Recurrent palsy

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Classification according to ICD-10
G52.2 Diseases of the vagus nerve [X. Cranial nerve]
J38.0 Paralysis of the vocal folds and the larynx
ICD-10 online (WHO version 2019)

Recurrent palsy is the medical term for damage to the recurrent laryngeal nerve , which directs the movement instructions for the internal larynx muscles from the brain to the larynx and is therefore important for vocalization and breathing.

Anatomy and Introduction

The recurrent laryngeal nerve got its name due to its anatomical course: it arises in the neck from the vagus nerve (10th cranial nerve), extends to the edge of the chest on the right and into the chest on the left, then turns around an artery and runs back to the larynx at the neck ( lat. recurrere ). Its function is in particular the transmission of nerve signals to the muscles, which enable regulation of the position and tension of the vocal folds and thus voice formation, but also the transmission of nerve signals from the lining of the larynx to the brain.

Unilateral damage to the nerve manifests itself in hoarseness as a result of impaired mobility of the vocal cord / vocal fold. If such damage occurs on both sides, the vocal folds obstruct the flow of breathable air and the patient suffers from difficult breathing.

Since the nerve passes the thyroid gland in the immediate vicinity, the most common damage is observed in thyroid or neck operations. In order to avoid damage, the nerve is specifically sought out during these operations. Even better is neuromonitoring , in which even the smallest irritations of the nerve are made visible by measuring electrical muscle impulses.

Due to the high risk potential of neck operations, an examination of the vocal cord mobility by an ENT doctor or phoniatrist is carried out regularly after the operation .

In addition to thyroid operations, there are a number of possible causes such as heart operations, intervertebral disc operations on the cervical spine, tumors of the thyroid gland, the upper lobes of the lungs, the esophagus or other organs, as well as nerve damage after viral infections.

Definition / classification

Position of the vocal folds during respiration and phonation

The term recurrent palsy is often used synonymously by the doctor for a partial or complete standstill of one or both vocal folds. From a medical point of view, this can be misleading, as scarring on the larynx after long-term ventilation, injuries (luxations) and inflammation of the cartilage joint (rheumatism), but also the growth of a tumor into the vocal fold can lead to a standstill. Therefore, further examinations must be carried out by the ENT doctor or phoniatrist before one can speak of recurrent palsy. Just because z. B. in the case of tumor diseases result in further consequences, every (unclear) vocal cord arrest should be clarified.

Recurrent palsy is often referred to as vocal cord or vocal cord paralysis.

Vocal cord arrest can occur on one or both sides. The paralyzed vocal fold can stand still in various positions. It can be in the middle (median), next to the middle (paramedian, most common) or, less often, further to the side (intermediate or lateral).

The paralysis of the vocal folds may be flaccid or, as in the majority of cases, taut (i.e., with muscle tension retained). Many paralyzes are initially flabby and become taut over time. The cause is considered to be a disordered regrowth of the nerve from the damage site into the inner larynx muscles. This usually leads to tension, but not to a return of movement of the vocal folds, which is commonly described as synkinesia.

Symptoms

The main symptoms differ in unilateral and bilateral paresis.

The unilateral recurrent palsy caused by the incomplete closure of the vocal folds during the vocalization hoarseness. This can be recognized by a soft, breathy voice that cannot be increased. In addition, there is shortness of breath when speaking (because air escapes unused during voice training). Breathing itself is usually only impaired by an unfavorable position of the paralyzed vocal fold, since the opening of the other, the healthy vocal fold, is sufficient at rest and with light stress. If the nerve of origin ( vagus nerve ) is also affected, swallowing errors and swallowing problems can result.

If there is recurrent palsy on both sides, the remaining glottis is extremely narrow when you inhale and exhale. In addition, the powerless vocal folds are sucked in even further by the breath flow ( Bernoulli effect ). The flow of breathable air is often significantly impeded. This causes breathlessness, especially during exercise, respiratory infections and not infrequently also during sleep, as well as breathing noises that can be heard when breathing in and out ( stridor ). The patients often snore very loudly, sometimes with dangerous pauses in breathing ( sleep apnea ). In extreme cases, a tracheostomy tube is required in the case of bilateral paralysis. This vital measure is perceived by the patients as social stigmatization, from which they also suffer. Due to the reduced air exchange between the lungs and the environment, those affected on both sides often have problems with shortness of breath. In the case of additional illnesses, such as the flu, this can cause severe shortness of breath, especially in those affected on both sides. Laughter or an emotional situation can also cause shortness of breath. Those affected usually suffer from poor sleep quality and sometimes need sleep breaks during the day. Due to the constant insufficient supply of air, diseases of the cardiovascular system can occur as a result (e.g. high blood pressure). Muscle pain is less common and is probably also related to inadequate breathing. There is also a strong loss of physical performance, especially in the case of bilateral recurrent paralysis. Very often those affected are severely restricted in everyday life. Most patients with bilateral recurrent palsy are long-term or even permanently unable to work.

causes

root cause percentage distribution
Thyroid surgery (goiter) 35-40%
Idiopathic 30-35%
Tumor infiltration from other parts of the body 30%
Viral
trauma

Recurrent palsy can have many causes. The cause cannot always be proven. Such idiopathic pareses often affect the entire nerve of origin (vagus nerve). Viral infections of the nerve that cannot be detected or reactivation of existing viruses (mostly zoster / chickenpox virus) are suspected. Paralysis of the original nerve can also result from strokes, i.e. H. bleeding or vascular occlusion in the brain. Malignant tumors such as thyroid carcinoma or colonization of malignant tumors (metastases) can damage the recurrent laryngeal nerve or the vagus nerve and cause paresis. Tumors can also occur directly in the brain and thus damage the region of origin of the vagus nerve. Injuries to the nerve also occur from surgeries on the thyroid, spine, neck vessels, heart, and lungs. Recurrent palsy is rarely caused by direct injury to the neck or by pressure on the nerve, e.g. B. caused by a breathing tube.

Swell:

diagnosis

The standards for clarifying vocal cord arrest are not uniform. Important indications of possible causes result from the precise recording of the medical history.

Basically, if there is nerve damage with an unknown cause, a tumor disease in the course of the vocal cord nerves should be excluded. This is done through a thorough ENT endoscopy and in addition through medical imaging procedures (ultrasound examination of the neck, computed tomography (CT) of the chest, especially in the case of left-sided paralysis and magnetic resonance imaging (MRI) of the neck including the base of the skull and, if necessary, the brain). If a tumor is suspected, the parts of the throat (the hypopharynx) and the upper esophagus are shown in an anesthetic endoscopy and the passive mobility of the vocal cord cartilage (arytenoid cartilage) is checked.

Voice diagnostics are used to assess voice quality and vocal performance. The voice findings are important for planning and assessing the success of a possible voice therapy (speech therapy treatment).

In the case of incomplete or only partially healed paralyzes, a stroboscopic larynx examination can be used to create a kind of slow-motion recording that provides information about the tension and fine mobility of the vocal folds during vocalization. Stroboscopy and voting results are important for the development of an individual treatment plan to improve the voice.

Breath tests ( spirometry , body plethysmography ) are used to measure the restriction of the air passage through the larynx, especially in patients with bilateral paresis.

An electromyography of the larynx muscles (larynx EMG), in which the electrical activity of the larynx muscles is derived via thin needle electrodes, is used to more precisely differentiate between nerve damage and other causes of a mobility disorder of the vocal folds as well as the localization of the damage location in the nerve course. The larynx EMG can, within certain limits, give a prognosis for the course of recurrent palsy. Bad chances of recovery can be recognized early in the larynx EMG. This special examination is not yet available across the board in the treatment centers.

All examination results must always be seen in context by the attending physician and an individual diagnosis and treatment plan must be drawn up for each patient.

Epidemiology

Scientific opinions on this subject assume around ten thousand unilateral and one thousand bilateral vocal cord paralysis per year in German-speaking countries. However, detailed information in the scientific literature is very sparse and not always clear.

treatment

Treatment depends on the cause and the prevailing complaints.

If an underlying disease that requires treatment is the cause of the vocal cord arrest or recurrent palsy, such as a tumor disease, this should be treated accordingly. If the symptoms are minor, for example in the case of a quickly recovering unilateral paresis, special treatment is not always necessary. After the appropriate diagnosis, the ENT doctor or phoniatrist will check the further course.

In the case of unilateral vocal cord paresis with a bad voice, the treatment is aimed at improving the voice. The preferred form of therapy in this case is voice exercise treatment ( speech therapy ). Through special exercises, the therapist succeeds in improving the closure of the vocal folds when giving voice. As complete a contact as possible between the two vocal folds is important for an efficient and harmonious vibration sequence in the voice. If this cannot be achieved in the course of speech therapy, further measures are required. These aim to move the paralyzed vocal fold closer to the midline (medialization) and thus to the healthy side. In many cases, medialization can be achieved by injecting the vocal folds (vocal fold augmentation). There are various substances of different consistency and residence time in the tissue, so that the most suitable substance can be selected for each case. Vocal cord augmentations can be performed under local or brief general anesthesia.

Surgical procedures to mediate the paralyzed vocal folds come into consideration when augmentation alone is not sufficient. Essentially two methods are used. The medialization of the vocal folds from the outside by inserting a "stamp" between the vocal folds and thyroid cartilage (thyreoplasty type I according to Isshiki, with the body's own cartilage, silicone, titanium braces or Goretex strips) and the inward rotation of the vocal fold adjustment cartilage (arytenoid adduction) using special rein sutures. Both methods can also be combined.

In the case of bilateral vocal cord paralysis, the focus is on ensuring adequate breathing. In an emergency, it may be necessary to make an incision in the windpipe ( tracheotomy ).

If breathing is permanently restricted during physical exertion, an operative enlargement of the glottis is aimed for. Since such an intervention endangers the quality of the voice and usually cannot be reversed, glottic enlargements should only be carried out when the larynx can no longer be expected to move again due to the healing of at least one vocal cord nerve. Due to the slow regrowth of the nerve, a healing period of at least 6 to 12 months is generally recommended. A laryngeal EMG could estimate the prognosis earlier and in some cases shorten the waiting time for a glottic dilatation.

Illustration of an implanted larynx pacemaker

A distinction is made between a partially reversible procedure for the lateral displacement of a vocal fold by means of a special suture (lateralization according to Lichtenberger) and various permanent procedures of glottic expansion. In these cases, one of the (very rarely both) vocal folds is incised with the laser beam and parts of the vocal fold or the anterior cartilage are removed. This expansion of the airway almost always leads to a certain deterioration in the voice, since it is no longer possible to completely close the vocal folds. The more the expansion is made, the weaker the voice becomes. It is therefore necessary to find the best possible compromise between improving breathing and maintaining the voice.

In order to meet the requirement of maintaining the voice and still improving breathing, an at least partial restoration of vocal cord mobility is necessary. A look at research suggests that dynamic treatment approaches will be possible in the future.

Recurrent paresis could in future be treated with a so-called larynx pacemaker. This new type of implant has already been used in a first-in-human study in several patients. Initial results show that the method is safe and provide initial indications that the method allows breathing to be improved without impairing voice quality.

Individual evidence

  1. ^ A b C. Pototschnig, WF Thumfart: Electromyographic evaluation in vocal cord disorders. In: Acta oto-rhino-laryngologica belg. 1997, 51, pp. 99-104.
  2. ↑ a b c d e f A. Rubin, RT Sataloff: Vocal fold paresis and paralysis. In: Otolaryngol Clin N Am. 40 (2007), pp. 1109-1131.
  3. ↑ a b c d B. Benjamin: Vocal cord paralysis, synkinesis and vocal fold motion impairment. In: A NZ J Surg. 2003; 73, pp. 784-786.
  4. ↑ R. Crumley: Laryngeal synkinesis revisited. In: Ann Otol Rhinol Laryngol. 2000; 109, pp. 365-371.
  5. ↑ a b c d e U. Glatz, vocal cord paralysis - innovative treatments; DMW - German Medical Weekly; Issue 03, 2013.
  6. ^ A b D. Goldfarb, W. Keane, L. Lowry: Laryngeal pacing as a treatment for vocal fold paralysis. In: J Voice. 1994; 8 (2), pp. 179-185.
  7. ↑ a b c d A. H. Müller, G. Förster: Reinnervation and neurostimulation of the larynx. In: ENT. 2013 Feb; 61 (2), pp. 102-107.
  8. ↑ a b c W. Harnisch, S. Brosch, M. Schmidt, R. Hagen: Breathing and voice quality after surgical treatment for bilateral vocal cord paralysis. In: Arch Otolaryngol Head Neck Surg. 2008 Mar; 134 (3), pp. 278-284.
  9. ↑ HM Tucker: Laryngeal Nerve Injuries: Evaluation and Management. In: Operative Techniques in Otolaryngology-Head and Neck Surgery. (1999) Vol. 10, No. 4, pp. 276-285.
  10. ↑ Rosenthal et al: Vocal Fold Immobility: A longitudinal analysis of etiology over 20 years. In: Laryngoscope. 117 October 2007, pp. 1864-1870.
  11. ^ GF Volk, R. Hagen, C. Pototschnig, G. Friedrich, T. Nawka, C. Arens, A. Mueller, G. Foerster, M. Finkensieper, R. Lang-Roth, C. Sittel, C. Storck, M. Grosheva, MN Kotby, CM Klingner, Orlando Guntinas-Lichius: Laryngeal electromyography: a proposal for guidelines of the European Laryngological Society. In: Eur Arch Otorhinolaryngol. 2012 Oct; 269 (10), pp. 2227-2245.
  12. ↑ S. Djugai, D. Boeger, J. Buentzel, D. Esser, K. Hoffmann, P. Jecker, A. Mueller, G. Radtke, S. Bohne, M. Finkensieper, GF Volk, O. Guntinas-Lichius: Chronic vocal cord palsy in Thuringia, Germany: a population-based study on epidemiology and outcome. In: Eur Arch Otorhinolaryngol. 2013 Aug 22
  13. ^ T. Nawka, U. Wiesmann, U. Gonnermann: Validation of the German version of the Voice Handicap Index. In: ENT. 2003 Nov; 51 (11), pp. 921-930.
  14. ↑ a b c L. Sulica, A. Blitzer: Vocal Fold Paralysis. Springer, Berlin / Heidelberg / New York 2006, ISBN 3-540-23765-8 .
  15. ^ A. Müller, FP Paulsen: Impact of vocal cord paralysis on cricoarytenoid joint. In: Ann Otol Rhinol Laryngol. 2002 Oct; 111 (10), pp. 896-901.
  16. ↑ a b A. H. Mueller: Laryngeal pacing for bilateral vocal fold immobility. In: Curr Opin Otolaryngol Head Neck Surg. 2011 Dec; 19 (6), pp. 439-443.
  17. ↑ M. Grosheva, C. Wittekindt, C. Pototschnig, W. Lindenthaler, O. Guntinas-Lichius: Evaluation of peripheral vocal cord paralysis by electromyography. In: Laryngoscope. 2008 Jun; 118 (6), pp. 987-990.

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