© Borgis - New Medicine 2/2003, s. 12-14
Lechosław P. Chmielik, Lidia Zawadzka-Głos, Mieczysław Chmielik, Małgorzata Badełek-Izdebska, Anna Jakubowska1
Vocal fold paralysis and paresis in children in ENT Clinic records
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik M.D.
1Department of Paediatric Radiology and Radiotherapy
Head: Prof. Andrzej Marciński M.D.
Vocal fold paralysis is a disease of varied and complicated aetiology. In the Paediatric ENT Clinic in Warsaw, from 1998 to 2003, 43 children with vocal fold paralysis were admitted. Radiological and endoscopic examinations were used for diagnosis. We tried to establish the aetiology and pathomechanism of the condition. We have summarized the material and made correlations between different diagnostic methods, and proposed a strategy for therapy.
Vocal fold movement dysfunctions can be caused by functional disorders or organic processes in the central or peripheral nervous system. A degree of voice loss is the first symptom of vocal fold movement dysfunctions. After that, breathing difficulties occur.
The aetiology of functional paresis is compound, and – is still the subject of scientific research. Functional disorders of the larynx are divided into: phonastenia, pseudophonastenia, spastic aphonia and hysterical aphonia (7).
Ten percent of all cases are central paralysis. They are a part of a more compound clinical picture in disorders of the vascular system, brain inflammatory processes, multiple sclerosis, tumours, syphilis, syringomelia, bulbar syndrome, pseudobulbar syndrome and inferior posterior cerebellar artery syndrome (6, 7). Ninety percent of the cases are peripheral paralysis of the larynx muscles. This is due to the topography of these muscles (6, 7). The left recurrent laryngeal nerve originates from the vagus nerve to the front at the level of the arch of the aorta, and ascends into the groove between the trachea and oesophagus. The inferior laryngeal nerv e is the terminal branch of the recurrent laryngeal nerve. The inferior laryngeal nerve innervates the muscles of almost the whole pharynx, except the cricothyroid muscle, which is innervated by the superior laryngeal nerve. The left laryngeal nerve is extremely susceptible to disease processes in the thorax. The right recurrent laryngeal nerve originates from the vagus nerve at the level of the subclavian artery, curving round it from front to back and ascending.
Peripheral paralysis can be caused by the following: inflammatory factors – bacterial or viral infections; toxic factors – alcohol, haematological diseases, avitaminosis; compression factors – basal skull tumours, nasopharynx tumours, megalnodules of the neck, tumours of the superior part of the pharynx and trachea, tumours of the mediastinum, changes in the configuration of the heart and great vessels, lung and bronchi tumours; traumatic factors – basal skull fractures, iatrogenic complications during intubation, bronchoscopy, oesophagoscopy, operations on the neck, oesophagus, trachea, great vessels and the heart.
Studies on the vagus nerve carried out by many scientists have established the following classification for vocal fold paralysis (5, 7):
– a high lesion of the vagus nerve gives the intermedial position of the vocal fold,
– total breaking of the recurrent nerve gives the paramedial or medial position, but the vocal fold is not changed,
– unilateral paresis only of the internal branch of the superior laryngeal nerve causes no movement symptoms,
– bilateral paresis only of the external branch of the superior laryngeal nerves gives vocal fold relaxation and an inability to speak in a high voice. There are no voice changes in people that do not use their voice professionally,
– paresis only of the recurrent laryngeal nerve and the internal branch of the superior laryngeal nerve causes the paramedial position of the vocal fold, and abduction and rotation of the arytenoid cartilages.
Bilateral vocal fold paralysis causes dyspnoea, when it is paralyzed in the median and paramedian position. In the intermedial position rest dyspnoea cannot occurr. Dyspnoea occurs when the breathing surface of the glottis is decreased by 3/4. This condition needs prompt intervention as a rule (6).
Unilateral vocal fold paralysis does not cause breathing defects, and the defence function of the larynx is not disturbed as a rule. The type of voice disorder depends on the position of the vocal fold. In the medial and paramedial positions the voice can be unchanged, but in the intermedial position the voice is silent, aphonic or hoarse (7).
MATERIAL AND METHOD
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