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Otorhinolaryngology Department
CVMC

Larynx and Trachea

Group 6.
PGI Lacambra, Abigail
PGI Miguel, Ryan James
JI Tumbali, Ma. Angelica
JI Bugtong, Zyra B
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LEARNING OBJECTIVES

1. To discuss the basic anatomy and physiology of the larynx.

2. To know the physiology of phonation.
3. To familiarize the basic anatomy and physiology of the trachea.
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L A RY N X
Anatomy
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E M B RY O L O G Y A N D D E V E L O P M E N T
• 4th week: respiratory diverticulum  larynx, trachea, and
lungs.
• 6th week: laryngeal lumen becomes obliterated
(mesenchyme)
• 10th week: recanalization
 At birth: C2 or C3
 6-8 y/o: C5

Branchial arches
Hyoid bone Second and third
Laryngeal cartilages Fourth and sixth
Cricothyroid muscle Fourth arch
,SLN
Intrinsic laryngeal Sixth arch
muscles , RLN
 5 Laryngeal cartilages and joints
Triticeous
Cuneiform cartilage
Epiglottis
cartilage

Hyoid
bone

Thyroid Corniculate
cartilage cartilage

Arytenoid
cartilage Cricothyroid Cricoarytenoid
joint joint

Cricoid cartilage
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Laryngeal muscles
Extrinsic Laryngeal Muscles
Depressor muscles Sternohyoid, Thyrohyoid and Omohyoid
Elevator muscles Geniohyoid, digastric, mylohyoid and stylohyoid
Pharyngeal Constrictor Superior,middle,inferior constrictor
muscles
Cricopharyngeus
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Intrinsic laryngeal muscles
Interarytenoid muscle
Posterior cricoarytenoid (transverse and oblique
(Cereatocricoid muscle) interarytenoid muscles) Cricothyroid muscle

Lateral cricoarytenoid muscle Thyroarytenoid muscle Thyroarytenoid muscle

(lateralis muscle) (lateral part) (medial part - voacalis muscle)
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Extrinsic laryngeal ligaments

Median Thyroepiglottic
thyrohyoid ligament
ligament

Lateral thyrohyoid
ligament

Hyo-epiglottic
ligament
Thyrohyoid
membrane

Cricotracheal
ligament
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Intrinsic laryngeal ligaments

Quadrangular
membrane

Median
Cricothyroid
ligament
Vestibular ligament

Vocal ligament

Cricothyroid Cricovocal
ligament ligament
10
Topograhic anatomy of the larynx
Compartments, spaces and divisions and of the larynx
Laryngeal
Vestibule

Laryngeal
Ventricle

Paraglottic
Pre-epiglottic
space
space

Pyriform fossa

Glottis
(rima glottidis)
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Laryngeal mucosa
12
Laryngeal nerve supply
13
Laryngeal blood supply and lymphatic drainage
14

L A RY N X
Physiology
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Larynx: key functions

1. Conducts air from pharynx to trachea.

2. Facilitates production of speech.
3. Protection of the Lower Airway:
 To prevent aspiration during swallowing
 Cough
 Variation of glottic resistance according to respiratory demand
 Valsalva maneuver

Reflexes
• Manipulations within the larynx (e.g., intubation)  Vasovagal reflex pathways
• Hyperactive laryngeal reflex  Sudden infant death
16
Phonation
Requirements for normal phonation:
1. Appropriate vocal fold approximation
2. Adequate expiratory force
3. Control of length and tension
4. Intact layer structure of lamina propria for mucosal mobility
5. Adequate vocal fold bulk—(vocalis muscle may become atrophic with aging,
neuropathy, or disuse)
6. Resonance of vocal tract
17
Phonation: Mechanism
Exhaled air increases subglottic pressure to push vocal folds apart

Airflow through glottis creates negative pressure, pulling vocal folds back together
(Bernoulli effect).

Myoelastic forces also pull the vocal folds back together.

Cycle begins again as glottis closes.

18 TRACHEA
Anatomy

• From C6-C7 to the T4-T5

vertebra

• 12-20 hyaline cartilage

‘rings’
Anterior Posterior
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Trachea: Relations

• Length: 10-13 cm in adults

(cervical part: 6-7 cm)

• Transverse diameter: 13-20 mm

(F: 13-16 mm; M: 16-20 mm)
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Trachea: Blood supply, Lymphatic drainage & Innervation

BLOOD SUPPLY
• Inferior thyroid artery
(from the thyrocervical trunk)
• Superior thyroid artery

LYMPHATIC DRAINAGE
• Vertical lymphatic chain
(Deep cervical lymph nodes)
• Paratracheal and mediastinal
group of lymph nodes
INNERVATION
• Vagus nerve
• Sympathetic trunk
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TRACHEA
Physiology

 Lined by two rows of ciliated epithelium with goblet cells.

1. Transports the inspiratory air to the lungs and channels the expiratory air
from the lungs to the mouth and nose.
2. Mucociliary clearance mechanism
• contributes to the cleaning, warming, and humidification of the inspired
air.
LARYNX &
TRACHEA
DIAGNOSTICS AND DISEASES
 Cardinal Symptoms

Inspiratory
Dyspnea
stridor

Phonation
problems Eating
(hoarseness difficulties
)
 METHODS OF
EXAMINATION
 INSPECTION AND PALPATION
INSPECTION PALPATION

Configuration of the larynx Bimanual

Inspiratory Jugular retraction d/t Contour irregularities

laryngotracheal obstruction
Sites of tenderness
Observe for the mobility of the larynx
Suspicions of malignancy: include thyroid
gland and cervical soft tissues
 INDIRECT
LARYNGOSCOPY
● Classic Indirect Laryngoscopy
● Telescopic laryngoscopy
● Flexible endoscopy
INDIRECT LAYNGOSCOPY
CLASSIC LARYNGOSCOPY

• Materials: laryngeal mirror, light source, head mirror, gauze sponge

• Patient is sitting upright, with dentures removed
INDIRECT LAYNGOSCOPY
TELESCOPIC LARYNGOSCOPY

 Rigid endoscope with a 90- degree view that can illuminate and magnify the area being examined.
 Area displayed in natural position
 For biopsies and tissue ablation in the conscious patient
INDIRECT LAYNGOSCOPY
FLEXIBLE ENDOSCOPY

 Ideal for patients with a powerful gag reflex, despite adequate topical anesthesia
 Necessary also when it is needed to combine laryngeal inspection with tracheobronchoscopy.
 Disadvantage: delivers poor images over rigid telescopes.
 DIRECT
LARYNGOSCOPY
Direct Laryngoscopy
● Provides direct view into the larynx, most commonly performed under general anesthesia
● Use either intubation anesthesia or injector ventilation without an endotracheal tube.
IMAGING OF THE LARYNX
● Plain Radiographs
● CT Scan
● MRI
● Ultrasonography
● Laryngography
Plain Radiography
● Anteroposterior and Lateral Projections: demonstrate skeletal framework of the larynx
● Useful in patients with laryngeal fractures or suspected foreign body.
● Stenoses in laryngotracheal junction.

CT SCAN AND MRI

● Yield more diagnostic information
● Define the precise existent of laryngeal and tracheal masses

ULTRASOUND AND FUNCTION TEST

● Ultrasound: evaluate prelaryngeal and paralaryngeal soft tissues, mass erosions. However, intralaryngeal structures
cannot be clearly visualized.
● Laryngography: inner surface of the larynx is wet with a contrast medium, no longer has any practical importance today.
Trachea
●Cardinal Symptoms
○Cough
○Sputum production
○Respiratory distress
Methods of examining the trachea

●Inspection
○Cervical mass
●Palpation
○Palpate thyroid gland
●Indirect Laryngoscopy
○View the upper part of trachea through the glottis
●Endoscopic examination (Flexible tracheoscopy, Rigid tracheoscopy)
○If tracheal pathology is suspected
Flexible tracheoscopy
●Performed under topical anestheesia
●Permits a detailed evaluation of the trachea and the entire bronchial tree
●Can be:
○Diagnostic procedure
■Specimen retrieval
○Therapeutic procedure
■Fiberoptic intubation, foreign body extraction
Rigid Tracheoscopy

●Performed under general anesthesia

●Risk of bleeding
Plain radiographs
●PA/L view
○Demonstrate the tracheal air column along with any
intraluminal lesions or masses that are causing
extrinsic tracheal compression
MALFORMATIONS OF THE
LARYNX and TRACHEA
Malformations of the trachea
 LARYNGOMALACIA
EPIDEMIOLOGY
 Most frequent cause of congenital stridor (60-75% cases)

ETHIOPATHOGENESIS:
 The supraglottic structures are abnormally soft and pliable, causing them to collapse during inspiration.
 Neurologic abnormalities
 Infectious processes

SYMPTOMS:
 Low pitched inspiratory stridor (audible from birth)
 Constant or intermittent and may change with the position of the child (loud on supine)
 Feeding difficulties

DIAGNOSIS:
 Laryngoscopy  aryepiglottic folds are shortened and arytenoid cartilages are bowed anteriorly and toward
each other

 Soft, pale “omega-shaped” epiglottis

 Extreme case: epiglottis completely covers the laryngeal inlet

 LARYNGOMALACIA

DIFFERENTIAL DIAGNOSIS:
 Rare Cleft Anomalies: (+) dysphagia with recurrent episodes of aspiration
 Congenital cysts and Laryngoceles rules out by laryngoscopy

TREATMENT:
 Stridor resolves without treatment in the first 2 years of life as the laryngeal skeleton becomes more rigid.
 Rare cases: temporary tracheotomy
 Asssurance: since the condition is harmless in most cases.
 CONGENITAL LARYNGEAL CYSTS
● Develop on the laryngeal side of the
epiglottis or at the subglottic level
● Common in ventricular fold and
aryepiglottic fold
● Attributed to appendicular constriction of
laryngeal ventricle
● Contains mucus and lined with ciliated,
columnar, or squamous epithelium
● Large cysts  dyspnea, hoarseness,
occasional dysphagia
● Removed during microlaryngoscopy
 LARYNGOCELES
● Extremely rare cause of airway
obstruction in infants and small children.
● In most cases, this extends past the
superior border of the thyroid cartilage
and protrudes through the thyrohyoid
membrane
● Common in players of wind instruments.
 CONGENITAL LARYNGEAL WEB and
GLOTTIC ATRESIA
ETHIOPATHOGENESIS:
 Membrane-like stenosis of the glottis plane
 Incomplete recanalization  laryngeal web
 Complete failure of recanalization  Glottic atresia

SYMPTOMS:
 Inspiratory stridor
 Breathy, aphonic voice
 Usually discovered only when the patient is to be
intubated

DIAGNOSIS:
 Laryngoscopy: web is seen stretching across the
anterior commissure
 Leaving a residual posterior glottis airway sufficient
for respiration

TREATMENT:
 Divided during microlaryngoscopy, although there is
risk of recurrent synechia formation in the anterior
commissure.
 To prevent this, doctors place stent (keel) between the
focal folds
 CONGENITAL SUBGLOTTIC STENOSIS
EPIDEMIOLOGY:
 Most common stenosing anomaly
 Second most cause of congenital stridor

ETIOPATHOGENESIS:
 Incomplete form of subglottic atresia, presents as a ring-shaped narrowing 2-3
mm below the glottis plane
 Soft stenosis: thickened fibrous tissue
 Hard stenosis: malformation of cricoid cartilage

SYMPTOMS:
 Inspirtatory stridor unaffected by position/ “FIXED STRIDOR”

DIAGNOSIS:
 Narrowing of laryngeal lumen below the glottis plane.

TREATMENT:
 Surgical procedure to enlarge the larynx
CONGENITAL VOCAL CORD PARALYSIS
ETIOPATHOGENESIS:
● Lesion of the vagus nerve or its branches (unilateral/ bilateral)

SYMPTOMS:
● Hallmark of a unilateral recurrent nerve palsy that does not require treatment: weak cry in a normally
breathing infant
● Cardinal symptom of bilateral congenital vocal cord paralysis: respiratory distress with stridor and cyanosis
● Impaired swallowing due to loss of pharyngeal sensation (superior laryngeal nerve)

DIAGNOSIS AND DIFERENTIAL DIAGNOSIS:

● Unilateral or bilateral vocal cord fixation
● If both cords are immobile, diff dx should include congenital ankylosis of the cricoarytenoid joints.
Differentiated by electromyographic testing of the vocal muscle.

TREATMENT:
● Bilateral paralyisis  secure airway by tracheotomy or by early fixation of one vocal cord
Infectious Diseases of the Larynx and Trachea in Children

●Diseases associated with croup symptoms

○Croup syndrome
■Inspiratory stridor caused by laryngeal or subglottic stenosis
■Associated with respiratory distress, cough, and hoarseness
○True croup
■Laryngitis in the setting of diphtheria
○Pseudocroup
■Collective term for viral, bacterial, and spastic forms of subglottic laryngitis
○Diphtheria/True Croup
■Results from membrane formation and airway stenosis
■Symptoms
●Hoarseness, barking cough, inspiratory stridor
○Acute subglottic Laryngitis/Pseudocroup/Acute Laryngotracheobronchitis
■Viral disease (parainfluenza/influenza/RSV/Measles/VZV/Rubella)
■Symptoms
●Hoarseness, dry barking cough, Stridor during evening hours or few hours after
sleep
■Treatment
●Mild cases-Supportive
●Severe Cases-Intubation
○Bacterial Laryngotracheitis
■Primary Viral with subsequent bacterial superinfection (staphylococci,
Streptococci, H. Influenzae)
■Gradual onset of rhinitis and pharyngitis, with expiratory and inspiratory
stridor, crackles on both lungs
■Treatment
●Antibiotic therapy, supplemented with mucolytic agents
○Acute Spasmodic Laryngitis
■Predominantly seen on male infants
■Etiology not fully understood
●Can be caused by allergies
●GERD
■A child with no previous signs of infection wakes at night because of
coughing, stridor and dyspnea
■Treatment
●Self-limiting
●Acute Epiglottitis
○Affects children 2-8 years of age
○Caused by H. influenzae
○Marked by high-grade fever, inspiratory stridor, respiratory distress, dysphagia
○Diagnosis
■Examination of oral cavity and pharynx
●“cherry red epiglottis”
●Abscess formation
○Treatment
■Antibiotic Therapy
■Intubation-severe cases
■Vaccination: H. influenzae
●Laryngeal Involvement by Infectious diseases
○Syphilitic Laryngitis
■Occurs in acquired syphilis, in all stages
Inflammatory Diseases of the Larynx and Trachea in adults
●Acute Laryngitis
○Occurs in URTI that descends to involve the larynx
○Has viral etiology, and bacterial superinfction
○Hallmark: Hoarseness
○Diagnosis
■Inspection of Larynx
●Redness, thickening or edema of vocal cords
○Treatment
■Voice rest
■Mucolytic agents, and Anti-Inflammatory agents
●Acute Epiglottitis
○Bacterial Inflammation (H. influenzae, S. pneumoniae,
GABHS)
○High Risk of airway Obstruction
■Patient must be hospitalized for observation and treatment
■IV antibiotics, Anti-inflammatory agents
●Angioneurotic Laryngeal Edema, Acute Laryngeal edema
○Rare, paroxysmal disease
○Hereditary angioneurotic edema is caused by deficiency in C1 esterase
inhibitor
○Edematous swelling of larynx causes stridor
○Diagnosis
■Indirect laryngoscopy
■Serologic test
○Treatment
■Cortocsteroids, antihistamines, Epinephrine
●Chronic Nonspecific Laryngitis
○Most prevalent in smokers and persons who abuse their voice
○Hoarseness, rapid vocal fatigue, frequent throat clearing, dry cough
○Diagnosis
■Telescopic laryngoscopy
●Cobblestone apperance
○Treatment
■Identify causal irritants
■Acute exacerbations- Antibiotics
●Reinke’s Edema
○A subepithelial fluid collefction forms between the glottic epithelium and
the vocal ligament (reinke’s space)
○Main etiologic factors: Nicotine abuse and Voice abuse
○Hoarseness, frequent throat clearing, decrease in habitual voice pitch
○Diagnosis
■Laryngoscopy
● glassy, edematous swelling at the level of vocal cords
○Treatment
■Microsurgical removal of edema
●Posterior Laryngitis/Gastroesophageal reflux Laryngitis
○Intractable hoarseness, foreign body sensation
○Results from injury to the laryngeal and pharyngeal mucosa caused by
chronic exposure to gastric acid
○Diagnosis
■Laryngoscopy
●Garden fence appearance
○Treatment
■Underlying cause of Acid reflux
Laryngitis in Chronic Infectious Diseases
●Tuberculous Laryngitis
○Secondary to active PTb
○Severe hoarseness, frequent throat clearing, aphonia
○Diagnosis
■Laryngoscopy
●Redness and thickening of vocal cord
○Treatment
■Mucosal changes will heal in response to Anti-Tb therapy
●Contact Ulcer
○Caused by chronic voice abuse
○Hoarseness, foreign-body sensation, throat pain
○Diagnosis
■Laryngoscopy
●Hammer and anvil effect
■Treatment
●Voice therapy
Foreign-body Aspiration and Injuries to the Larynx and trachea
● Foreign body Aspiration occurs in children as well as adults
○ Oropharyngeal swallowing abnormalities predispose to foreign-body aspiration
○ Symptoms depend on the size, shape, and composition of the foreign body, its location, and the age of the patient
○ Can immediately lead to death
■ “Bolus Death”
Diagnosis
clinical examination
Radiographs
Endoscopy
Treatment
Heimlich maneuver
○ Endoscopy
●External Injuries to the Larynx and Extrathoracic Trachea
○Caused by Trauma
■Direct attack to the anterior neck
■Hyperextension of the neck
○Symptoms
■Pain, Dysphagia, hemoptysis, Respiratory Distress
○Diagnosis and Treatment
■Initial management: Secure airway
■Endoscopy
■CT scan
●Assess extent of injury
●Internal Injuries to the Larynx and trachea
○Thermal Injuries
■Scalds and burns
■Result from aspiration , burns due to hot foods or drinks, surgical laser
○Chemical agents
■Affect the pharynx and supraglottic larynx
○Chemical agent injury are mainly caused by household cleansers
■Accidental swallowing in children
■Suicidal attempts in adults
○Acids-Coagulative necrosis
○Alkali-Liquefactive necrosis
○Airway obstruction due to mucosal selling
○Diagnosis and treatment
■Initial approach: secure airway
■Systemic therapy for the caustic ingestion
○Mechanical Injuries
■Result of medical procedures such as intubation, endoscopy, foreign-body extraction
■Effects of prolonged Intubation
●Damage to mucosa
○Major pathogenic factor is a possible disproportion of the caliber of the endotracheal tube
and the internal diameter of the cricoid cartilage
TUMORS OF THE LARYNX
AND TRACHEA
BENIGN NEOPLASM MALIGNANT TUMORS
● Vocal cord polyps ● Laryngeal Carcinoma
● Cysts and Mucoceles ● Chondroma
● Papillomas ● Osteochondroma
● Layngeal papillomatosis ● Osteoma
● Vocal nodules ● Tracheopathia osteochondroplastica
BENIGN NEOPLASMS OF THE
LARYNX
 VOCAL CORD POLYPS
EPIDEMIOLOGY:
● Adults in speaking profession, with a preponderance of males.

ETIOPATHOGENESIS:
● Most frequent cause: mechanical alteration of the vocal cords caused by vocal
overuse (phonotrauma) and chronic inflammation
● Histo: polypoid mucosal hyperplasia with inflammatory component
● Most are unilateral (90%) and located on the free edge of anterior 2/3 of the
vocal cords.

SYMPTOMS:
● Cardinal symptom: hoarseness

DIAGNOSIS:
● Grayish red sessile or pedunculated mass on the vocal cord

TREATMENT:
● Microsurgical removal followed by voice therapy
 CYSTS AND MUCOCELES
EPIDEMIOLOGY:
● Common in older patients, rare in children

ETIOPATHOGENESIS:
● Cystic lesions are from the mucosal glands of the
laryngeal mucosa  lined by squamous or
columnar epithelium
● Mucus filled retention mucoceles and
extravasation mucoceles  respiratory epithelium

SYMPTOMS:
● Hoarseness, globus sensation, dyspnea

DIAGNOSIS:
● Smooth, epithelium- covered masses of varying
sizes

TREATMENT:
● Removal by endolaryngeal microsurgery
PAPILLOMAS AND LARYNGEAL PAPILLOMATOSIS
EPIDEMIOLOGY:
● Most common benign tumors in children.
● 2 – 4 years old  juvenile papillomas
● 10-40 years old  solitary juvenile papillomatosis with
multiple lesions that spread to the trachea and bronchial
system

ETIOPATHOGENESIS:
● HPV (6 and 11)

SYMPTOMS:
● Hoarseness, inspiratory stridor

DIAGNOSIS:
● Multiple soft, reddish- pink, villous, raspberry like lesions

TREATMENT:
● CO2 laser surgery
● Beta interferon
● virostatics
 VOCAL NODULES
EPIDEMIOLOGY:
● Children (screamer’s nodules)
● Singer’s nodules
● Professional speakers (women)

ETIOPATHOGENESIS:
● Harmful vocal habits affecting the junction of anterior and
middle thirds of the vocal cords.
● Histo: fibrosis with epithelial thickening and submucosal
connective tissue proliferation

SYMPTOMS:
● Hoarseness, diplophonia, habitual throat clearning, foreign
body sensation

TREATMENT:
● Treatment of choice: voice therapy
● Surgical removal (large nodules)
MALIGNANT LARYNGEAL
TUMORS
 LARYNGEAL CARCINOMA
EPIDEMIOLOGY:
● Most common head and neck malignancies (40%)

ETIOPATHOGENESIS:
● Epithelial changes, chronic laryngitis

HISTOLOGY, SITES OF OCCURRENCE:

● Majority: keratinized or nonkeratinized squamous cell carcinomas (90-95%)
● 60% are located in the glottis plane, 40% in the glottis region, and 1% in subglottis
● Transglottic carcinoma  carcinoma of glottis, morgagni pouch and ventricular fold that has an indeterminate
site of origin
● Glottic malignancies have better prognosis that supraglottic and subglottic cancers because of its limited lymphatic
drainage.
● Distant metastases are unusual with laryngeal malignancies.

SYMPTOMS:
● Foreign body sensation, habitual throat clearing, dysphagia, respiratory distress, hemoptysis
● Hoarseness of voice for glottis malignancies (main reason enabling early diagnosis)
● Note: hoarseness of > 2-3 weeks should be investigated by laryngoscopy
● Otalgia (earache in the absence of ear abnormality)  signify tumor related irritation of the vagus nerve
 LARYNGEAL CARCINOMA
DIAGNOSIS:
● Indirect layngoscopy  vocal cord mobility
● Palpation of the laryngeal skeleton and soft tissues of the
neck
● Ultrasound of cervical soft tissues to detect probable
regional metastases.
● Microlaryngoscopy  define the tumor extent and obtain
samples

TREATMENT:
● Surgery (highest cure rate) and radiotherapy
● Larynx- sparing and voice- sparing partial resection
prescribed for patients with circumscribed tumors.
● Early glottis cancers  radiotherapy alone for superior
voice quality after treatment

PROGNOSIS:
● Depends on the location and stage of the dse.
TRACHEAL TUMORS
CHONDROMA, OSTEOCHONDROMA, OSTEOMA
● Appear endoscopically as a thickening of tracheal or bronchial cartlages surrouned by a capsule.
● Grow very slowly but can potentially cause bronchopulmonary destruction.

TRACHEOPATHIA OSTEOCHONDROPLASTICA
● Based on the malformation of the tracheal and bronchial cartialges
● Abnormal deposits of cartilaginous tissue causing progressive airway obstruction.
● No casual treatment.
● Manifested by wheezing, coughing, hemoptysis and increasing respiratory distress.

MALIGNANT TUMORS OF THE TRACHEA

● The most common type is adenoid cystc carcinoma.
● High possibilities to invade nearby structures
● Essential pallaitve measure: airway maintenance by tumor debulking, stent insertion or tracheotomy
NEUROGENIC DISORDERS
OF THE LARYNX
 RECURRENT LARYNGEAL NERVE PARALYSIS
(UNILATERAL)
SYMPTOMS:
● Hoarseness

DIAGNOSIS:
● Noted during inspiration, with the vocal cord fixed in a
paramedian position.
● Electromyography (EMG) helpful in differentiating a
recurrent laryngeal nerve lesion from arytenoid dislocation
(usullay caused by intubation trauma) and arytenoid
fixation

TREATMENT:
● Depends chiefly on the cause.
● In cases of severed nerve, there is little hope in
reapproximating the ends due to erratic nature of
regeneration by axonal sprouting.
● Spontaneous recovery 6-12 months for unsevered nerve.
 RECURRENT LARYNGEAL NERVE PARALYSIS
(BILATERAL)
SYMPTOMS:
● Dyspnea (vocal cords assume a closed postion due to
stronger action of adductor muscles over abductor
muscles)

DIAGNOSIS:
● Laryngoscopy during respiration shows cords fixed in
paramedian position and passive motion in response to
airflow.

TREATMENT:
● Immediate tracheotomy is unavoidable in majority of
cases
● Surgical procedures to widen the glottis should be
considered no earlier than 6 months after the onset of
paralysis.
SUPERIOR LARYNGEAL NERVE PARALYSIS
● Iatrogenic: Thyroid surgery (affect only motor component)
● Laryngeal surgery (aslo affects the sensory component)
● Less common than recurrent laryngeal nerve paralysis
● Voice therapy can be done in some of the cases
● Cases of internal brach involvement: impairment of laryngeal sensation
● Bilateral lesions: dysphagia with aspiration

DIAGNOSIS:
● Vocal cord on the affected side appears flaccid
VAGUS NERVE PARALYSIS
SYMPTOMS:
● Combination of the symptoms of recurrent laryngeal nerve
paralysis and superior laryngeal nerve paralysis
● Bilateral: Dyspnea
● Unilateral: Hoarseness

DIAGNOSIS:
● Immobile vocal cord, fixed in an intermediate position

TREATMENT:
● Immediate tracheotomy is unavoidable in majority of
cases
● Surgical procedures to widen the glottis should be
considered no earlier than 6 months after the onset of
paralysis.