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VOCAL CORD PARALYSIS                             187

mediastinal glands or tumour, e.g. Hodgkin's disease, (6) any enlargement of
the left atrium, e.g. mitral stenosis, (7) peripheral neuritis, and (8) aortic

The lesions affecting the right recurrent laryngeal nerve are: (1) carcinoma
of the thyroid gland, (2) operative trauma from thyroidectomy, pharyngeal
pouch removal or myotomy procedures, (3) carcinoma of the oesophagus, (4)
carcinoma of the apex of the right lung, (5) peripheral neuritis, and (6)
subclavian aneurysm.


As the cord will be in the cadaveric position {Fig. 92) the patient will be
practically aphonic at the onset of the paralysis. In a matter of a week or two

Fig. 92. Laryngeal paralysis. Mirror image to show
left vocal cord in cadaveric position. (CL = centre

the opposite cord will cross the midline on phonation and the voice will begin
to return. Closure of the gap is aided by the mucosa of the normal cord
becoming more lax. The paralysed cord later drops to a lower level than
normal as the arytenoid falls forward. The quality of the voice at this time is
harsh, warbling and breathy—a sound called diplophonia. It is almost
impossible for a normal cord ever to meet a paralysed cord lying in the
cadaveric position, especially posteriorly, and so a normal voice will never
return unless some form of surgery is undertaken.

TREATMENT. Provided that the causative lesion is curable or is under control,
this condition is worth treating because the voice is so poor and it can easily be
improved. If the causative lesion is incurable it is kinder to leave the paralysis
untreated unless the patient insists on surgery.

All treatment is directed to replacing the cord in the midline and this can be
accomplished either endoscopically or by open operation.

1. Teflon Infection. Using a special syringe which delivers a measured amount
of Teflon paste the paralysed cord is injected at direct laryngoscopy. It is
important that this procedure is carried out under local anaesthesia so that the
patient can phonate, and Teflon paste can be injected until a satisfactory
voice is produced. Once Teflon is in place it cannot be removed, so that
injection must be undertaken slowly.