vocal cord paralysis
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Representative coronal (a) and axial (b, c) illustrations demonstrating the normal course of the bilateral vagus and recurrent laryngeal nerves. The right recurrent laryngeal nerve loops posteromedially under the right subclavian artery (a, b), and the left recurrent laryngeal nerve loops posteromedially beneath the aortic arch (a, c)
Aortic
pseudoaneurysm • Vocal cord paralysis due to thoracic aortic pseudoaneurysm - Ganzer Fall bei Radiopaedia
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Laryngocele. A 67-year-old man with history of prior tongue base and oropharyngeal squamous cell carcinoma status post radiation completed 8 years prior presents with dysphagia and hoarse voice. Axial (a) and coronal (b) contrast-enhanced CT images demonstrate bilateral supraglottic laryngoceles (arrows) with mild extralaryngeal extension on the left
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Representative illustration of the brainstem demonstrating the normal configuration of the cranial nerves and their associated nuclei. The vagus nerve originates from the nucleus ambiguus of the medulla
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Representative illustration of the larynx at the level of the true vocal folds demonstrating the normal configuration of the cartilaginous structures and intrinsic musculature
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Carotid space trauma. A 33-year-old woman who sustained a stab wound to the neck, subsequently noted to have a weak voice; laryngoscopy confirmed vocal cord paralysis. Axial CTA of the neck (a) reveals a radiopaque marker at the entry site (white arrow); air is seen within the deep soft tissues anterior to the left carotid sheath contents (white arrowhead), indicating violation of the left carotid space. 3D-volume-rendered CTA image (b) of the left carotid artery shows irregular caliber and focal outpouching of the distal left common carotid artery (black arrowheads), representing pseudoaneurysm. Findings are consistent with left vocal cord paralysis due to vagal nerve injury
Vocal cord
paralysis • Vocal cord paralysis - Ganzer Fall bei Radiopaedia
Vocal cord
paralysis • Left vocal cord paralysis secondary to pseudocoarctation of the aorta - Ganzer Fall bei Radiopaedia
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Laryngeal carcinoma. A 59-year-old man with 45-pack-year smoking history presenting with 6 weeks of hoarseness. Axial (a) and coronal (b) contrast-enhanced CT images reveal near-complete obliteration of the laryngeal airway by a polypoid soft tissue mass, which extends inferiorly into the subglottic airway. Note the trace residual airway remnant anteriorly (white arrow). There is asymmetric high attenuation of the right arytenoid cartilage (white arrowhead), consistent with sclerosis and involvement of the lesion. Axial fusion PET/CT image (c) reveals a hypermetabolic mass centered at the larynx (black arrow). Biopsy revealed squamous cell carcinoma
Vocal cord
paralysis • Papillary thyroid carcinoma causing vocal cord palsy - Ganzer Fall bei Radiopaedia
Vocal cord
paralysis • Recurrent laryngeal nerve palsy due to hilar mass - Ganzer Fall bei Radiopaedia
Vocal cord
paralysis • Vocal cord paralysis due to aortic arch pseudoaneurysm - Ganzer Fall bei Radiopaedia
Ortner"s
Syndrome. NCCT chest axial section showing cardiomegaly with grossly dilated left atrium
Ortner"s
Syndrome. Coronal NCCT section of the neck reveals dilatation of left pyriform sinus and laryngeal ventricle.
Ortner"s
Syndrome. Axial NCCT section reveals Left vocal cord palsy with overadduction of the right vocal cord with medial convex border
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Laryngeal polyp. A 57-year-old man heavy smoker reporting sore throat, hoarseness, and stridor. Coronal (a) and sagittal (b) contrast-enhanced CT images reveal a polypoid lesion arising from the left wall of the larynx (arrows). Laryngoscopy (not shown) revealed a round mass with ball-valve obstruction of the glottis. Subsequent biopsy confirmed a laryngeal polyp
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Oropharyngeal squamous cell carcinoma. A 40-year-old man presenting with tender neck mass, dysphagia to solid food, odynophagia, and voice changes. Axial (a) and sagittal (b) contrast-enhanced CT images reveal an enhancing mass at the left oropharynx (arrows) and extensive left-sided lymphadenopathy, including a large level II nodal conglomerate with central areas of necrosis (arrowheads). Biopsy revealed this to be human papilloma virus (HPV)-mediated squamous cell carcinoma. Voice change was attributed to encroachment upon the carotid space resulting in vagal nerve irritation.
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Jugulotympanicum paraganglioma. A 49-year-old woman with voice change and pulsatile tinnitus. Coronal T2-weighted MR images (a, b) and axial contrast-enhanced T1 image (c) demonstrate a T2-hyperintense, enhancing mass centered at the left jugular bulb (white arrows) extending into the hypotympanum (white arrowhead). Axial CT of the temporal bones (d) reveals abnormal soft tissue in the left middle ear (black arrow) with osseous "moth-eaten" destruction at the jugular foramen (black arrowhead); the cochlear promontory in preserved (not shown). Based on location and appearance, findings are consistent with a jugulotympanicum paraganglioma (glomus jugulotympanicum tumor)
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Skull base metastasis. A 63-year-old woman with several weeks of right-sided ear infection and hoarseness, followed by sudden onset right facial droop. Axial post-contrast T1-weighted (a) and DWI/ADC (b, c) MR images reveal a large enhancing infiltrative lesion with diffusion restriction at the skull base (arrows). Axial CTA image (d) demonstrates osseous destruction and obliteration of the right internal jugular vein (arrowheads). This was found to be metastatic adenocarcinoma of unknown primary
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Pulmonary artery aneurysm. A 78-year-old man with advanced congestive heart failure secondary to congenital pulmonary artery stenosis status post multiple corrective surgeries, now presenting with progressive shortness of breath and speaking difficulty despite adequate management of heart failure. Axial CTA image (a) through the mediastinum reveals aneurysmal dilatation of the left pulmonary artery (white arrows). An axial CTA image through the larynx (b) reveals thickening of the left aryepiglottic fold (white arrowhead) and dilatation of the left piriform sinus (black arrow). A coronal CTA image (c) demonstrates effacement of the aortopulmonary window (black arrows) by the pulmonary artery aneurysm (white arrows) with presumed compression of the left recurrent laryngeal nerve
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Endocarditis. A 41-year-old previously healthy man presents with intermittent hoarse voice and unexpected weight loss. Axial contrast-enhanced CT images through the larynx (a) and mediastinum (b) reveal left vocal fold rotation (white arrow) and lymphadenopathy surrounding the left carotid and subclavian arteries (white arrowheads). A coronal CTA image (c) reveals an ascending aortic aneurysm (black arrows). Echocardiogram (d) reveals a bicuspid valve with vegetations (gray arrow) and severe aortic stenosis. Overall, findings are consistent with compression/stretching of the left recurrent laryngeal nerve due to reactive lymphadenopathy and a dilated aortic arch in the setting of endocarditis
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Metastatic mediastinal lymphadenopathy. A 59-year-old woman with right breast cancer status post chemoradiation completed 5 years prior presents with rapidly progressive hoarseness. An axial non-contrast CT image (a) demonstrates anteromedial rotation of the left posterior vocal fold and arytenoid cartilage (white arrow) with associated left-sided dilatation of the laryngeal ventricle (white arrowhead). Associated PET image (b) demonstrates compensatory FDG uptake in the contralateral vocal fold (gray arrow). Contrast-enhanced CT (c) and PET (d) images more inferiorly reveal hypermetabolic prevascular lymphadenopathy in the superior mediastinum (black arrowheads). Overall, these findings are consistent with left vocal cord paralysis due to compression of the left recurrent laryngeal nerve by a metastatic prevascular lymph node
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Lung cancer. A 79-year-old woman with 55-pack-year smoking history presenting with hoarse voice and chronic vomiting. Coronal contrast-enhanced images of the larynx (a) and lungs/mediastinum (b) reveal medialization of the left vocal fold (white arrow) with dilation of the ipsilateral piriform sinus (white arrowhead). A large mass centered in the left upper lobe extends into the aortopulmonary window and also encases a vessel (black arrow). These findings are consistent with left vocal cord paralysis due to compression of the left recurrent laryngeal nerve in the setting of stage IV lung cancer
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Thyroid carcinoma. A 78-year-old man presenting with persistent cough, hoarse voice, and dyspnea. Chest radiograph (a) reveals a right paratracheal mass indenting the subglottic trachea (white arrow). Subsequent neck US (b) and chest CTA (c) reveal a solid heterogenous mass with calcifications (white arrowheads), which narrows but does not invade the glottic/subglottic airway. Fine needle aspiration revealed follicular thyroid carcinoma
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Vagal Schwannoma. A 53-year-old man with months of cough and hoarseness, thought to be reflux but not improved with proton pump inhibitor. Axial T2 (a), axial post-contrast T1 (b, c), and coronal post-contrast T1 (d) MR images reveal a well-circumscribed enhancing mass (arrows) with cystic components extending through the right jugular foramen (note the "waist") into the carotid space. The right internal jugular vein (arrowheads) is compressed within the carotid sheath. Findings are characteristic for a vagal schwannoma, with intracranial and extracranial extent
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Meningioma. A 45-year-old woman initially presenting with right sensorineural loss, followed by headache, dysphagia, dysphonia, imbalance, and vasovagal syncope. Coronal (a), sagittal (b), and axial (c) post-contrast T1-weighted MR images reveal a dural-based mass at the right cerebellopontine angle (white arrows) extending into the internal auditory canal, as well as through the jugular foramen into the carotid space. Axial contrast-enhanced CT (d) reveals diffuse hyperostosis of the right temporal bone with opacification of the mastoid air cells (black arrowheads). Overall, findings are consistent with a meningioma. Incidental severe right maxillary sinus mucosal thickening is also seen
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Laryngeal papillomatosis. A 26-year-old man with recurrent tracheal/laryngeal papillomatosis status post tracheal diversion and radiation therapy. A coronal contrast-enhanced CT image (a) reveals nodular soft tissue attenuation (white arrows) replacing the laryngeal structures. Subsequent axial attenuation-corrected PET image (b) reveals marked FDG-avidity (black arrow)
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Vagal paraganglioma. A 67-year-old man presenting with raspy voice. Sagittal T1 post-contrast (a), axial T1 (b), and axial T2 (c) MR images reveal a T1-hypointense, avidly enhancing lesion with heterogeneous areas of high T2 signal (arrows) centered within the left carotid space. The internal carotid artery is displaced anteromedially (arrowheads). Pathology was consistent with a vagal paraganglioma (glomus vagale tumor)
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Jugular paraganglioma. A 55-year-old woman with relatively sudden onset hoarseness and dysphagia to liquids, who was found to have right vocal cord paralysis on laryngoscopy. Coronal T2 (a) and axial T1 post-contrast (b) MR images reveal a T2-isointense, avidly-enhancing lesion at the right jugular fossa (arrows) extending intracranially, with mild mass effect upon the right cerebellar hemisphere. Foci of low signal (“pepper”) represent flow voids, reflecting hypervascularity. Based on location and appearance, findings are consistent with a jugular paraganglioma (glomus jugulare tumor)
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Lateral medullary infarction. A 33-year-old woman with history of migraines presenting with acute onset vertigo, nausea, weak voice/swallow, and left extremity sensorimotor deficits after chiropractic manipulation. Diffusion-weighted MRI (a) reveals numerous acute embolic infarctions involving the bilateral cerebellar hemispheres and bilateral thalami, with notable involvement of the left PICA territory including the left lateral medulla (black arrowhead). TOF MRA MIP image (b) reveals absence of flow related enhancement within the left V4 segment and PICA (white arrowhead). Axial TOF image (c) reveals small caliber flow within the residual true lumen (white arrow), with surrounding crescentic lower signal in the false lumen. This constellation of findings is consistent with left vertebral artery dissection with showering of emboli resulting in infarction
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Thyroidectomy. A 63-year-old woman status post total thyroidectomy and radioablation for papillary thyroid carcinoma. Neck ultrasound (a), I-131 whole body scintigraphy (b), and axial/coronal post-contrast CT images (c, d) demonstrate no evidence for residual thyroid tissue in the thyroid bed. In addition, the left vocal fold is medialized (arrow) with dilatation of the left laryngeal ventricle, suggesting vocal cord paralysis due to iatrogenic injury
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Hypertrophic olivary degeneration. A 69-year-old man with history of hypertension presenting with new onset palatal myoclonus, hoarse voice, and ataxia. Axial T2 (a) and susceptibility-weighted (b) MR images reveal a lesion at the left parasagittal pontomedullary junction at the level of the facial colliculus demonstrating bubbly high T2 signal internally surrounded by a rim of low T2 signal intensity (arrow) and associated blooming (solid arrowhead), compatible with a cavernous malformation. Thin section axial T2 image (c) reveals hyperintensity and expansion of the left inferior olivary nucleus (dashed arrowhead), consistent with hypertrophic olivary degeneration. Lesions involving the dento-rubro-olivary tract (such as this cavernous malformation) can lead to hypertrophic olivary degeneration
A radiologic
review of hoarse voice from anatomic and neurologic perspectives. Laryngeal amyloidosis. A 69-year-old woman with recurrent laryngeal amyloidosis despite multiple interventions. Axial CT image (a) reveals marked soft tissue thickening of the laryngeal structures extending into the right pre/paraglottic space (white arrows) representing amyloid infiltration, and dystrophic calcification (white arrowhead) representing post-treatment change. The true vocal cords are not identifiable. 3D surface volume rendering (b) demonstrates marked narrowing of the glottic airway (gray arrows)
Ortner"s
Syndrome. Coronal NCCT section of the neck reveals flattening of the subglottic arch (arrow) and dilatation of the left pyriform sinus.
Vocal cord paralysis/paresis (VCP), also known as vocal fold paralysis/paresis, refers to the impaired mobility of the true vocal cord or fold due to neurologic dysfunction.
Clinical presentation
Unilateral vocal cord paralysis usually presents with dysphonia (hoarseness), characterized as a breathy, weak voice due to air leaking through the glottic gap as one vocal cord is unable to adduct fully. Patients may also complain of dysphagia or choking as glottic incompetence increases the risk of aspiration.
Bilateral vocal cord paralysis may present as dyspnea if the paralyzed cords rest close to the midline, reducing the glottic area available for air movement.
The diagnosis may also be made incidentally on laryngoscopy or imaging as up to one-third of patients with impaired vocal cord impairment are asymptomatic .
Pathology
Neurologic dysfunction resulting in vocal cord paralysis most common localizes to the recurrent laryngeal nerve, but can also be due to upstream lesions affecting the vagus nerve (from which the recurrent laryngeal nerve branches off) or the brain. Injury to the recurrent laryngeal nerve affects motor function of most of the intrinsic laryngeal muscles (posterior cricoarytenoid, lateral cricoarytenoid, transverse arytenoid, oblique arytenoid, and thyroarytenoid).
In comparison, injury to the superior laryngeal nerve, which supplies only the cricothyroid muscle, causes subtle changes in voice and is less clinically significant.
Unilateral involvement is much more common than bilateral involvement . The left side is most commonly affected, likely because the longer course of the left recurrent laryngeal nerve presents greater opportunity for injury.
Etiology
- superior thoracic masses, e.g. lung cancer (most common ), aortic pathologies (e.g. thoracic aortic aneurysm), thyroid cancer, laryngeal cancer
- masses affecting the vagus nerve, e.g. jugular foramen masses, carotid body tumors
- surgical iatrogenic injury, especially post thyroidectomy
- idiopathic
- blunt and penetrating trauma in the head and neck, and thorax
- congenital anomalies, e.g. meningomyelocele, Chiari malformation, hydrocephalus
Radiographic features
The imaging features of vocal cord paralysis include the following:
- enlarged pyriform sinus
- medialization and thickening of the aryepiglottic fold
- enlarged laryngeal ventricle (sail sign)
- atrophy of the thyroarytenoid muscle, which makes up the bulk of the true cord
- anteromedial deviation of the arytenoid cartilage
- abducted vocal cord during breath-hold imaging with compensatory medial bowing of the contralateral cord
- atrophy of the posterior cricoarytenoid muscle
Laryngeal ultrasonography allows dynamic, real-time assessment of vocal fold adduction and abduction, and has demonstrated high fidelity with the diagnostic gold standard, flexible endoscopy . The most commonly utilized sonographic window is obtained by placing the (linear or curvilinear) transducer on the midline neck, seeking a transverse window through the thyroid cartilage. Supine patient positioning with slight neck extension during the exam is optimal.
- sonographic landmarks are the true vocal folds, false vocal folds, and arytenoid cartilages
- the true vocal folds are hyperechoic and the more superficial of the structures
- the presence and symmetry of vocal fold motion is assessed through eliciting quiet inspiration, an apneic pause, and phonation
- unilateral absence of true/false folds and arytenoid motion, typically accompanied by compensation of the contralateral structures, is highly indicative of unilateral vocal cord paralysis
Practical points
When vocal cord paralysis has been diagnosed, a cause should be actively sought along the course of the recurrent laryngeal nerve from origin in the brainstem, through the neck, and should always include the superior mediastinum.
Siehe auch:
- Larynx
- Plica vocalis
- Nervus laryngeus recurrens
- Larynxmuskulatur
- Ortner-Syndrom 1 - cardiovokales Syndrom
- Heiserkeit
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