Investigation is indicated, whose objective is shown in Table 1.

Table 1

Unilateral or Bilateral Recurrent Nerve Paralysis

CAUSESDETAILS

ThyroidectomyMost frequent cause of a laryngeal muscle paralysis

Malignant goiter

Bronchial carcinomaParticularly common in tumors arising from the upper

and middle lobes and with involvement of the mediastinal lymph node

metastases

Esophageal carcinomaParticularly of the upper third

Mediastinal diseasesLymphogranulomas, non-Hodgkin’s lymphoma, metastases,

mediastinitis

Aneurysms of the aorta or the subclavian arteryCongenital or syphilitic

Operations on the hypopharynx or the esophagusFailure to display the

course of the nerve during resection of the hypopharyngeal diverticulum

Cardiomegaly of various causesMay also occur in Ortner’s syndrome

Pulmonary tuberculosis

Pleural plaques

Blunt or sharp cervical trauma

Infective-toxicInfluenza; herpes zoster; rheumatism; syphilis; tissue

toxins such as lead, arsenic, or organic solvents; quinine

Intubation anesthesiaStretching of the recurrent nerve by incorrect

position of the patient or pressure the tube

Neurologic diseasesWallenberg’s syndrome, poliomyelitis, bulbar paralysis,

multiple sclerosis, cerebral tumors

IdiopathicIt should be noted that a diagnosis of idiopathic recurrent

nerve paralysis should only be made after all other causes have been

excluded. In the great majority of these patients spontaneous recovery

occurs within 2 to 3 months. After a longer period the chances of recovery

become less.

Treatment. If the causal disease cannot be treated satisfactorily, the patients

are given proserine, euphylline, biostimulators, vitamins, speech therapy,

electrotherapy to achieve compensatory vocal cord closure by the action of the

still-functioning vocal cord.

Bilateral recurrent paralysis

Pathogenesis you can see in Table 1.

Symptoms. (1) Dyspnea occurs with the possibility of asphyxia due to narrowing

of the glottic chink. Inspiratory stridor is particularly loud during sleep or

physical activity. (2) Initially, there is dysphonia which lasts for a variable

period, depending on the cause, and thereafter a weak, but only slightly hoarse

voice. (3) Feeble cough is also symptomatic.

Diagnosis. This is based on laryngoscopic findings. In bilateral paralysis the

vocal cords are in the paramedian position.

Treatment

1. Relief of the airway takes first priority. Immediate tracheotomy is often

necessary.

2. Cause removal.

3. Conservative treatment: proserine, euphylline, vitamins, biostimulators,

speech therapy, electrotherapy.

4. If remission does not occur, an operation to widen the glottis is indicated

at the earliest 10 to 12 months later if the patient wishes to be rid of his

tracheostomy tube.

Principles of surgery. An arytenoidectomy is carried out, and one of the

paralyzed vocal cords is moved laterally or superolaterally. The operation is

done endoscopically.

Speech therapy is used to supplement the operation.

The wider the glottic opening after operation the more unsatisfactory is the

voice.

Unilateral or bilateral paralysis

of the superior laryngeal nerve

Symptoms. These include aspiration of food and drink, loss of power of the

voice, and inability to sing in the higher part of the range, particularly in a

bilateral paralysis. Breathing is scarcely affected.

Pathogenesis. The paralysis affects the function of the cricothyroid muscle as

well as the sensory nerve supply to the supraglottic part of the larynx. The

paralysis is due to mechanical lesions of the nerve particularly after thyroid

gland operations, tumors, and viral infections.

Diagnosis. Laryngoscopy shows that the vocal cords are in the intermedian

position, the tension of the vocal cords is reduced so that the glottis does not

close completely on phonation, in unilateral paralysis, the ipsilateral vocal

cord is often shortened and lies lower than the nonparalyzed side.

Treatment. Corticosteroids should be tried, proserine, euphylline, vitamins,

biostimulators, electrotherapy and speech therapy is prescribed.

Combined lesions of the laryngeal nerves

Included are lesions of the superior laryngeal and recurrent laryngeal nerves .

Symptoms. Unilateral paralysis includes dysphonia and breathy voice due to air

loss. The healthy vocal cord compensates later. Aspiration occurs because of

absence of the sensory protection. In bilateral paralysis, there is dysphonia or

aphonia and almost always good respiration at rest. There is also aspiration and

a marked feeling of breath shortage during bodily exertion.

Pathogenesis. The basic cause is central or peripheral damage to the vagus nerve

causing a flaccid paralysis with immobility of the affected vocal cord in the

intermediate position. There is bilateral flaccid paralysis with bilateral

lesions .

Diagnosis. Laryngoscopy shows one or both of the vocal cords to be bowed and

paralyzed in the intermediate position.

Treatment. It is seldom possible to treat the cause of this paralysis, and the

mainstay of treatment is speech therapy.

If speech therapy for a unilateral atrophic vocal cord paralysis does not

succeed in producing compensation by movement of the healthy vocal cord across

the midline, the volume of the affected side of the larynx may be supplemented

to produce a satisfactory voice by injection of the affected vocal cord with

teflon paste.

Larynx stenosis

Larynx stenosis, a narrowing of larynx space, which leads to difficult

breathing, may be caused by the following causes:

1. Inflammatory edema of larynx (acute laryngotracheitis, phlegmonic laryngitis,

epiglottis abscess, suppurative processes in pharynx, parapharyngeal and

retropharyngeal spaces, in the region of the vertebra column cervical part, of

lingual root and soft tissues of the oral cavity floor).

2. Noninflammatory edema of larynx (allergologic, angioneurotic).

3. Larynx traumas (bullet, dull, shooting, cutting, thermal, chemical, after the

radiotherapy of the neck organs diseases, owing to the long intubation, long

superior tracheobronchoscopy).

4. Foreign bodies in the larynx, esophagus superior part.

5. Disorders of larynx innervation (bilateral paralysis of the recurrent

laryngeal nerves).

6. Infectious diseases (diphtheria, measles, scarlet fever, chicken-pox).

7. Larynx tumors (in adults - more often carcinoma, in children papillomatosis),

infectious granulomas (scleroma, syphilis, tuberculosis).

8. Chronic atrophic laryngitis.

9. The diseases of cardiovascular system, which are accompanied by blood

circulation insufficiency and the kidneys diseases, complicated by uremia.

According to the development time the following kinds of larynx stenosis are

made out:

1. Lightning - like - develops during few seconds, minutes.

2. Acute - develops during few hours (up to twenty four hours).

3. Subacute - develops during few days (up to week)

4. Chronic - develops during weeks and more.

It is necessary to know 4 stages of larynx stenosis:

1 stage - of compensatory respiration

2 stage - of incomplete compensation of respiration

3 stage - decompensation

4 stage - terminal one

In cases of 3 and 4 stages the tracheostomy is indicated.

Tracheotomy, laryngotomy and intubation

Indications. Tracheotomy, laryngotomy and intubation are life-saving measures

which must often be carried out as emergency procedures.

Tracheotomy

Depending on the site of tracheal entry, tracheotomy may be divided into high

access, above the thyroid isthmus, middle access, after division of the isthmus,

and low access, below the isthmus. In urgent cases a high tracheotomy is usually

carried out, although a low tracheotomy is usually carried out in children.

Principle of the operation. The operation may be carried out under intubation

anesthesia using an endotracheal tube or the rigid bronchoscope or under local

anesthesia. A collar incision is made halfway between the suprasternal notch and

the superior border of the thyroid cartilage, or a median vertical incision may

be used. The trachea is dissected out in the midline, and a window is then

created through one or two rings. Hemostasis must be secured because of the

danger of aspiration of blood. A tracheotomy tube of suitable size is

introduced, and the wound is closed as far as possible.

Indications for Tracheotomy

The relief of upper respiratory obstruction remains important reason for

tracheostomy. Any condition of disease, oedema or obstruction by disease such as

carcinoma, may demand tracheostomy.

Aspiration of secretion. This is important part of treatment where secretions

are retained in the trachea and bronchi, particularly when the effort of

cleaning the secretions is exhausting the patient. Suction through a

tracheostomy opening can be life-saving. In patients with an acute exacerbation

of severe pulmonary disease, tracheostomy also serves to reduce the dead air

space.

Protection of the airway. In cases of neurological disease in which there is

anaesthesia of the larynx or in which the cough reflexes are inhibited because

of muscular paralysis, tracheostomy with a cuffed tube provides the necessary

protection of the airway from overflow and aspiration of secretions from the

pharynx into the tracheo-bronchial tree.

Comatose states, as form head injury or poisoning, will frequently benefit from

thracheostomy which can ensure airway protection and adequate ventilation.

Wounds and accidents involving the mouth or pharynx.

Assisted respiration can be carried out most conveniently through a cuffed

tracheostomy tube connected to a mechanical respirator in the patient with

respiratory paralysis.

Intubation

Short-term intubation, orotracheal intubation (i. e., less than 48 hours).

For respiration of patients under muscle relaxants, e. g. Intubation anesthesia

In acute obstructive respiratory insufficiency whose cause can probably be

relieved within 24-48 hours by minor operative procedures or antiinflammatory

measures such as steroids and antibiotics or which can be relieved in a short

period by assisted respiration, assisted respiration as a temporary emergency

measure; if a tracheotomy is impossible or contraindicated.

Long-term intubation, nasotracheal intubation, (i.e., for several days or

weeks).

Long-term intubation should not be undertaken in adults because of the great

danger of resulting scar tissue stenosis in the larynx or trachea. Also modern

forms of tubes and cuffed tubes do not reliably prevent the development of

stenosis which may only become manifest several months later. Patients with

infections of the airway, those taking steroids, those with hypotension, or

those under the influence of intoxicants are particularly at risk.

On the other hand, in small children prolonged intubation using the correct

technique (transnasal-endotracheal) and inert soft materials often produces

fewer complications than a tracheotomy.

Technique. Intubation may be carried out without anesthesia in patients who are

already deeply unconscious, otherwise, a short intravenous anesthetic relaxant

is used. The operator must be able to ventilate the patient with a mask, which

should be available. The operator must have sufficient practical experience in

intubation.

Intubation technique. (1) The position of the patient must be such that the head

and neck are mobile and accessible. (2) The blade is introduced and the glottis

exposed. (3) The tube is introduced into the trachea through the glottis under

direct vision. (4) The tube is secured. Correct positioning of the tube is

assessed by the air flow. The tube is connected to a respirator and fixed with

adhesive plaster.

An indwelling tube to provide assisted respiration, e.g., in the intensive care

unit or after cervical injuries, etc., should not be retained for longer than 24

to 48 h and certainly for no more than 72 h. Otherwise, there is a danger of

scar tissue stenosis of the trachea. If assisted respiration is needed for

longer periods, the tube should be replaced by a tracheotomy. Infants are an

exception because experience has shown that a soft transnasal tube carries less

risk than a tracheotomy.

Increasing respiratory obstruction due to tracheal stenosis may not manifest

itself for several months.

Laryngotomy

This is an emergency procedure. It must be revised as rapidly as possible by a

regular tracheostomy because of the danger of laryngeal stenosis.

Principle of the operation. A skin incision is made just superior to the

prominent arch of the cricoid cartilage with the head extended. At this point

the cricothyroid ligament lies superficially under the skin, and there are no

large vessels at this site. The membrane is exposed and a horizontal incision is

made in it. The incision is held open with a tube or a spreading instrument.

Part 9

TUMOURS AND INFECTIOUS GRANULOMAS

OF THE UPPER RESPIRATORY TRACTS AND EAR

TUMOURS OF THE NOSE

Rhinophyma

This condition occurs almost exclusively in males past middle age in whom it may

cause considerable deformity, and thus distress, on account of the

disfigurement. It is due to hypertrophy of the sebaceous glands of the tip of

the nose, and produces a marked swelling of the nasal apex which becomes bulbous