Combined paralysis of larynx

Combined / complete paralysis of recurrent and superior laryngeal nerves:

Unilateral:

This causes paralysis of all muscles of larynx on one side except the interarytenoids which receives bilateral innervation.

Etiology:

Thyroid surgery happens to be the common cause of this problem when both recurrent and external laryngeal nerves of one side may be compromised.

This condition can also occur in lesions involving nucleus ambiguus or that of vagus nerve proximal to the origin of superior laryngeal nerve. The offending lesion thus could lie in the medulla, posterior cranial fossa, jugular foramen or parapharyngeal space.

Clinical features:

Since all the muscles of larynx on one side are paralyzed vocal cord will lie in the cadaveric position i.e. 3.5 mm from the midline. The healthy cord is unable to approximate the paralysed cord causing a glottic chink and glottic incompetence. This causes hoarseness of voice and aspiration of liquids through glottis. Cough is ineffective due to air waste.

Treatment:

1. Speech therapy - This facilitates the healthy cord to compensate for the paralysed cord

2. Procedures to medialize the paralysed cord

Bilateral combined paralysis:

Both recurrent and superior laryngeal nerves on both sides are paralysed. In this rare condition all laryngeal muscles are paralysed and both cords lie in cadaveric position. There is also total anesthesia of larynx. This condition is also known as the dead larynx. This condition is really difficult to manage.

Clinical features:

Aphonia Inability to cough Aspiration Bronchopneumonia

Management:

Tracheostomy

Gastrostomy (feeding)

Epiglottopexy

Total laryngectomy