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Neurogenic dysphonia

Neurogenic dysphonia. Neurogenic Dysphonia: Topics. Neurology of the larynx Organizational Framework Selected Disorders Vocal fold paresis/paralysis Essential Tremor Spasmodic Dysphonia Selected Central Nervous System Disorders. UW-Madison Neuro Website. Nerve supply to Larynx.

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Neurogenic dysphonia

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  1. Neurogenic dysphonia

  2. Neurogenic Dysphonia: Topics • Neurology of the larynx • Organizational Framework • Selected Disorders • Vocal fold paresis/paralysis • Essential Tremor • Spasmodic Dysphonia • Selected Central Nervous System Disorders

  3. UW-Madison Neuro Website

  4. Nerve supply to Larynx

  5. Nerve supply to Larynx

  6. Relation of nerves to thyroid gland

  7. Neurologic Voice Disorders: A Classification Scheme • Hypoadduction • Hyperadduction • Phonatory Stability • Short term • Long term • Phonatory Incoordination/Voiced-voiceless • Mixed • Miscellaneous (Ramig & Scherer, 1992)

  8. Vocal Fold Paresis/paralysis

  9. Causes of vocal fold paralysis/paresis Central • Medullary lesions affecting nucleus ambiguus Peripheral (Vagus nerve lesions) • Disease (tumors of lung, esophageal, thyroid) • Surgical trauma (thyroid, anterior cervical spine, lung resection, carotid artery Sx) • Nonsurgical trauma (penetrating wounds, blunt trauma) • Neurological disease (Guillain-Barre, ALS) • Peripheral neuropathy Idiopathic • Diagnosis of exclusion • Often presumed viral

  10. Anatomical level Pharyngeal n. Superior laryngeal n. Recurrent laryngeal n. Degree of involvement

  11. Laterality Unilateral Bilateral Degree of mobility Paresis Weakness Hypomobility Paralysis Immobility Degree of Nerve Injury (Rubin & Sataloff, 2007) 1°: Neurapraxia and full recovery 2°: Wallerian degeneration but full recovery 3°: Misdirected neural regeneration 4°: Scarring which may block regeneration 5°: Complete nerve transection Degree of involvement

  12. Signs and symptoms • Breathy voice • Hoarse voice • Low volume • Limited pitch range & pitch control problems • Increased effort and frequent vocal fatigue • Weak cough • Aspiration of liquids during swallowing

  13. Recurrent laryngeal nerve Typically affects ad/abductors Paramedian position common Bilateral impairment can cause airway problems Superior laryngeal nerve Deceptively normal position Superior + Recurrent laryngeal nerve Vocal fold(s) may be more abducted than in recurrent only May affect vertical position of vocal fold making compensation more difficult *Reinnervation pattern will influence vocal fold position Median Paramedian Abduction Vocal fold position

  14. Unilateral Right Recurrent N. paralysis: Inspiration

  15. Unilateral Right Recurrent N. paralysis: Phonation

  16. Videoendoscopic evaluation Goals • Assess vocal fold mobility • Determine degree of glottic closure • Relate mobility to voice production • Differentiate level of involvement • Identify/rule out compensatory behaviors • supraglottic compression • Differentiate paresis/paralysis from CA joint immobility*

  17. CA joint immobility • Ankylosis (fixation)/Dislocation • Presumed etiology • arthritis • trauma • joint disease • Appearance • Similar to vocal fold paralysis Differentiating paralysis from ankylosis/dislocation • Can be difficult to differentiate with indirect laryngoscopy • Reduced passive mobility under direct laryngoscopy • Paralysis • Mobility normal during passive movement • Affected side “jostles” when contralateral arytenoid hits it • Ankylosis/dislocation • Reduced mobility during passive movement • Affected side does not “jostle” when contralateral arytenoid hits it

  18. Videoendoscopic evaluation Phonatory Maneuvers • Seek to isolate adductors, abductors, tensors • Abduction: • sniffing/quick inhalation • on/off voicing • Adduction: • voicing at various levels • on/off voicing • Sharp cough

  19. Videoendoscopic evaluation Phonatory Maneuvers • Tensor: • glissando/pitch gliding • Asymmetries often revealed during repetitive & alternating activities

  20. Superior laryngeal nerve damage • Tricky to identify • Controversial list of laryngoscopic signs • Sluggish adduction • Asymmetry during glissando • Laryngeal tilt toward weak side with voluntary increase in pitch • Posterior commissure rotates toward weak side • Obliquely shaped glottis due to rotation • Lower vocal fold height on involved side • Bowed, thin and shortened vocal fold • Recent evidence: “movement” of petiole of epiglottis toward affected side during phonation

  21. Video Examples

  22. Diagnosis: Additional tests • Electromyography (EMG)

  23. Treatment Issues • Voice Quality • Aspiration • Airway

  24. Treatment • Behavioral • Surgical • Recovery can occur up to 6-12 months post-insult • Permanent procedures need to be delayed

  25. Behavioral Management • Optimizing voice production and reduce maladaptive behaviors • Tension reduction • Facilitating techniques • Treatment for “hypofunction”* • Half swallow • Pushing • Head turn • Manual compression *need to be very careful not to create hyperfunction

  26. Surgical Management: • Medialization procedures • Reinnervation Experimental procedures • Laryngeal pacing

  27. Surgical Management:Medialization procedures • Intrafold injections • Implantation (Isshiki Type I thyroplasty) • Arytenoid Adduction

  28. Intrafold Injection

  29. Intrafold Injection • Injection of material to increase vocal fold bulk ~ increase glottic closure • Materials include • Gelfoam (temporary) • Teflon (problems with fibrosis and migration) • Autologous fat (will resorb) • Autologous & bovine collagen (slower to resorb) • Dermis, fascia etc

  30. Intrafold Injection Surgical Approaches • Peroral • Direct • Indirect • Percutaneous (through cricothyroid space)

  31. Implantation • Placing/implanting solid material just medial to thyroid cartilage thus pushing the vocal fold medially • Type I thyroplasty • Materials include • Silicone • Gore-Tex • Cartilage

  32. Arytenoid Adduction

  33. Reinnervation • Prevent atrophy and unfavorable reinnervation • Possibilities • Ansa cervicalis • phrenic n. • hypoglossal n. • sympathetics

  34. Bilateral Involvement • When airway problems are an issue Options • Tracheotomy • Cordotomy • Arytenoidectomy • Thryoplasty (Lateralization) • Dennervation/Reinnervation

  35. Bilateral Involvement • When airway is OK and voice is an issue Options • Medialization procedures • Unilateral or bilateral

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