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

Notes

• • Vocal cords have ciliated columnar epithelium

    • Trauma (smoke etc) converts to squamous epithelium

  • SCC is by far the commonest cancer in the neck