Injuries



●● Personal experience with EMG in the Personal experience with EMG in the management of vocal fold paralysismanagement of vocal fold paralysis−− Unpublished study in 20 patients undergoing thryoplasty Unpublished study in 20 patients undergoing thryoplasty

for management of chronic UVPfor management of chronic UVP�� EMG performed with needles placed under direct EMG performed with needles placed under direct

visualization in ORvisualization in OR�� 18/20 with active voluntary potentials18/20 with active voluntary potentials

−− Mirrors current clinical experience in performing 3 Mirrors current clinical experience in performing 3 –– 5 5 laryngeal EMG/month with certified electromyographerlaryngeal EMG/month with certified electromyographer

Acute Injuries



●● In the recovery room In the recovery room −− Elies W Elies W et alet al, Possibilites and limits of reconstructive , Possibilites and limits of reconstructive

surgery of the RLN, Laryngorhinootology 1992 surgery of the RLN, Laryngorhinootology 1992 Jan;71(1):35Jan;71(1):35--8.8.�� Suggest acute reSuggest acute re--exploration may allow decompression exploration may allow decompression

and return of functionand return of function�� Small study on 10 patientsSmall study on 10 patients�� Little support Little support

Acute Injuries



●● In the recovery room In the recovery room −− Immediate reImmediate re--exploration exploration –– little support little support

�� Unilateral paralysis usually observedUnilateral paralysis usually observed

−− Acute needs for airway management in bilateral Acute needs for airway management in bilateral paralysisparalysis�� ReRe--intubateintubate�� TracheotomyTracheotomy�� Suture lateralizationSuture lateralization

Acute Injuries

10/24/2008

7



●● In the recovery room In the recovery room –– Airway managementAirway management−− ReintubationReintubation

�� Friederich T Friederich T et alet al, Therapeutic management of postoperatively , Therapeutic management of postoperatively diagnosed bilateral recurrent laryngeal nerve paralysis, Zentralbl diagnosed bilateral recurrent laryngeal nerve paralysis, Zentralbl Chir. 2000;125(2):137Chir. 2000;125(2):137--43 43

�� IncidenceIncidence▪▪ Transient bilateral paralysis up to 5.9% dependent on indication for Transient bilateral paralysis up to 5.9% dependent on indication for

surgerysurgery▪▪ Permanent bilateral paralysis 1.9%Permanent bilateral paralysis 1.9%▪▪ Presentation varied from airway obstruction to only voice complaintsPresentation varied from airway obstruction to only voice complaints▪▪ Rate of recovery unpredictableRate of recovery unpredictable

Acute Injuries



●● In the recovery room In the recovery room –– Airway managementAirway management−− Reintubation Reintubation –– little support little support −− TracheotomyTracheotomy−− Temporary suture lateralizationTemporary suture lateralization

� Lichtenberger G . Prevention and management of bilateral vocal Prevention and management of bilateral vocal cord paralysis by and after thyroid surgery. Otolaryngol Pol. cord paralysis by and after thyroid surgery. Otolaryngol Pol. 2004;2004;5858((11):):165165

Acute Injuries



Bilateral Vocal Fold Paralysis - Acute Airway

Acute – 3 weeks out Suture lateralization



●● During the postoperative visitDuring the postoperative visit−− ReRe--assureassure−− ReferRefer

−− Role of ElectromyographyRole of Electromyography�� UnprovenUnproven

−− Management of voice and swallowing difficultiesManagement of voice and swallowing difficulties

Acute Injuries

10/24/2008

8


EvaluationEvaluation

●● Evaluation of voiceEvaluation of voice−− Perceptual analysis by trained observerPerceptual analysis by trained observer−− Vocal range, quality, power and enduranceVocal range, quality, power and endurance

●● Laryngeal EMGLaryngeal EMG−− DiagnosticDiagnostic−− Guides expectations in cases with partial functionGuides expectations in cases with partial function


Management Management –– Speech TherapySpeech Therapy

●● Eliminate/Reduce maladaptive Eliminate/Reduce maladaptive compensatory behaviorscompensatory behaviors

●● Pitch retrainingPitch retraining−− Success is limitedSuccess is limited

SLN Injury


Management Management –– Speech TherapySpeech Therapy

●● Eliminate/Reduce maladaptive compensatory behaviorsEliminate/Reduce maladaptive compensatory behaviors

●● Vocal function exerciseVocal function exercise−− Sustained vowel sounds with appropriate airflowSustained vowel sounds with appropriate airflow−− Strengthen vocal foldsStrengthen vocal folds−− Suggested to aid in return of functionSuggested to aid in return of function

�� Empiric evidence is limitedEmpiric evidence is limited

RLN Injury


Management Management –– Surgery Surgery

●● IndicationsIndications−− Breathy dysphonia preventing patient from workingBreathy dysphonia preventing patient from working−− AspirationAspiration−− Need to improve cough for pulmonary functionNeed to improve cough for pulmonary function

●● Injection laryngopalsty with temporary agentInjection laryngopalsty with temporary agent−− CollagenCollagen−− Glycerin basedGlycerin based

Acute Unilateral RLN

10/24/2008

9


Injection Laryngoplasty for Injection Laryngoplasty for Unilateral Vocal Fold ParalysisUnilateral Vocal Fold Paralysis

●●Historically Historically -- Injection into paraglottic space Injection into paraglottic space for the management of unilateral paralysis for the management of unilateral paralysis ––“…to restore the ability to laugh..”“…to restore the ability to laugh..”


Limitations of Injection LaryngoplastyLimitations of Injection Laryngoplasty

●● Ability to restore preAbility to restore pre--phonatory glottic configurationphonatory glottic configuration


Injection SubstancesInjection Substances

●●Teflon®Teflon®●●FatFat●●FasciaFascia●●CollagenCollagen

−− Cymetra®Cymetra®−− Cosmoplast ®Cosmoplast ®−− Zyderm ®Zyderm ®

●●Calcium hydroxylapatiteCalcium hydroxylapatite●●Hyaluronic Acid Hyaluronic Acid -- Radiese ®Radiese ®●●Glycerine Glycerine –– Radiese Voice Gel ®Radiese Voice Gel ®


Percutaneous Injection TechniquesPercutaneous Injection Techniques

10/24/2008

10


Percutaneous Injection TechniquesPercutaneous Injection Techniques


Direct Microlaryngoscopy Injection Direct Microlaryngoscopy Injection TechniquesTechniques

●● Microscopic guidanceMicroscopic guidance●● Placement Placement

−− Deep to vocal ligamentDeep to vocal ligament−− Membranous vocal foldMembranous vocal fold


Direct Microlaryngoscopic Injection Direct Microlaryngoscopic Injection TechniquesTechniques


Direct Microlaryngoscopic Injection Direct Microlaryngoscopic Injection TechniquesTechniques

10/24/2008

11



●● IndicationsIndications−− DysphoniaDysphonia−− Failure of speech therapyFailure of speech therapy

●● Injection laryngoplasty with “Injection laryngoplasty with “permanentpermanent” agent” agent−− Similar to temporary agentSimilar to temporary agent

Chronic Unilateral RLN



●● IndicationsIndications−− DysphoniaDysphonia−− Failure of speech therapyFailure of speech therapy

●● Injection laryngoplasty with “permanent” agentInjection laryngoplasty with “permanent” agent−− Similar to temporary agentSimilar to temporary agent

●● Open type 1 thryoplasty with or without arytenoid Open type 1 thryoplasty with or without arytenoid adductionadduction

Chronic Unilateral RLN


Considerations for Successful SurgeryConsiderations for Successful Surgery

1.1. Laryngeal anatomy and physiology for voiceLaryngeal anatomy and physiology for voice−− Vocal fold resting positionVocal fold resting position−− Neurologic toneNeurologic tone

2.2. Patient vocal behaviorsPatient vocal behaviors−− DesirableDesirable−− UndesirableUndesirable


Considerations for Successful SurgeryConsiderations for Successful Surgery1. Lary ngeal anatom y and phy sio logy for v oice2. Patient v ocal behav iors

3.3. SpeechSpeech--Language Pathology assistanceLanguage Pathology assistance−− Preoperative Preoperative

�� Counseling to set realistic goalsCounseling to set realistic goals�� Therapy to reduced hyperfunction Therapy to reduced hyperfunction –– “unload”“unload”

−− Postoperative therapyPostoperative therapy

4.4. Surgical techniquesSurgical techniques−− Continuous laryngeal visualizationContinuous laryngeal visualization−− Vocal process Vocal process

�� Position 3Position 3--dimensionaldimensional�� Stabilization with arytenoid adductionStabilization with arytenoid adduction

10/24/2008

12


Laryngeal Function after Unilateral Laryngeal Function after Unilateral ParalysisParalysis

●● Dependent on ability to achieve closure in three Dependent on ability to achieve closure in three dimensionsdimensions−− Horizontal Horizontal −− VerticalVertical

●● Asymptomatic Asymptomatic -- 30%30%●● Patients with poor closure in any dimension will have Patients with poor closure in any dimension will have

greater symptomsgreater symptoms−− Breathy dysphoniaBreathy dysphonia−− Loss of glottic valvingLoss of glottic valving−− AspirationAspiration


Patient SelectionPatient Selection

●● Non Non –– anxiousanxious

●● Cervical mobilityCervical mobility

●● Voice characteristicsVoice characteristics−− Breathy not strainedBreathy not strained−− Patient should be “unloaded” by SLP Patient should be “unloaded” by SLP

prior to interventionprior to intervention

“Ideal”“Ideal”


Operative SetOperative Set--upup

●● Suspended fiberoptic laryngoscopeSuspended fiberoptic laryngoscope

●● Video towerVideo tower

●● Turn patient 180Turn patient 180oo from anesthesiafrom anesthesia

●● Head of bed elevationHead of bed elevation

●● Neck extensionNeck extension



10/24/2008

13




AnesthesiaAnesthesia

●● Do not over sedateDo not over sedate

●● Infusion/dripInfusion/drip−− Dexmetomadine Dexmetomadine –– short acting alphashort acting alpha--2 agonist2 agonist

�� Reduce anxietyReduce anxiety�� Minimal sedationMinimal sedation

−− Propofol Propofol –– short acting potentiation of GABAshort acting potentiation of GABA--A receptorA receptor�� Reduces anxietyReduces anxiety�� SedatingSedating�� Causes apneaCauses apnea

Sedation Sedation -- SystemicSystemic


AnesthesiaAnesthesia

●● Do not inject to toxic levelsDo not inject to toxic levels

●● Xylocaine 1% with Epinephrine 1:100,000Xylocaine 1% with Epinephrine 1:100,000−− Short acting Short acting –– 1 hour1 hour

Mixed 1 to 1 withMixed 1 to 1 with

●● Marcaine ½% with Epinephrine 1:200,000Marcaine ½% with Epinephrine 1:200,000−− Longer acting up to 4 hoursLonger acting up to 4 hours

Analgesia Analgesia -- LocalLocal


Surgical InterventionSurgical Intervention

●● GoalsGoals−− MedializeMedialize the immobile vocal fold in the the immobile vocal fold in the horizontalhorizontal

planeplane

−− Adjust the Adjust the heightheight of the vocal fold in the of the vocal fold in the verticalverticalplaneplane

●● Improve glottic closureImprove glottic closure

●● ProceduresProcedures−− Medialization Laryngoplasty (ML)Medialization Laryngoplasty (ML)−− Arytenoid Adduction (AA)Arytenoid Adduction (AA)

10/24/2008

14


Surgical InterventionSurgical Intervention

●● Type I thyroplasty with carved silastic block Type I thyroplasty with carved silastic block

−− Adjusts Adjusts medialmedial//horizontalhorizontal positionposition

−− Awake with local anesthesiaAwake with local anesthesia

−− Flexible endoscopic visualization of larynxFlexible endoscopic visualization of larynx

●● Arytenoid Adduction Arytenoid Adduction

−− Adjusts Adjusts verticalvertical positionposition

−− If voice results and laryngeal configuration are not If voice results and laryngeal configuration are not adequate from medialization aloneadequate from medialization alone


Intraoperative Monitoring of Vocal Fold Intraoperative Monitoring of Vocal Fold PositionPosition●● ContinuousContinuous

●● Provides visual feedback to Provides visual feedback to surgeon surgeon −− Patients cannot always Patients cannot always

cooperatecooperate−− Allows identification of vocal fold Allows identification of vocal fold

levellevel−− Allows observation of Allows observation of

supraglottic configuration during supraglottic configuration during phonationphonation


Medialization LaryngoplastyMedialization Laryngoplasty


10/24/2008

15

OHNS Website: http://ohns.ucsf.edu OHNS Website: http://ohns.ucsf.edu


Cartilage

TA Muscle

Perichondrium

Paraglottic Space

TA Muscle Fascia


10/24/2008

16


InstrumentationInstrumentation


Preparing the ImplantPreparing the Implant


Medialization LaryngoplastyMedialization Laryngoplasty

10/24/2008

17


Arytenoid AdductionArytenoid Adduction



10/24/2008

18


Medialization Laryngoplasty with Medialization Laryngoplasty with Arytenoid AdductionArytenoid Adduction

PreoperativePreoperative


Medialization Laryngoplasty with Medialization Laryngoplasty with Arytenoid AdductionArytenoid Adduction

PostoperativePostoperative


ConclusionsConclusions

●● Injury is best avoidedInjury is best avoided

●● Recognition in ORRecognition in OR−− Primary repair if possiblePrimary repair if possible

●● Little support for reLittle support for re--explorationexploration

●● Airway management in setting of acute obstructionAirway management in setting of acute obstruction−− TracheotomyTracheotomy−− Suture lateralizationSuture lateralization


ConclusionsConclusions

●● Expectant management for nerve recoveryExpectant management for nerve recovery−− 30% develop enough return of tone that voice is adequate30% develop enough return of tone that voice is adequate

●● Surgical management of acute injury is indicated when Surgical management of acute injury is indicated when voice demands are significantvoice demands are significant

●● Outcomes of management for chronic unilateral paralysis Outcomes of management for chronic unilateral paralysis with vocal repositioning techniques are good to excellentwith vocal repositioning techniques are good to excellent

Management of Laryngeal Nerve Injuries · Management of Laryngeal Nerve Injuries Mark S. Courey,...

Documents

Transcript of Management of Laryngeal Nerve Injuries · Management of Laryngeal Nerve Injuries Mark S. Courey,...