| We report the first case (to our knowledge) of vocal cord paralysis as a primary manifestation of invasive pulmonary aspergillosis, which occurred in a 69-year-old woman without immunodeficiency. Her chest radiograph showed left upper lobe infiltration with pleural thickening, and a computed tomogram of her chest showed a thick pleural reaction and fibrosis around the arch of the aorta. A transbronchial biopsy specimen revealed aspergillus infection. The patient was treated with oral itraconazole. However, since vocal cord paralysis persisted, the patient underwent type I thyroplasty to improve vocal function. A review of the literature showed that the incidence of invasive pulmonary aspergillosis has increased, even in nonimmunocompromised subjects, and that the disease has a potential for recurrent laryngeal nerve palsy. Therefore, invasive pulmonary aspergillosis should be considered in patients with vocal cord paralysis. ( info) |
12/508. Idiopathic bilateral vocal fold weakness. OBJECTIVE: To describe an unrecognized clinical entity, idiopathic bilateral vocal fold weakness, and propose recommendations regarding the diagnosis and management of these cases. STUDY DESIGN: Retrospective, nonrandomized case study. methods: All cases of bilateral vocal fold weakness evaluated at the University of washington voice disorders Clinic between 1991 to 1998 were reviewed. RESULTS: Four patients with bilateral laryngeal weakness were determined to have idiopathic bilateral vocal fold paresis following exhaustive workups, including videostroboscopy, bilateral laryngeal electromyography (EMG), neurological consultation, and other pertinent studies. CONCLUSIONS: Performing bilateral laryngeal EMG is an essential aspect of the workup of any laryngeal weakness case, particularly if the etiology is unknown on presentation. Idiopathic bilateral vocal fold weakness is an underrecognized but real clinical diagnosis that will become more familiar with the increasing utilization of laryngeal EMG in clinical situations. ( info) |
13/508. Neuralgic amyotrophy presenting with bilateral vocal cord paralysis in a child: a case report. Acute stridor and bilateral vocal cord paralysis is not uncommon in the neonate but is unusual in the older child. We report the first case of bilateral vocal cord paralysis secondary to neuralgic amyotrophy, a peripheral polyneuropathy, in a 5-year-old child. An extensive workup revealed a paralyzed right hemidiaphragm, arm weakness and an EMG pattern consistent with neuralgic amyotrophy. Neuralgic amyotrophy is an uncommon disorder in pediatric patients which may involve cranial and peripheral nerves including the phrenic nerves and rarely the recurrent laryngeal nerves. We propose that the diagnosis be considered in children who present with bilateral vocal cord paralysis and other associated neurologic findings. ( info) |
14/508. A smoker with paroxysmal dyspnea. A 40-year-old woman who had experienced recurring episodes of dyspnea for 28 years presented to the emergency department with increasing shortness of breath, wheezing, and dry cough of three days' duration. She had been seen at another hospital shortly after symptoms began but left against medical advice. She did not have fever, chills, or other symptoms of upper respiratory infection. ( info) |
15/508. Invasion of the recurrent laryngeal nerve by adenoid cystic carcinoma. An unusual cause of true vocal fold paralysis. True vocal fold paralysis and goitre are both common problems encountered in ENT practice. Their co-existence, however, should arouse suspicion of the presence of malignant thyroid disease. A rare case of true vocal fold paralysis caused by a clinically occult subglottic adenoid cystic carcinoma, in a 72-year-old, is described. The existence of multinodular goitre in this patient was co-incidental and confounded the diagnostic process. ( info) |
16/508. Botulinum toxin injection in the treatment of vocal fold paralysis associated with multiple sclerosis: a case report. Botulinum toxin has been demonstrated clinically to be an effective treatment for a variety of laryngeal problems, most notably spasmodic dysphonia. As in other movement disorders, the theory behind the injection of this substance in the larynx has been a weakening of the vocal fold musculature to relieve uncoordinated and spasmodic movement of the vocal folds, presumably rebalancing the forces within the intralaryngeal musculature. Recently, this concept was applied to help reposition the arytenoid cartilage in acute and longstanding anteromedial cricoarytenoid dislocations. This same concept may apply to the paralyzed vocal fold. In support of this idea, a number of investigators have shown that immobile, clinically paralyzed vocal folds may still have partial voluntary motor unit activity. This voluntary activation may not produce clinically evident movement but may be sufficient to produce tone within the fold. If the voluntary motor units in the abductor musculature of the paralyzed fold are weakened with botulinum toxin, the continued pull of the functioning adductor musculature may be sufficient to medialize the paralyzed fold. This idea has been supported by animal experiments, which have shown that botulinum toxin may affect the ability of the fold to rebalance itself. With this evidence in mind, a patient with fold immobility secondary to multiple sclerosis was treated in an attempt at laryngeal rebalancing, using botulinum toxin to medialize the fold. However, instead of simply having the fold return fixed to the midline, the patient regained normal laryngeal mobility and voice. While it is unclear whether the botulinum toxin alone was responsible, the coincidence of this occurrence certainly requires reporting. This paper is a report of the first successful treatment of vocal fold paralysis using botulinum toxin to treat vocal fold fixation in a patient with multiple sclerosis. ( info) |
17/508. Transient left vocal cord paralysis during laparoscopic surgery for an oesophageal hiatus hernia. A 45-year-old male, with symptoms of many years standing of gastro-oesophageal reflux disease, was subjected, under general anaesthesia, to laparoscopic fundoplication. Tracheal intubation yielded no problems but great difficulties were encountered during tube insertion into the oesophagus. After surgery, aphonia developed. Laryngological examination demonstrated paralysis of the left vocal cord. Voice strength returned to the pre-operative status after 3 months, and laryngological examination confirmed normal mobility of both cords. The possible cause of the complication was damage to the left recurrent laryngeal nerve which occurred during insertion of the tube into the oesophagus. Gastro-oesophageal reflux disease causing 'acid laryngitis' can create conditions favouring this type of complication. ( info) |
18/508. Vocal fold paralysis secondary to cardiac countershock (cardioversion). Application of electrical energy to the heart is effective in treating many dysrhythmias. There are, however, also disadvantages associated with cardioversion. employment of external electrical current has been shown to induce epicardial and myocardial damage at the site of electrode application. We present the only case in the English literature of vocal fold paralysis in which the single identified associated event was cardioversion. In this case of temporary vocal fold paralysis, there was no invasive procedure to directly damage the nerve. echocardiography of the patient revealed a large left atrium, placing the recurrent laryngeal nerve in an abnormal anatomic position where it was vulnerable to the electric current. ( info) |
19/508. Late complication of type 1 thyroplasty: a case report. We present a previously unreported late complication of medialization laryngoplasty (ML), also described as a thyroplasty, type 1. Five years following ML with Silastic, a 64-year-old female presented with dysphonia and a mass in the laryngeal ventricle on the ipsilateral side of the ML. A computed tomography scan of the larynx revealed migration of the thyroid cartilage window into the ventricle without migration of the Silastic implant. These findings were confirmed on surgical exploration. Following removal of the Silastic implant and the thyroid cartilage window fragment, the patient was successfully remedialized with autologous lipoinjection. Migration of the thyroid cartilage window appears to be a late complication of ML when the thyroid cartilage window is left intact and not removed. Complications of ML are discussed; specifically, difficulties resulting from retention of the thyroid cartilage window at the time of the ML are addressed. ( info) |
20/508. Benign disease of the thyroid gland and vocal fold paralysis. Development of vocal fold paralysis in the presence of thyroid disease is strongly indicative of thyroid cancer, and requires surgical exploration. At the same time, vocal fold paralysis does not relieve the surgeon of his obligation to identify and preserve the recurrent laryngeal nerves, since the cause of the paralysis may be a benign disease, with a fair chance of functional recovery after surgery. We hereby report a case of recurrent laryngeal nerve palsy secondary to a multinodular goitre. ( info) |