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13.03.14 ENT clinic notes

Things to remember about the RLN
  • 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


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