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Neuromuscular Laryngeal Dysfunction

Alterations in the form and function of the vocal cords present as changes in voice or speech patterns

Neuromuscular Laryngeal Dysfunction

the cause can be abnormalities of the intrinsic or extrinsic laryngeal musculature, neurologic dysfunction, aging

Vocal Cord Paralysis

Diseases that affect the vagus nerve or the laryngeal branches can result in vocal cord paralysis and impaired laryngeal sensation
Unilateral cord paralysis is about 75% and the Left is more common b/c its longer and more circuitous

Vocal Cord Paralysis

CNS lesions and peripheral lesions (90%) involving the vagus nerve
Peripheral: Neoplasm, postsurgical, idiopathic, medical/inflammatory, trauma
CNS: Parkinson's Disease, Stroke, MS

Vocal Cord Paralysis

Hoarseness is most common, stridor, SOB, changes in vocal quality, cough, aspiration

Vocal Cord Paralysis

Testing:
Flexible laryngoscopy can assess vocal cord function, position, sensation.
CXR
CT or MRI
Direct laryngoscopy or bronchoscopy are useful.

vocal cord paralysis

Treatment:
Speech therapy if minimal voice changes
Surgical intervention may be needed in more severe cases

bilateral vocal cord paralysis

Uncommon
Results in the inability to abduct the vocal cords

bilateral vocal cord paralysis

Causes:
Probable postsurgical injury (after a total thyroidectomy)/ recurrent laryngeal nerve
CNS abnormality, MS, CVA, ALS/ Vagal nerve

bilateral vocal cord paralysis

Presentation:
Laryngeal nerve: stridor, possible respiratory distress, Voice intact because vocal cords are adducted
Vagal nerve: weak voice, history of aspiration, short of breath on exertion, often other cranial nerves involved

bilateral vocal cord paralysis

Treatment:
Endotracheal intubation to secure the airway or tracheotomy

presbyphonia

Can be a part of the normal aging process.
Causes:
Structural change with age, calcification of the laryngeal cartilage, loss of vocal cord elasticity, decrease in muscle bulk

presbyphonia

Presentation:
Breathy, tremulous, weak voice with pitch alterations and early fatigability
Exam shows a posterior glottic gap, bowing of the vocal cords and muscle atrophy

presbyphonia

Treatment:
Eliminate vocal strain
Speech Therapy
Surgery can be considered

Parkinson's Disease

May develop vocal dysfunction secondary to bradykinesia and difficulty initiating voluntary muscle activity

Parkinson's Disease

Presentation:
Breathy, hypophonic, tremulous, monotone
Vocal cords are adynamic and bowed

Parkinson's Disease

Treatment:
Voice training with SLP
Medication: Dopamine for tremors can be helpful.

Myasthenia Gravis

Neuromuscular junction disorder with weakness and fatigue of the skeletal muscles. Affects all ages

Myasthenia Gravis

Cause:
Acetylcholine deficiency causes an inability of the myoneural junction depolarization

Myasthenia Gravis

Presentation:
Gradual onset
Diplopia and ptosis of the eyelids. Facial weakness
Voice alteration with weakness of the laryngeal muscles and difficulty speaking. Voice fatigue
Dysphagia and Dyspnea

Myasthenia Gravis

Testing:
Acetylcholinesterase testing and EMG

Myasthenia Gravis

Treatment:
Voice improves after rest
May need emergent airway
Acetylcholinesterase: neostigmine
Fluids
Avoid fatigue
Range of motion

ALS

Progressive degeneration of anterior horn cells in the spinal cord that causes wasting and weakness of the skeletal muscle

ALS

Presentation:
Usually involves the hands, forearms, legs and progresses to the rest of the body the face, throat and respiratory system
Raspy, monotone voice, difficulty speaking and difficulty swallowing
Depressed gag reflex
Pooling secretions in the larynx and hypopharynx

ALS

Treatment:
Discussion of future treatment and advance directive
Consideration of mechanical ventilation

ALS

Death is often due to respiratory insufficiency or aspiration pneumonia

Laryngeal Neoplasia

There are benign, premalignant, and malignant neoplastic lesions

Laryngeal Neoplasia

Presentation can include hoarseness, dysphagia, odynophagia, and aspiration

Benign

: Vocal cord nodules, polyps, granulomas

Laryngeal Neoplasia

Benign to premalignant: Recurrent respiratory papillomatosis

Laryngeal Neoplasia

Leukoplakia
Laryngeal cancer

RRP

Most common benign neoplastic process of larynx
Cause:
Infection HPV (human papilloma virus). Usually type 6 and 11

RRP

Presentation:
Juvenile onset Usually age 2-4 years. Otherwise in the 30's. Rare after age 40
Recurrent growth of exophytic warty lesions
Presents with hoarseness, stridor, cough
More aggressive in children and recurrent

RRP

Treatment:
CO2 laser resection, cold steel dissection. Intralaryngeal cidofovir (Vistide) off-label use.
Neither are curative. HPV DNA remains present.

Leukoplakia

Denotes white patch or plaque on mucous membrane
Cause:
Most common inciting agent is cigarette smoking

Leukoplakia

Presentation:
May be asymptomatic, hoarseness, voice changes
May be Isolated to vocal cords or larynx diffusely
Keratinization of the mucosa occurs. It may involve dysplastic epithelial changes
Painless white patch on the tongue, inside cheek, lower lip, floor of the mouth and it CANNOT be scraped off

Leukoplakia

Considered a premalignant lesion
Carcinoma develops in less than 5% of cases to 30%
Erythroplakia has a 60% rate of changing to malignancy

Leukoplakia

Diagnosis and Treatment:
Excisional biopsy both diagnostic and therapeutic, especially in those with a history of alcohol and tobacco use

Leukoplakia

Follow up:
Laryngoscopy to observe for recurrence or progression

Laryngeal Cancer

In U.S. incidence 11,100 new cases per year with 4300 deaths
Most common type is squamous cell ~ 90%

Laryngeal Cancer

Male/female ratio 4:1

Laryngeal Cancer

Causes:
Major risk factors tobacco and ETOH use
Ionizing radiation, occupational exposure
RPR in types 16 &18. Leukoplakia

Laryngeal Cancer

Glottic malignancy outnumbers supraglottic in the US but not worldwide.
Supraglottic have a richer lymphatic drainage. More often diagnosed with nodal metastasis
Malignancy from the subglottis is rare

Laryngeal Cancer

Hoarseness, stridor, dysphagia, odynophagia, hemoptysis, weight loss, mass is neck, referred otalgia
Airway compromise, aspiration
Cancer of the true vocal cords, hoarseness occurs early. Hoarseness longer than two weeks deserves careful inspection
The supraglottic cancer is often asymptomatic until the cancer is larger. (advanced stage): Muffled voice

Laryngeal Cancer

Glottic cancer is found earlier. Earlier change in voice
Head and neck examination, lymph node exam. Back of mouth and tongue. Laryngoscopy in the office
Patient should undergo general anesthesia for bronchoscopy, esophagoscopy, and direct laryngoscopy with biopsy. Done in OR setting and all 3 done. (SCC metastasizes to lung, mediastinum, liver then elsewhere) Cervical lymph nodes then lungs. CXR. May need CT or MRI, PET scan

Laryngeal Cancer

Treatment
Depends upon staging
Surgery, radiation, chemotherapy alone or in combo
Early recognition and treatment (especially of the true vocal cords, b/c it is more easily recognized) has a good prognosis
Voice preserving laryngectomy, total laryngectomy

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