• Vocal cord paralysis is a sign not a diagnosis
• RLN palsy is only idiopathic if you've scanned all the way down to the diaphragm
• Bit like Bell's palsy
• Leave it six months as it may recover
• After that can surgically move and fix the vocal cord to restore voice
• Left is more commonly affected that right as it has a longer course
• If the palsy is due to cancer they're in trouble
• Impingement typically comes from mediastinal lymph node, not from the primary
• RLN has sensory as well as motor functions
• Patients can't feel their swallow => Risk of choking and aspiration
• Aspiration pneumonia is the most common cause of death

Causes of horse voice

• Inflammatory
• Bacterial
• TB and syphilis are the big historical causes
• Viral
• Traumatic
• Granuloma after prolonged intubation
• Direct trauma
• Vocal cord nodules
• These are not neoplastic - just due to oedema and inflammation
• Neoplastic
• Benign
• Malignant
• T1 = One side of the cords only
• T2 = Involving anterior commisure and both sides
• T3 = Local invasion
• T4 = Distant spread
• RLN palsy
• Other rare causes
• Reinke's edema: Swelling of the vocal folds due to oedema in superficial lamina propria of vocal cords (Reinke's space) due to:
• Smoking
• GORD
• Hypothyroidism
• Chronic voice abuse
• Psychogenic (test with distraction during endoscopy)

Frey's syndrome

• Causes Gustatory Sweating
• Results as a side effect of parotid gland surgery or due to injury to auricotemporal nerve
• Following damage the parasympathetic fibres regenerate in the wrong direction and make their way to the skin where they inappropriately innervate sweat glands
  

Nerve branches

• Trigeminal
• Ophthalmic
  
• Maxillary
• Mandibular
• Facial
• Two - Temporal
• Zulus - Zygomatic
• Buggered - Buccal
• My - Mandibular
• Cat - Cervical
  

Notes

• Vocal cords have ciliated columnar epithelium
• Trauma (smoke etc) converts to squamous epithelium
• SCC is by far the commonest cancer in the neck