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Moderator:- Dr.

Vivek
Student:- Dr.Imran
Contains Trachealis
glands, small muscle
arteries, overlies
nerves, esophage
lymph al muscle
vessels and and
elastic fibers epithelium
Average cross-sectional
area of the male adult
trachea is approximately
2.8 cm2
Transverse (lateral)
diameter of 25 mm and
sagittal (anteroposterior)
diameter of 27 mm are the
upper limits of normal
(males)
The lower limit of normal
for both transverse and
sagittal diameters is about
13 mm in men and 10 mm
in women
U-shaped trachea (27%)

C-shaped trachea (49%)


A saber-sheath or scabbard trachea is.
The saber sheath trachea has been
described in up to 5 % of elderly men.

Women - round configuration


Men - sagittal widening and transverse
narrowing.
Tracheal Index (TI)
defined as
(transverse/saggital
diameter)<0.6

12% of elderly men


with COPD.
Normal shape Expansion during inhalation Circumferential collapse

A C E

B D F

Saber sheath Dynamic collapse Crescent shape collapse


Tracheal Relationships
Cervical
Thoracic
Cervical Trachea
Anterior Posterior Lateral
Skin Esophagus 2 Lateral lobes of Thyroid
Sup. & Deep facia
Strap muscles Recurrnent Laryngeal Comman Carotid Artery
Sternocleidomastoid Nerves
Sternohyoid
Sternothyroid

Isthmus of Thyroid Prevertebral Internal Jugalar


fascia VeinVagus

Inferior Thyroid Vein Omohyoid


Thyroidea Ima
Artery<10%
Pre-tracheal facia External jugular
Plexus Thyroideus Impar vein
Thoracic Trachea
Anterior Posterior Lateral

Thymus Gland Esophagus Vagus


Phrenic Nerves

Left Branchiocephalic Vein Recurrnent Laryngeal Superior


Nerves vena cava antero-
laterally on right side

Arch of Aorta Prevertebral Lungs covered by


fascia Pleura
The left common
carotid and left
subclavian arteries
Thoracic
Duct on left side
Azygos vein on right
side
Esophagus lies
Posterior
Note Trachealis muscle
Esophagus
Recurrent Laryngeal
Nerves

18
Cervical Tracheal
Relationships-
Anterior

Skin
Superficial & Deep
fascia.

2nd to the 4th


rings are covered by
the isthmus of the
thyroid.
Inferior Thyroid Veins
Thyroidea Ima Artery-
>10%
Pretrachal Fascia invests
Trachea
Thyroid Gland
Larynx
Note:
Thyroidea Ima Vein
Plexus Thyroideus Impar
2 Lateral Lobes-
Thyroid Gland
Carotid Sheath and Anterolateral View
Contents
Common Carotid
Artery
Internal Jugular Vein
Vagus Nerve
Posterior View
Carotid Sheath and
Contents
Internal Jugular Vein
(Lateral)
Common Carotid
Artery (Medial)
Vagus Nerve
(Posterior)
Thymus Gland (or
Thymic Remnant in
adults)
Left Brachiocephalic
Vein
Aortic Arch
Vagus Nerves
Phrenic Nerves
Lungs covered by Pleura
General Sensation- Vagus & Recurrent
Laryngeal Nerves
Autonomic Innervation
Sympathetic-Decreases
Secretions(T1,T2)
Parasympathetic-Increases
Secretions(Vagus)
Inferior Thyroid Arteries- Cervical
Portion
Bronchial Arteries- Thoracic Portion
Venous plexuses situated around
trachea and oesophagus ultimately
drain into inferior thyroid venous
plexus.
lymph nodes located around trachea,
the brachio-cephalic and right
common carotid arteries.
Indications & Complications of
Tracheostomy
What is Tracheostomy

The word tracheostomy is


derived from the Latin trachea
and tomein (to make an
opening).

Tracheostomy is an operative
procedure that creates a surgical
airway in the cervical trachea .
What is this & what are its indications ???

Answer at the end of presentation


1932 to prevent pulmonary infection in
neurologically impair patients secondary
to infections (poliomyelitis).
1943 to remove bronchial secretions in
cases of myasthenia gravis and tetanus.
1951 to reduce the volume of dead space,
use in COPD and severe penumonia.
1950 positive pressure through
tracheostomy for patients with
poliomyelitis.
1955 obstruction secondary to infection:
diphteria, Ludwigs angina.
1961 Obstructions secondary to tumour,
infectious disease and trauma.
Tracheotomy Indications
To bypass obstruction
Tracheotomy Indications
Prolonged intubation

- Need for prolonged respiratory support, such as in


Bronchopulmonary Dysplasia

- To reduce anatomic dead space and increase the chance for


mechanical ventilation withdrawal

- To improve the patient`s quality of life (easier toilet,


ability to speak and eat, increase the mobility)

- Neuromuscular diseases paralyzing or weakening chest


muscles and diaphragm
PROTECTION of AIRWAY
Neurological Diseases(Polyneuritis, GBS)
Coma (GCS<8, risk of aspiration)

Elective Tracheostomy as Adjunct to H&N surgeries


<14 days on ETT(relative)
>21 days on ETT
Tracheotomy Indications
Miscellaneous
-Congenital abnormalities. (Pierre Robin, Triecher Collins
syndromes)

- Obstructive Sleep Apnea Syndrome.

- Aspirations related to muscle or sensory problems.

-Prophylaxis (as preparation for extensive H&N


procedures, before radiotherapy for H&N CA)

-Cervical spinal cord injuries with respiratory muscles


paralysis.
No absolute contraindications exist to
tracheostomy

RELATIVE
Laryngeal CA(strong)

it may lead to increased incidence of stomal


recurrence(a diffuse infiltrate of neoplastic tissue at the junction of the
amputated trachea and skin )
Physical assessment also surgical and
anesthesiological

CBC

PT, PTT, INR

Patient/apotropus confirmation
Types of Tracheostomy

1) Open procedure

a) High tracheostomy (Cricothyroidectomy)


b) Low tracheostomy

2) Percutaneous procedure
High tracheostomy (Cricothyroidectomy)
Landmark
Cricothyroid membrane Crycoid cartilage
Thyroid cartilage
Emergency Cricothyrotomy Protocol

Indications:
A patient that requires intubation and
Unable to intubate and
Unable to adequately ventilate

Conditions:
Patient 40 kg and 12 years old

Contraindications:
Suspected fractured larynx
Inability to localize the cricothyroid membrane
Techniques

1) Seldinger (Melker) Cricothyrotomy

2) Needle Cricothyrotomy
Low Tracheostomy

Skin Prep with povidine


iodine,
chlorohexidine(savlon)

Draping

Good light source and


suction machine ready
and tested to be
functional
Transverse Incision

Incision 1 cm below the cricoid or halfway between


the cricoid and the sternal notch.

Incision length=6cm/ anterior border of SCM msc


lateral
Blunt dissection of
subcut tissue

Transversely

Retracted as shown
Strap msc is divided
longitudinally at
midline

Thyroid
ismuth is
divided at
midline by 2
haemostat
and cut edge
secured by
2/0 vicryl
Depending on
the TT size abt
4cm longitudinal
opening is made
in trachea below
2nd ring
Tube is
anchored
Percutaneous Dilational
Tracheostomy
Benefits include elimination of need for
operating room use or anesthesia, and
significant reduction in cost.

Should be done in carefully selected patients

Under fiber optic control

To be ready to switch to open procedure


PERCUTANEOUS DILATIONAL TRACHEOTOMY

Guidewire and catheter are advanced


Guidewire introduction, with together into the trachea as far as the
removal of sheath skin positioning marks on the guide
catheter to the skin.[
Guidewire, guide
catheter, and dilator
unit are advanced
together into the
trachea to the skin
positioning mark
The tracheotomy tube is
loaded onto a dilator and
advanced into the trachea
over the guidewire and
catheter. The guidewire and
catheter are removed,
leaving only the
tracheostomy tube in the
trachea
PCV check(pressure controlled ventilation)

Repeat X-Ray soft tissue neck

Strong Analgesia

Antibiotics

IV fluid until able to tolerate orally


Risk factors for complications
Age: infants and adults over 75

Obesity

Smoking

Poor nutrition

Recent illness, especially an upper-respiratory infection

Alcoholism

Chronic illness

Diabetes
Apnea due to loss of hypoxic respiratory drive.
This is mainly important in the awake patient.
Ventilatory support must be available .
Falseroot
Bleeding

Pneumothorax or pneumomediastinum
Damage to the vocal cords (direct)
Injury to adjacent structures: recurrent
laryngeal nerves, the great vessels, and the
esophagus.
Post-obstructive pulmonary edema
Hypotension
Arrhythmia
Early bleeding: This is usually the result of increased
blood pressure as the patient emerges from
anesthesia and begins to cough.
Plugging with mucus
Tracheitis
Cellulitis
Tube displacement
Subcutaneous emphysema
Atelectasis
Bleeding - tracheoinnominate fistula
Tracheo- and laryngomalacia
Stenosis
Tracheoesophageal fistula
Tracheocutaneous fistula
Granulation
Scarring
Failure to decannulate
Tube changes:
Indications: soiled, cuff rupture.
Complications: insertion into a false passage bleeding,
and patient discomfort.
Avoid within 1st week.
First tube change by surgeon.
Difficult cases (obese, short and thick neck), be
prepared for endotracheal intubation.
Tracheostomy tube cuff pressures ---20 to 25 mm Hg.

Overly low cuff pressures < 18 mm Hg, may cause the cuff
to develop longitudinal folds, promote microaspiration of
secretions collected above the cuff, and increase the risk
for nosocomial pneumonia.

Excessively high cuff pressures above 25 to 35 mm Hg


exceed capillary perfusion pressure and can result in
compression of mucosal capillaries, which promotes
mucosal ischemia and tracheal stenosis.

Cuff pressure should be measured with calibrated devices


and recorded at least once every nursing shift and after
every manipulation of the tracheostomy tube.
Humidification of the inspired gas is a standard
of care for tracheostomized patients.

Thermovent
Indications For Suctioning

Secretions in the trach

Suspected aspiration of gastric or upper airway


secretions

Increase in peak airway pressures when on ventilator

Increase in respirations or sustained cough or both

Gradual or sudden decrease in ABG

Sudden onset of respiratory distress when airway


patency is questioned
After the track is formed 4-5 days after the
operation.

Rate of exchange depends on clinical


situation of the specific patient type of
discharge, type of tube, medical status, age..

Usually every 14 days.

Should be done by experienced staff.


Cuffed and uncuffed

Fenestrated and unfenestrated

Single and double lumen

Various diameters
To protect airway
To allow ventilation

Uncuffed Cuffed
Allow patient to
ventilate past tube via
upper airway
Allow speech
Double lumen allows
easy cleaning
Single lumen has a
greater internal
diameter
Other Types of Tubes

Montgomery T-Tube
Bivona Fome-Cuff Single Cannular Shiley
Tracheaostomy Tube Pediatric TT
Tracheostomy Speaking Valve

Passy-Muir

A tracheostomy speaking valve is a one-way valve,


allows air in, but not out
forces air around the tracheostomy tube, through the
vocal cords and out the mouth upon expiration,
enabling the patient to vocalize
Tracheostomy tube prevents normal upward
movement of the larynx during swallowing and hinders
glottic closure.

Between 20% and 70% of patients with a chronic


tracheostomy experience at least one episode of
aspiration every 48 hours

Keep head elevated to 45 during periods of tube


feeding
Resolution of pathology that necessitated the
tracheotomy (upper airway obstruction,
pneumonia)
Normal protective laryngeal mechanisms (no
aspirations during normal swallowing, good
coughing)
No planed further interventions (radiotherapy,
H&N operations)
No mechanical ventilation
Answer

Jacksons tracheostomy

Fullers tracheostomy tube


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NEWS & PERSPECTIVE DRUGS & DISEASES CME & EDUCATION ACADEMY

Drugs & Diseases > Otolaryngology and Facial Plastic Surgery

Complications of Thyroid Surgery


Updated: Feb 07, 2017 | Author: Pramod K Sharma, MD; Chief Editor: Arlen D Meyers, MD, MBA more...

Practice Essentials
Practice Essentials
During the 1800s, the mortality rate from thyroid
Overview surgery was approximately 40%. Most deaths were
caused by infection and hemorrhage. Sterile
Bleeding surgical arenas, general anesthesia, and improved Recommended
surgical techniques have made death from thyroid
Injury to the Recurrent surgery extremely rare today.
Laryngeal Nerve DISEASES & CONDITIONS

By developing a thorough understanding of thyroid Autoimmune Thyroid Disease


Hypoparathyroidism and Pregnancy
anatomy and of the ways to prevent each
complication, the surgeon can minimize each
Thyrotoxic Storm patient's risk. Potential major complications of DISEASES & CONDITIONS
thyroid surgery include bleeding, injury to the Neurological Manifestations of
Injury to the Superior recurrent laryngeal nerve (see the first image Thyroid Disease
Laryngeal Nerve below), hypoparathyroidism, hypothyroidism,
thyrotoxic storm, injury to the superior laryngeal
Infection nerve (see the second image below), and infection.

Hypothyroidism

Impact of New
Technology

Guidelines Summary

Show All

Media Gallery
Anatomy of the recurrent laryngeal nerve
References (RLN).

View Media Gallery


Superior laryngeal nerve (SLN).

View Media Gallery

Minor complications
Postoperative surgical site seromas may be
followed clinically and allowed to resorb, if small
and asymptomatic; large seromas may be aspirated
under sterile conditions. Poor scar formation is
frequently preventable with proper incision location
and surgical technique.

Postoperative bleeding
The incidence of bleeding after thyroid surgery is
low (0.3-1%), but an unrecognized or rapidly
expanding hematoma can cause airway
compromise and asphyxiation. Patients present
with neck swelling, neck pain, and/or signs and
symptoms of airway obstruction (eg, dyspnea,
stridor, hypoxia). Evaluation is as follows:

Physical examination; remove all bandaging


and examine the neck for swelling
Imaging studies may be useful in cases of mild
neck swelling without airway compromise
Fiberoptic laryngoscopy may be warranted in
patients with airway issues without apparent
wound hematoma, to assess vocal fold
function/LI>

Prevention

Avoid traumatizing the thyroid tissue during


the procedure
Provide good intraoperative hemostasis
Avoid the use of neck dressings, as dressing
that covers the wound may mask hematoma
formation
No definitive evidence suggests that drains
prevent hematoma or seroma formation

Injury to the recurrent laryngeal nerve


Recurrent laryngeal nerve (RLN) injury results in
true vocal-fold paresis or paralysis. Deliberate
intraoperative identification and preservation of the
RLN minimizes the risk of injury.

Evaluation

Techniques for assessing vocal fold mobility


include indirect and fiberoptic laryngoscopy
Documentation of vocal fold mobility should
Documentation of vocal fold mobility should
be a routine part of the preoperative workup
Postoperative visualization should also be
performed, as patients may be asymptomatic
at first
Laryngeal electromyography (EMG) may be
useful to distinguish vocal fold paralysis from
injury to the cricoarytenoid joint secondary to
intubation, and it may yield prognostic
information

Presentation

In unilateral vocal cord paralysis, hoarseness


or breathiness may not manifest for days to
weeks; other potential sequelae are dysphagia
and aspiration
Bilateral vocal-fold paralysis usually manifests
immediately after extubation; patients may
present with biphasic stridor, respiratory
distress, or both

Treatment

In unilateral vocal cord paralysis, corrective


procedures may be delayed for at least 6
months to allow time for improvement in a
reversible injury, unless the nerve was
definitely transected during surgery; surgical
treatment options are medialization (most
common) and reinnervation
In bilateral vocal cord paralysis, emergency
tracheotomy may be required, but if possible,
first perform endotracheal intubation;
cordotomy and arytenoidectomy, the most
commonly performed surgical procedures,
enlarge the airway and may permit
decannulation of a tracheostomy
The patient must be counseled that his or her
voice will likely worsen after surgery

Hypoparathyroidism
Hypoparathyroidism can result from direct trauma
to the parathyroid glands, devascularization of the
glands, or removal of the glands during surgery.
Postoperative hypoparathyroidism, and the
resulting hypocalcemia, may be permanent or
transient. Hypocalcemia after thyroidectomy is
initially asymptomatic in most cases.

Evaluation of parathyroid function is performed in


either of the following ways:

Follow ionized calcium (or total calcium and


albumin) levels perioperatively
Measure PTH postoperatively; a normal level
accurately predicts normocalcemia

Treatment is as follows:

Asymptomatic hypocalcemia in the early


postoperative period should not be treated
with supplemental calcium
In symptomatic patients, replace calcium with
IV calcium gluconate
In symptomatic patients, replace calcium with
IV calcium gluconate
Typically, patients who begin to have
symptoms can be started on oral calcium and
vitamin D
In 1-2 months, an attempt to wean the patient
off oral calcium may be made
Dependence on calcium supplementation for
longer than 6 months usually indicates
permanent hypoparathyroidism

Thyrotoxic storm
Thyrotoxic storm is an unusual complication that
may result from manipulation of the thyroid gland
during surgery in patients with hyperthyroidism. It
can develop preoperatively, intraoperatively, or
postoperatively. Signs and symptoms of thyrotoxic
storm are as follows:

Anesthetized patients: Evidence of increased


sympathetic output (eg, tachycardia
hyperthermia)
Awake patients: Nausea, tremor, and altered
mental status
Cardiac arrhythmias may also occur
Progression to coma in untreated patients

Treatment is as follows:

For thyrotoxic crisis during thyroidectomy,


stop the procedure
Administer IV beta-blockers, propylthiouracil,
sodium iodine, and steroids
Use cooling blankets and cooled IV fluids to
reduce the patient's body temperature
Carefully monitor oxygenation

Injury to the Superior Laryngeal Nerve


The external branch of the superior laryngeal
nerve (SLN) is probably the nerve most commonly
injured in thyroid surgery, with an injury rate
estimated at 0-25%. Trauma to the nerve results in
an inability to lengthen a vocal fold and, thus,
inability to create a high-pitched sound; this may be
career-threatening for singers or others who rely
on their voice for their profession. Speech therapy
is the only treatment. Presentation and diagnosis
are as follows:

Most patients do not notice any change in


their voice
Occasional patients present with mild
hoarseness or decreased vocal stamina
On laryngoscopy, posterior glottic rotation
toward the paretic side and bowing of the
vocal fold on the weak side may be noted; the
affected vocal fold may be lower than the
normal one
Videostroboscopy demonstrates an
asymmetric, mucosal traveling wave
Laryngeal EMG demonstrates cricothyroid
muscle denervation
Infection
Currently, postoperative infection occurs in less
than 1-2% of all thyroid surgery cases. Sterile
surgical technique is the key to prevention; routine
use of perioperative antibiotics has not proven to
be beneficial.

Presentation

Cellulitis typically presents as erythema,


warmth, and tenderness of neck skin around
the incision
A superficial abscess produces fluctuance and
tenderness
A deep neck abscess may manifest subtly but
can produce fever, pain, leukocytosis, and
tachycardia

Evaluation

Send purulence expressed from the wound or


drained from an abscess for Gram stain and
culture
CT imaging is useful when a deep neck
abscess is thought to be possible
To exclude esophageal perforation in patients
with a deep neck abscess, an esophageal
swallow study performed with sodium
amidotrizoate and meglumine amidotrizoate
solution (Gastrografin) may be useful

Treatment

Treat cellulitis with antibiotics that provide


good coverage against gram-positive
organisms (eg, staphylococci and streptococci)
Drain abscesses, and direct antibiotic
coverage according to culture findings
For deep neck abscesses, begin with broad-
spectrum antibiotics (eg, cefuroxime,
clindamycin, ampicillin-sulbactam) until
definitive culture results are available

Hypothyroidism
Hypothyroidism is an expected sequela of total
thyroidectomy. Measurement of TSH levels is the
most useful laboratory test for detecting or
monitoring of hypothyroidism in these patients.

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ANATOMY OF LUNGS

-
1. Gross Anatomy of Lungs 6. Histopathology of
Alveoli
2. Surfaces and Borders of
Lungs 7. Surfactant
3. Hilum and Root of Lungs 8. Blood supply of lungs
4. Fissures and Lobes of 9. Lymphatics of Lungs
Lungs
10. Nerve supply of Lungs
5. Bronchopulmonary
11. Pleura
segments
12. Mediastinum
GROSS ANATOMY OF LUNGS

Lungs are a pair of respiratory organs situated in a thoracic cavity.


Right and left lung are separated by the mediastinum.

Texture -- Spongy
Color Young brown
Adults -- mottled black due to
deposition of carbon particles
Weight-
Right lung - 600 gms
Left lung - 550 gms
THORACIC CAVITY
SHAPE - Conical
Apex (apex pulmonis)

Base (basis pulmonis)

3 Borders - anterior (margo anterior)


- posterior (margo posterior)
- Inferior (margo inferior)

2 Surfaces - costal (facies costalis)


- medial (facies mediastinus)
- anterior (mediastinal)
- posterior (vertebral)
APEX
Blunt Grooved by
b -
Lies above the level of Subclavian artery
anterior end of 1st Rib. Subclavian vein
Reaches 1-2 cm above
medial 1/3rd of clavicle.
Coverings
cervical pleura.
suprapleural membane
BASE

Semilunar and concave.

Rests on dome of Diaphragm.

Right sided dome is higher than left.


BORDERS
ANTERIOR BORDER

1. Corresponds to the anterior


(Costomediastinal) line of pleural reflection.

2. It is deeply notched in the left lung posterior


to 5th costal cartilage by the pericardium
and extends vertically downwards to form
Lingula. This is called cardiac
notch(percussion in this area gives a dull
note as compared to dull note obtained over
lung).
INFERIOR BORDER
Thin and sharp

It seperates the base of lung from the


costal surface and extends into
phrenicocostal sinus.
POSTERIOR BORDER
Thick and ill defined

Fits into deep paravertebral gutter.

Extends from C7 to T10.


SURFACES OF THE LUNG

1. Costal Surface - It is in contact with costal


pleura and overlying
thoracic wall.
2. Medial Surface - Posterior / Vertebral Part
- Anterior / Mediastinal Part
Relations of Posterior Part

1. Vertebral Part

2. Intervertebral Discs

3. Posterior Intercostal Vessels

4. Splanchic Nerves
RELATIONS OF ANTERIOR PART
RIGHT SIDE LEFT SIDE

1. Right atrium 1. Left ventricle


2. Small part of RV 2. Pulmonary trunk
3. SVC 3. Arch of Aorta
4. Right brachiocephalic 4. Descending thoracic
vein(lower part) aorta
5. Azygos vein 5. Left Subclavian Artery
6. Esophagus 6. Thoracic duct
7. IVC 7. Left Brachiocephalic
8. Trachea Vein
9. Right vagus nerve 8. Left vagus nerve
10. Right phrenic nerve 9. Left phrenic nerve
10. Left recurrent
laryngeal nerve
HILUM

It is a large depressed area that lies


near the centre of the medial surface.

Various structures enter and leave the


lung via its root.
ROOT OF THE LUNG

The root is enclosed in


a short tubular sheet of
pleura that joins the
pulmonary and
mediastinal parts of
pleura . It extends
inferiorly as a narrow
fold - The pulmonary
ligament.

It lies opposite of the


bodies of 5th, 6th and
7th thoracic vertebra
STRUCTURES OF THE ROOT
Principal Bronchus on the
left side.
Eparterial and Hyparterial
on the right side.
One pulmonary artery .
Two pulmonary veins -
Superior
Inferior
Bronchial arteries
One on right side
Two on left side
Bronchial veins
Anterior and
posterior pulmonary
plexus of nerves.
Lymphatics
Bronchopulmonary
Lymphnodes
Areolar tissue.
ARRANGEMENT OF STRUCTURES IN
THE ROOT
BEFORE BACKWARDS

1. Superior pulmonary vein.

2. Pulmonary artery.

3. Bronchus.
ARRANGEMENT OF STRUCTURES IN
THE ROOT
ABOVE DOWNWARDS

A. Right Side

1. Eparterial Bronchus.
2. Pulmonary Artery.
3. Hyparterial Bronchus.
4. Inferior Pulmonary
Vein.
.
ARRANGEMENT OF STRUCTURES IN
THE ROOT
ABOVE DOWNWARDS

B. Left Side

1. Pulmonary artery.

2. Bronchus.

3. Inferior pulmonary vein


FISSURES AND LOBES OF LUNGS
OBLIQUE FISSURE

It begins posteriorly at the level of 5th


thoracic vertebra.

Passes antero-inferiorly in a spiral


course to meet the inferior margin close
to 6th costochondral junction.
HORIZONTAL FISSURE
It extends from anterior margin at the level of
4th costal cartilage.

Runs horizontally backwards to meet the


oblique fissure in the mid-axillary line.

Pulmonary pleura extends into the fissures of


the lungs so that the lobes can move on each
other during respiration.
BRONCHOPULMONARY
SEGMENTS

These are well defined areas of the


lungs, each of which is aerated by a
segmental / tertiary bronchus.
Trachea

Right and Left Principal Bronchus

Lobar Bronchi(Secondary)[2L,3R]

Segmental Bronchi(Tertiary)[8L,10R]

Terminal Bronchioles(25000 in no.)

Respiratory Bronchioles

Alveolar ducts
ACINUS
Alveolar sacs

Alveoli
The ultimate pulmonary unit from respiratory
brochiole to alveoli is called Acinus.

There are about 28 orders of division of


tracheo-bronchial tree.

Total no. of alveoli has been estimated to be


between 200 - 600 million, with a total surface
area of 40 - 80 meter square.
BRONCHOPULMONARY SEGMENTS

Right main bronchus Left main bronchus

1. Shorter 1. Longer

2. Wider. 2. Narrower.

3. More in line with 3. More oblique than


trachea. the right.
BRONCHOPULMONARY SEGMENTS

Right Main Bronchus

Right upper lobe Bronchus Right Middle lobe Bronchus Right Lower Lobe Bronchus

Segmental Bronchi Segmental Bronchi Segmental Bronchi

Apical
Apical
Medial Anterior
Anterior
Lateral Posterior
Posterior
Medial and Lateral
BRONCHOPULMONARY SEGMENTS

Left Main Bronchus

Left upper lobe Bronchus Left lower lobe bronchus

Upper Branch Lower Branch Segmental Bronchi

Apical
Anterior Superior Lingular Anterior
Apico-posterior Inferior Lingular Posterior
Lateral
These segments are pyramidal in shape with
apex towards the root of lung.

Each segment is an independent respiratory unit.

Each segment has its own separate


artery(branches of pulmonary artery).

Pulmonary Veins run in inter-segmental planes


between adjoining segments.

Thus a bronchopulmonary segment is not a


bronchovascular segment as it does not have
its own vein.
CLINICAL SIGNIFICANCE

Segmental resection with minimal


destruction to the surrounding lung
tissue.

To visualize the interior of a bronchi


through a bronchoscope when diseases
process is limited in a segment.
HISTOPATHOLOGY OF ALVEOLI
ALVEOLAR WALL
1. Alveolar epithelial cells-
Type I pneumocytes
Type II pneumocytes
2. Basement Membrane
3. Interstitial Space-
Collagen
Elastin
Unmyelinated Nerves
Macrophages
4. Capillary Basement
Membrane
5. Capillary Endothelial Cells.
.
Type I Pneumocyte

Pavement epithelial
cells of alveoli .
Less in no. than
type II.
More surface
area(flattened)
Contain pinocytic
vesicles.
Specialized for
diffusion of gases.
Type II Pneumocytes
More numerous than
type I.
Cuboidal in shape.
Rich in
mitochondria, ER
and vacuoles
containing
osmiophillic lamellar
bodies.
Type I are
precursors of type II.
ENDOTHELIAL CELLS
Most numerous .
Presence of
pinocytic vacuoles
that meet the
luminal surface to
form caveolae.
Walls of caveolae
has, ACE.
Source of NO,
natural pulmonary
vasodilator.
ALVEOLAR MACROPHAGES
Primary defence
mechanism.

Takes part in
inflammatory and
immunological
reactions.

Activates lysosomes ,
proteases,complement
, thromboplastin,
cytokines - IF-, TNF-
, IL-1, IL-8.
SURFACTANT
Lines the inner layer of alveolar epithelium.

Synthesized by SER of type II pneumocytes.

Function
1. To reduce the surface tension of alveoli mainly during
expiration, thus reduces the work of lung inflation.
2. Waterproofing.

Surfactant synthesis starts after 26 weeks of


fetal life. Therefore premature infants,with
insufficient surfactant suffer from HMD.
All the best
Nose and Paranasal
Sinus
Dr. Deepak K Gupta

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NASAL CAVITIES
Uppermost parts of the
respiratory tract and contain
the olfactory receptors
Elongated wedge-shaped
spaces with a large inferior
base and a narrow superior
apex
Skeletal framework
consisting mainly of bone
and cartilage
Nares external opening of
nose
Choanae - open into the
nasopharynx

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Skeletal framework
Bones that contribute to the skeletal framework of
the nasal cavities include
Unpaired: ethmoid, sphenoid, frontal bone, and vomer;
Paired: nasal, maxillary, palatine and lacrimal bones, and
inferior conchae

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Ethmoid bone
Most complex bones in the skull
Contributes to the roof, lateral wall, and medial wall
of both nasal cavities, and contains the ethmoidal cells
(ethmoidal sinuses)
Cuboidal in overall shape
Two rectangular box-shaped ethmoidal labyrinths one
on each side
These are united superiorly across the midline by a
perforated sheet of bone (cribriform plate).
A second sheet of bone (perpendicular plate) descends
vertically in the median sagittal plane to form part of
the nasal septum
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Ethmoid bone

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External nose
Pyramidal in shape with its apex anterior in
position
Composed partly of bone and mainly of
cartilage
Bony parts - continuous with the skull bones and
parts of the maxillae and frontal bones
Cartilaginous Part - anteriorly, and on each side
Laterally - lateral processes of the septal cartilage,
major alar and three or four minor alar cartilages
Single septal cartilage in the midline that forms the
anterior part of the nasal septum

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Nasal Cartilage

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NASAL
CAVITIES

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NASAL CAVITIES
The nasal cavities are
separated - each other by
a midline nasal septum
Oral cavity below by the
hard palate
Cranial cavity above by
parts of the frontal,
ethmoid, and sphenoid
bones
Each nasal cavity has a
floor, roof, medial wall,
and lateral wall www.facebook.com/notesdental
Lateral wall
Characterized by three curved shelves of bone
(conchae)
One above the other and project medially and
inferiorly across the nasal cavity
The medial, anterior, and posterior margins of
the conchae are free
Increase the surface area of contact between
tissues of the lateral wall and the respired air
Openings of the paranasal sinuses, which are
extensions of the nasal cavity
Opening of the nasolacrimal duct
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Lateral wall
Conchae divide each nasal cavity into four air channels
Inferior nasal meatus between the inferior concha and the
nasal floor
Middle nasal meatus between the inferior and middle concha;
Superior nasal meatus between the middle and superior
concha;
Spheno-ethmoidal recess between the superior concha and
the nasal roof

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Lateral wall

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Medial Wall
Mucosa-covered surface of the thin nasal
septum
Oriented vertically in the median sagittal plane
Separates the right and left nasal cavities from
each other
It consists of
Anteriorly: Septal nasal cartilage
Posteriorly: mainly the vomer and the perpendicular
plate of the ethmoid bone;
Nasal spine of the frontal bone - meet in the
midline
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Medial Wall

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Floor
Smooth, concave, and much wider than the roof
It consists of
Soft tissues of the external nose;
Upper surface of the palatine process of the maxilla,
Horizontal plate of the palatine bone, which together
form the hard palate
Naris opens anteriorly into the floor,
Superior aperture of the incisive canal - deep to
the mucosa
immediately lateral to the nasal septum
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Floor

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Roof
Narrow and is highest in central regions where it is
formed by the cribriform plate of the ethmoid bone
Anterior to the cribriform plate - roof slopes inferiorly
to the nares and consist
nasal spine of the frontal bone and the nasal bones
lateral processes of the septal cartilage and major alar
cartilages
Posteriorly, the roof slopes inferiorly to the choana and
is formed by
Anterior surface of the sphenoid bone;
Ala of the vomer
Medial plate of the pterygoid process.
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Roof

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Regions of Nasal Cavities
Each nasal cavity consists of three general regions
Nasal vestibule
small dilated space just internal to the naris that is lined
by skin and contains hair follicles
Respiratory region
Largest part of the nasal cavity
Rich neurovascular supply
Lined by respiratory epithelium composed mainly of
ciliated and mucous cells
Olfactory region
small, is at the apex of each nasal cavity
Lined by olfactory epithelium which contains the
olfactory receptors
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Regions of
Nasal
Cavities

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Functions of Nasal Cavities
Main: housing receptors for the sense of smell
(olfaction)
Accessory
Adjust the temperature and humidity of respired air -
action of a rich blood supply,
Trap and remove particulate matter - hair in the
vestibule
Capturing foreign material in abundant mucus.
Mucus normally is moved posteriorly by cilia on
epithelial cells in the nasal cavities and is swallowed

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Nerve Supply of Nose
Three cranial nerves
Olfaction - the olfactory nerve [I]
General sensation - the trigeminal nerve [V],
Anterior - ophthalmic nerve [V1]
Posterior - maxillary nerve [V2]
Glands - parasympathetic fibers in the facial nerve
[VII] (greater petrosal nerve),
Join branches of the maxillary nerve [V2] in the
pterygopalatine fossa.
Sympathetic fibers are ultimately derived from
the T1 spinal cord level

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Nerve Supply

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Blood supply
Blood supply to the nasal cavities is by
Terminal branches of the maxillary and facial
arteries - originate from the external carotid
artery (ECA)
Ethmoidal branches of the ophthalmic artery,
which originates from the internal carotid artery.

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Blood Supply

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Blood Supply : Nasal Spetum
The anterior part of the septum contains a highly
vascularized area called Kiesselbachs area
Supplied by vessels from both major arteries.
This area is the most common site of significant
nose-bleed due to anastomoses.

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Lymphatics
Anterior regions
drains forward onto
the face by passing
around the margins of
the nares -
submandibular nodes
Posterior regions of
the nasal cavity and
the paranasal sinuses
drains into upper deep
cervical nodes through the
retropharyngeal nodes

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PARANASAL SINUS

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PARANASAL SINUS
Invaginations from the
nasal cavity that drain into
spaces associated with the
lateral nasal wall
There are four paranasal air
sinuses
Ethmoidal cells,
Sphenoidal,
Maxillary,
Frontal sinuses
Functions: skull lighter and
add resonance to the voice
Infection causes Sinusitis
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PARANASAL SINUS

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PARANASAL SINUS
Rudimentary or even
absent during birth
Enlarges rapidly at the
age of 6 to 7 yrs then
after puberty
Increase in size due to
Enlargement of Bones :
birth till adult life
Resorption of Bones:
old age
Lined by a respiratory
epithelium
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PARANASAL SINUS

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Frontal sinuses
One on each side
Variable in size and are the most superior of the
sinuses average size 2.5 cm
Each is triangular in shape
Rudimentary at birth and usually well-developed by
the age of 7 or 8 years
Part of the frontal bone under the forehead
Drains onto the lateral wall of the middle meatus via
the frontonasal duct
which penetrates the ethmoidal labyrinth and continues
as the ethmoidal infundibulum at the front end of the
semilunar hiatus

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Frontal sinuses

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Frontal sinuses
Relations of Sinus
Superior: anterior cranial fossa and contents
Inferior: orbit, anterior ethmoidal sinuses, nasal
cavity
Anterior: forehead, superciliary arches
Posterior: anterior cranial fossa and contents
Medial: other frontal sinus
Location of Ostium : Middle meatus

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Frontal sinuses
Branches of the supra-
orbital nerve and
Supra-trochlear nerve
from the ophthalmic
nerve [V1]
Blood supply is from
branches of the
anterior ethmoidal
arteries, supraorbital
and supra-trochlear
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Ethmoidal Sinus
Composed of three sets of ethmoidal air cells
Anterior
Middle
Posterior
3 to 18 ethmoid air cells on each side
Thin-walled, bony, honeycombed spaces collectively
form the ethmoidal labyrinth located between the
orbits and the nasal fossae
May invade any of the other 3 sinuses
Ethmoid bulla: middle ethmoid air cells produce the
swelling on the lateral wall of the middle meatus

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Ethmoid Sinus
Relations of Sinus
Superior: anterior cranial
fossa and contents,
frontal bone with sinus
Medial: nasal cavity
Lateral: orbit
Location of Ostium
Anterior: middle meatus
(frontonasal duct or
ethmoidal infundibulum)
Middle: middle meatus
(on or above ethmoid
bulla)
Posterior: superior
meatus

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Ethmoid Sinus
Innervated by:
the anterior and posterior ethmoidal branches of the
nasociliary nerve from the ophthalmic nerve [V1]
the maxillary nerve [V2] via orbital branches from the
pterygopalatine ganglion.
It receive their blood supply through branches of
the anterior and posterior ethmoidal arteries
Primary lymphatic drainage
Submandibular lymph nodes - anterior and middle
ethmoid sinuses
Retropharyngeal lymph nodes - posterior ethmoid
sinus

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Ethmoid Sinus : Blood Supply

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Opening of Paranasal Sinus

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Ethmoid Sinus : Nerve Supply

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Maxillary sinuses
One on each side, are the
largest of the paranasal
sinuses 3.5 X 2.5 X 3.5 cms
Completely fill the bodies of
the maxillae
Pyramidal in shape
Roof : inferior orbital margin
Floor : Alveolus of the maxilla
Base: lateral wall of nose
Apex : zygomatic process of
maxilla

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Maxillary sinuses
Relations of Sinus
Superior: orbit, infraorbital nerve and vessels
Inferior: roots of molars and premolars
Medial: nasal cavity
Lateral and anterior: cheek
Posterior: infratemporal fossa, pterygopalatine fossa and
contents
Location of Ostium : near the top of the base, in the
center of the semilunar hiatus, which grooves the
lateral wall of the middle nasal meatus
2nd opening may be present at the posterior end of hiatus

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Maxillary sinuses
Size of opening is large in isolated maxilla, but
it gets reduced in intact skull 3-4 mm
Unicate process of ethmoid and descending part
of lacrimal bine
Below - Inferior nasal conchae
Behind perpendicular plate of palatine bone
Further reduced by thick mucosa of nose

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Maxillary sinuses

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Maxillary sinuses
Innervated by infra-orbital and alveolar
branches of the maxillary nerve [V2],
Receive their blood through branches from
the infra-orbital and superior alveolar
branches of the maxillary arteries
Primary lymphatic drainage is to the
submandibular lymph nodes

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Maxillary sinuses: Blood Supply

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Maxillary sinuses : Nerve Supply

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Sphenoidal sinuses
Two large, irregularly shaped cavities
Separated by an irregular septum
Relations of Sinus
Superior: hypophyseal fossa, pituitary gland, optic
chiasma
Inferior: nasopharynx, pterygoid canal
Medial: other sphenoid bone
Lateral: cavernous sinus, internal carotid artery,
cranial nerves III, IV, V1, V2, and VI
Anterior: nasal cavity
Location of Ostium : Sphenoethmoidal recess
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Sphenoidal sinuses

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Sphenoidal sinuses

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Innervation
Innervation of the sphenoidal sinuses is
provided by
the posterior ethmoidal branch of the ophthalmic
nerve [V1]; and
the maxillary nerve [V2] via orbital branches from
the pterygopalatine ganglion.
Supplied by branches of the pharyngeal
arteries from the maxillary arteries

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Sphenoidal sinuses: Blood Supply

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Sphenoidal sinuses: Nerve Supply

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Opening of Paranasal Sinus

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Clinical Correlate : SINUSITIS
An inflammation of the membrane of the sinus
cavities caused by infections (by bacteria or
viruses) or noninfectious means (such as allergy)
2 types of sinusitis: acute and chronic
Common clinical manifestations
sinus congestion
Discharge
Pressure
face pain
headaches
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Acute Sinusitis
The most common form of sinusitis
Typically caused by a cold that results in
inflammation of the sinus membranes
Normally resolves in 1 to 2 weeks
Sometimes a secondary bacterial infection
may settle in the passageways after a cold;
bacteria normally located in the area -
Streptococcus pneumoniae and Haemophilus
influenzae)

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Chronic Sinusitis
An infection of the sinuses that is present for
longer than 1 month and requires longer
duration medical therapy
Typically either chronic bacterial sinusitis or
chronic noninfectious sinusitis
Chronic bacterial sinusitis is treated with
antibiotics
Chronic noninfectious sinusitis often is treated
with steroids (topical or oral) and nasal
washes
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Chronic Sinusitis
Locations
Maxillary: the most common location for sinusitis;
associated with all of the common signs and symptoms but
also results in tooth pain, usually in the molar region
Sphenoid: rare, but in this location can result in problems
with the pituitary gland, cavernous sinus syndrome, and
meningitis
Frontal: usually associated with pain over the forehead
and possibly fever; rare complications include
osteomyelitis
Ethmoid: potential complications include meningitis and
orbital cellulitis

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References
Grays Anatomy for Students 2nd Edition
Head and Neck Anatomy for Dental Medicine
Head, Neck and Dental Anatomy, 4th Edition
Netters Head and Neck Anatomy for Dentistry,
2nd Edition Neil S norton
Oral Development and Histology, 3rd Edition
Woelfel's Dental Anatomy
Ten Cates Oral Histology - Development,
Structure, and Function, 7th Edition

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VOCAL CORD PARALYSIS

Presented by:
Dr. Priyanjal Gautam
PG 3rd Yr. (MS-ENT)
NIMS Medical College & Hospital, Jaipur
INTRODUCTION

Vocal cord Paralysis : defined as total


interruption of nerve impulse resulting in no
movement of laryngeal muscles.

Vocal cord Paresis : defined as partial


interruption of nerve impulse resulting in weak or
abnormal movement of laryngeal muscles.
Vocal cord paresis/paralysis can occur at any age
or sex.

Effect of VC paralysis may vary & depends on the


patients use of his or her voice.

A mild vocal cord paresis can be the end to a


singer's career but it have only marginal effect on
any other professional career life.

Vocal cord Paralysis is a sign of a disease & not a


diagnosis by itself.
ANATOMY OF LARYNX
LARYNGEAL CARTILAGES
LARYNGEAL MUSCLES
NERVE SUPPLY OF LARYNX
NERVE SUPPLY OF LARYNX
MOTOR SENSORY

All the muscles which move Above the vocal cords,


the vocal cords (abductors, larynx is supplied by
adductors or tensors) are Internal Laryngeal Nerve
supplied by the Recurrent a branch of Superior
Laryngeal Nerve except the Laryngeal Nerve & below
cricothyroid muscle, which the vocal cords by
is supplied by Superior Recurrent Laryngeal Nerve.
Laryngeal Nerve.

Both of these are branches


of the Vagus Nerve.
RECURRENT LARYNGEAL NERVE
Rt. Recurrent laryngeal nerve
arises from the Vagus nerve at the
level of Subclavian artery, hooks
round it & then ascends between
the trachea & oesophagus.

The Lt. Recurrent laryngeal nerve


arises from the Vagus in the
Mediastinum at the level of Arch of
aorta, loops round it & then
ascends into the neck in the
tracheo-oesophageal groove.

Thus, Lt. Recurrent Laryngeal


Nerve has a much longer course
which makes it more prone to
paralysis as compared to the right
one.
SUPERIOR LARYNGEAL NERVE
It arises from Inferior
Ganglion of the Vagus
nerve, descends behind
Internal Carotid artery & at
the level of Greater cornu of
Hyoid bone, divides into
External & Internal
branches.

The external branch supplies


cricothyroid muscle while
the internal branch pierces
the thyrohyoid membrane &
supplies sensory innervation
to the larynx &
hypopharynx.
FUNCTIONS OF VOCAL CORDS

Vocal cord mainly has the following movements :

Adduction : approximation of vocal cord with


each other.

Abduction : movement of vocal cord away from


each other.
ADDUCTION OF VOCAL CORDS
ADDUCTION OF LARYNX
ABDUCTION OF LARYNX
CLASSIFICATION OF LARYNGEAL PARALYSIS

Laryngeal paralysis can be :


Unilateral or Bilateral & may involve

1. Recurrent laryngeal nerve

2. Superior laryngeal nerve

3. Both (Combined / Complete)


CAUSES OF LARYNGEAL PARALYSIS
In topographical manner they are :

1. Supranuclear : Rare

2. Nuclear : Vascular disease, Neoplastic disease, Motor neuron disease,


Polio & Syringobulbia

3. High vagal lesions : Post. fossa tumors, Tubercular meningitis, Fracture of


skull base, Nasopharyngeal cancer, Glomus tumor, Penetrating injury of
neck, Parapharyngeal tumors, Metastatic neck nodes, Lymphoma

4. Low vagal or recurrent laryngeal nerve

5. Systemic causes : Diabetes, Syphilis, Diptheria, Typhoid, Viral infections,


Lead poisoning

6. Idiopathic
VOCAL CORD POSITIONS
THEORIES ON POSITION OF VOCAL
CORD IN VOCAL CORD PARALYSIS
SEMONS LAW : states that, in all progressive organic
lesions, abductor fibres of the nerve which are
phylogenitically newer are more susceptible & thus the
first to be paralysed as compared to adductor fibres

WAGNER & GROSSMAN HYPOTHESIS : is the most


widely accepted theory. It states that complete
paralysis of the recurrent laryngeal nerve results in the
vocal cord being in paramedian because of an intact
cricothyroid muscle, which adducts the vocal cord.
When the Superior laryngeal nerve is also paralysed,
the vocal cord will be in intermediate or cadaveric
position because of loss of this adductive force.
RECURRENT LARYNGEAL NERVE PARALYSIS

(A) UNILATERAL Clinical features :


Unilateral injury to recurrent
laryngeal nerve results in - Asymptomatic
ipsilateral paralysis of all the - Change in voice
intrinsic muscles of larynx
ecxept the cricothyroid.
The voice in unilateral
The vocal cords thus assumes a paralysis gradually
median or paramedian improves due to
position & doesnt move compensation by healthy
laterally on deep inspiration. cord which crosses
midline to meet paralysed
one.

Treatment : Generally no
treatment is required.
(B) BILATERAL (B/L Abductor paralysis) :

Position of vocal cords : All the intrinsic muscles of


larynx are paralysed, vocal cords lie in median or
paramedian position due to unopposed action of
cricothyroid muscles.

Clinical features :
- Dyspnoea
- Stridor
Movement of Vocal cord during
inspiration & expiration
Treatment :
Usually 6 months is an adequate time to wait for any spontaneous recovery.

In acute stridor, Tracheostomy may be required.

- If patient doesnt want tracheostomy following option can be considered :

Lateralisation of the vocal cord: Aim is to move & fix the cord in a lateral
position to improve the airway. The various procedures are:

(a) Arytenoidectomy

(b) Vocal cord lateralisation through endoscope.

(c) Thyroplasty type II

(d) Cordectomy

(e) Nerve muscle implant


PARALYSIS OF SUPERIOR LARYNGEAL NERVE
(A) UNILATERAL (B) BILATERAL
Paralysis of cricothyroid muscle & ipsilateral An uncommon condition. Both the cricothyriod
anaesthesia of the larynx above the vocal muscles are paralysed along with anaesthesia
cord. of upper larynx.

Causes : Causes:
- Thyroid surgery - Surgical or accidental trauma
- Thyroid Tumors - Diptheria
- Cervical lymphadenopathy
- Diptheria.
- Neoplastic disease
Clinical features : Clinical features:
- Weak voice with decreased pitch - Both V.C. paralysis
- Anaesthesia of the larynx on one side - Anaesthesia of larynx
- Occassional aspiration. - Cough
- Chocking fits
Laryngeal findings include : - Weak & husky voice

- Askew position of glottis - Ant. Comissure is Treatment:


rotated to healthy side. - Tracheostomy with a cuffed tube & an
- Shortening of V.C. with loss of tension & V.C. oesophageal feeeding tube.
appears wavy - Epiglottopexy is an operation to close the
- Flapping of the paralysed vocal cord V.C. sags laryngeal inlet to protect the lungs from
down during inspiration & bulges up during repeated aspiration. It is a reversible
expiration. precedure.
COMBINED/COMPLETE VOCAL CORD PARALYSIS
(Recurrent & Superior Laryngeal Nerve Paralysis)
(A) UNILATERAL :

Paralysis of all the muscles of the larynx on one side except


interarytenoid which also receives innervation from opposite side.

Aetiology :
Thyroid surgery
Lesions of nucleus ambigus which may lie medulla, post. cranial fossa,
jugular foramen or parapharyngeal space.

Clinical features :
All the muscles of larynx on one side are paralysed
V.C. lie in cadeveric position ie. 3.5mm from the midline
Glottic incompetence results in hoarseness of voice & aspiration of
liquids
Treatment:
1. Speech therapy

2. Procedures to medialise the cord- Aim is to bring the


paralysed vocal cord towards the midline so that healthy cord
can meet it. This is achieved by :

(a) Injection of teflon paste

(b) Muscle or cartilage implant

(c) Arthrodesis of cricoarytenoid joint

(d) Thyroplasty type I


(B) Bilateral:

Both recurrent & superior laryngeal nerves on both sides are


paralysed.
Rare condition.
Both cords lie in cadaveric position.
Total anaesthesia of the larynx.

Clinical features :

-Aphonia: As V.C. cords doesnt meet at all.

-Aspiration: due to incompetent glottis & laryngeal anaesthesia.

-Inability to cough: due to inability of V.C. to meet which results in retention of


secretions in the chest.

-Bronchopneumonia- due to repeated aspirations & retention of secretions.


Treatment:

1. Tracheostomy

2. Epiglottopexy

3. Vocal cord plication

4. Total laryngectomy
CONGENITAL VOCAL CORD PARALYSIS
UNILATERAL BILATERAL

Causes :
More common
- Hydrocephalus
- Arnold-Chiari malformation
Causes :
- Intracerebral haemorrhage
- Birth trauma
- Meningocele
- Congenital anomaly of great
vessels or heart - Cerebral agenesis

Clinical features :
- Dyspnoea
- Stridor
EVALUATION OF VOCAL CORD PARALYSIS PATIENT
History Local Examination :

Symptoms: (a) Examination of larynx & laryngopharynx IDL,


FOL
(a) Change in voice
(b) Hoarseness (b) Neck examination
(c) Aphonia
(d) Vocal fatigue (c) Cranial nerve examination
(e) Neck pain
(f) Aspiration Investigations :
(g) Cough
- Nasopharyngolaryngoscopy
Past Medical & Surgical History :
- Videostroboscopy
Social History :
- Chest X-ray PA view
General Examination :
- C.T. with contrast- may evaluate the entire
course of recurrent laryngeal nerve

- MRI
DIFFERENTIAL DIAGNOSIS

1. Cricoarytenoid Fixation: caused by joint


subluxation or dislocation with ankylosis.
- Joint fixation by rheumatoid arthritris or gout.

2. Laryngeal malignancy: