Laryngeal Paralysis Research Articles

Atypical Presentation of a Common Disease: Shingles of the Larynx

Herpes zoster is a neurocutaneous disease resulting from the reactivation of endogenous varicella-zoster virus (VZV) in dorsal sensory or cranial nerve ganglia. Rarely, this infection manifests without the characteristic dermatomal rash, a condition termed zoster sine herpete. Viral spreading of herpes zoster in the head and neck may manifest as various signs and symptoms because of the multiple possible combinations of cranial neuropathies. With only six cases reported in the English literature up to now, isolated neuropathies of the vagus nerve in the absence of cutaneous lesions tend to be misdiagnosed as idiopathic laryngeal paralysis. We report a case of herpes zoster of the larynx in an 80-year-old man presenting with sore throat, dysphagia, and hoarseness. Endoscopic examination revealed unilateral vocal fold paralysis, pooling of secretions, and mucosal vesicles of the hemilarynx. After the diagnosis of VZV infection with polymerase chain reaction (PCR) testing, the patient was treated with valacyclovir and corticosteroids, leading to complete recovery after 2 months. Herpes zoster of the larynx is an uncommon condition that should be included in the differential diagnosis of laryngeal paralysis of idiopathic cause. We recommend performing a thorough examination of the pharyngolaryngeal structures and ordering PCR testing as the diagnostic method of choice.

Intracranial Vertebral Artery Aneurysms: Clinical Features and Outcome of 190 Patients

Vertebral artery (VA) aneurysms comprise approximately one-third of posterior circulation aneurysms. They are morphologically variable, and located critically close to the cranial nerves and the brainstem. We aim to represent the characteristics of these aneurysms and their treatment, and to analyze the outcome. We reviewed retrospectively 9709 patients with intracranial aneurysms. Of these, we included 190 with aneurysms at the VA or VA-posterior inferior cerebellar artery junction. These patients were treated in the Department of Neurosurgery, Helsinki, Finland, between 1934 and 2011. The 190 patients had 193 VA aneurysms, among which 131 (68%) were ruptured. The VA aneurysm caused a mass effect in 7 and ischemia in 2 patients. Compared to 4387 patients with a ruptured aneurysm in other locations, those with a VA aneurysm were older, their aneurysms were more often fusiform, and more often caused intraventricular hemorrhages. Among surgically treated aneurysms, clipping was the treatment in 91 (88%) saccular and 11 (50%) fusiform aneurysms. Treatment was endovascular in 13 (9%), and multimodal in 6 (4%) aneurysms. Within a year after aneurysm diagnosis, 53 (28%) patients died. Among the survivors, 104 (93%) returned to an independent or to their previous state of life; only 2 (2%) were unable to return home. Microsurgery is a feasible treatment for VA aneurysms, although cranial nerve deficits are more common than in endovascular surgery. Despite the challenge of an often severe hemorrhage, of challenging morphology, and risk for laryngeal palsy, most patients surviving the initial stage return to normalcy.

Preliminary report on meticulous operation of thyroid lobectomy

Thyroid lobectomy can be programmed to operate as "step by step". Each step must be performed meticulously with quality control, so as to minimize the complications of surgery. From May 2013 to Auguest 2014, the meticulous thyroid operation was conducted in 72 cases (144 lobectomies). Pre- and post-operative evaluations by strobe laryngoscopy, parathyroid hormone (PTH), and blood calcium examinations were conducted in all cases. Four cases (5.6%) had transient recurrent laryngeal nerve paralysis after surgery, but no permanent recurrent laryngeal nerve paralysis. There was no transient or permanent superior laryngeal nerve paralysis. Transient hypoparathyroidism occurred in 10 cases, with no permanent hypoparathyroidism. No case presented with postoperative bleeding or infection. "Meticulous operation of thyroid lobectomy" may minimize effectively the complication of surgery.

Atrial Septal Defect and Left Recurrent Laryngeal Nerve Paralysis: A Case of Ortner’s Syndrome and Literature Review

Introduction: Cardiovocal syndrome, or hoarseness resulting from vocal fold paralysis secondary to cardiovascular pathology, is commonly referred to as Ortner’s syndrome. We present a brief overview of vocal fold paralysis, present an illustrative case of Ortner’s syndrome, and provide a review of the pertinent literature. Here we aim to broaden one’s differential for vocal fold paralysis, discuss its importance as pertains to cardiovascular pathology and outcomes, and highlight the difficulties in therapeutic planning for these unique patients. Methods: A case report and literature review. Results: A 26-year-old female with an atrial septal defect and pulmonary hypertension presented with 5 months of hoarseness. Laryngoscopy revealed left vocal fold paralysis. Imaging from the skull base to chest showed an enlarged pulmonary artery (PA) in the absence of other abnormalities. Literature review suggests that this left laryngeal nerve paralysis results from nerve compression within the aortopulmonary window, a triangle defined by the aortic arch, PA, and ligamentumarteriosum. Imaging in our patient over 8 months demonstrated an increase in PA size from 3.9 to 4.2 cm correlating with the onset of hoarseness. Conclusions: Importantly, hoarseness second ary to laryngeal nerve compression in cardiovascular disease may correlate with a poorer prognosis, i.e., in thoracic aortic aneurysms and mitral valvestenosis. Awareness of vocal changes in the setting of cardiovascular disease improves diagnostic acumen in vocal foldparalysis.

Recurrent Laryngeal Nerve Paralysis after Esophagectomy: Respiratory Complications and Role of Nerve Reconstruction.

Recurrent laryngeal nerve paralysis (RLNP) after esophagectomy is a common complication and associated with aspiration pneumonia. In this study, we assessed the risk of RLNP and the usefulness of immediate reconstruction of recurrent laryngeal nerve (RLN) to prevent respiratory complications after esophagectomy. Seven hundred and eighty-two consecutive patients underwent an esophagectomy with three-field lymph node dissection, simultaneous gastric conduit reconstruction, and cervical anastomosis. Vocal cord function was observed using a flexible laryngoscope. Reconstruction between RLN and ipsilateral vagus nerve was performed during esophagectomy. RLNP was observed in 229 (29.3%) of the patients after esophagectomy: 198 unilateral and 31 bilateral cases. Of the 198 unilateral RLNP, vocal cord paralysis was observed predominantly on the left side (82.7%). RLNP was significantly associated with postoperative respiratory complications (P < 0.001) requiring a tracheotomy (P < 0.001) and mechanical ventilation (P < 0.001) and was also associated with esophagogastric anastomotic leakage (P = 0.015); consequently, the postoperative hospital stay was longer for patients with RLNP (P < 0.001). A longer operation time (P < 0.001) and advanced age (P = 0.038) were identified as significant independent predictors of RLNP. Resection of the RLN together with metastatic nodes was performed in 29 cases. The patients underwent RLN reconstruction (n = 11) had a significantly shorter postoperative hospital stay than those without RLN reconstruction (n = 18) (P = 0.019). In conclusion, RLNP was related to a poorer postoperative course among patients undergoing an esophagectomy. New surgical technologies are recommended for prevention of RLNP.

Photodocumentation of the development of type I posterior glottic stenosis after intubation injury.

Bilateral vocal fold immobility may result from bilateral recurrent laryngeal nerve paralysis or physiologic insults to the airway such as glottic scars. The progression of mucosal injury to granulation tissue, and then posterior glottis stenosis, is an accepted theory but has not been photodocumented. This paper presents serial images from common postintubation injury to less common posterior glottic stenosis with interarytenoid synechia.

Partial Recurrent Laryngeal Nerve Paralysis or Paresis? In Search for the Accurate Diagnosis.

“Partial paralysis” of the larynx is a term often used to describe a hypomobile vocal fold as is the term “paresis.” We present a case of a dysphonic patient with a mobility disorder of the vocal fold, for whom idiopathic “partial paralysis” was the diagnosis made after laryngeal electromyography, and discuss a proposition for a different implementation of the term.

Ortner′s (cardiovocal) syndrome: A rare presenting manifestation of critical mitral stenosis

We present a case of left recurrent laryngeal palsy in a 50-year-old lady who was the sole manifestation of critical mitral stenosis. In the absence of a giant left atrium, pulmonary artery hypertension with entrapment of recurrent laryngeal nerve (RLN) in the aortic window may have contributed to compression of left RLN. Mitral stenosis was relieved with balloon mitral valvotomy which lead to significant improvement in her hoarseness.

Safety of outpatient airway dilation for adult laryngotracheal stenosis.

To evaluate the safety of outpatient airway dilation for adult patients with subglottic or tracheal stenosis. The records of patients treated with airway dilation between October 2003 and September 2013 were reviewed. Outcomes of patients who underwent dilation as inpatients versus outpatients were compared. Emergency room visits, readmissions, and 3 or more primary care physician visits within 30 days postoperatively were specifically evaluated. Postoperative hemorrhage, airway edema, recurrent laryngeal nerve paralysis, reintubation, tracheostomy, tracheal rupture, pneumomediastinum, pneumothorax, acute respiratory distress, or death were also reviewed. One hundred fourteen dilations performed in 53 patients with airway stenosis were included. Outpatient dilation was performed in 93 (82%); 21 (18%) underwent the procedure in the inpatient setting. Complications were low among both inpatient and outpatient groups (10% vs 1%, P=.09). No complications occurred during the overnight stay of the inpatient group. Outpatient airway dilation is a safe and feasible procedure. It can be routinely performed on an ambulatory basis.

Spontaneous recovery of bilateral congenital idiopathic laryngeal paralysis: Systematic non-meta-analytical review

ObjectivesTo systematically review the frequency and time to spontaneous recovery in pediatric patients with bilateral congenital idiopathic laryngeal paralysis (BCILP). MethodsThe databases of Medline, EMBASE, Scopus, CINAHL, Cochrane Library and Proquest Dissertations were searched for English language articles reporting on laryngeal paralysis in pediatric patients. A bibliography search of the selected studies was done to identify additional articles. We included prospective or retrospective case-series studies of children and neonates diagnosed with BCILP at age <60 days and confirmed by direct laryngoscopy, with sufficient follow up and objective assessment for recovery.Two authors independently extracted the data and assessed the quality of each study. Discrepancies were resolved by consensus and adjudication by a third author. ResultsOf the 4229 articles identified by the search, only one study met our inclusion criteria. The study was a retrospective case series, and was of low quality. The mean age at diagnosis was fourteen days. Sixty-five percent of the patients recovered spontaneously, and the mean time to recovery was twenty-five months. Tracheostomy was performed in 71% of the patients. ConclusionsThe available literature is of low quality and provides weak evidence on the natural history of BCILP in pediatric population.

Hoarseness caused by arytenoid dislocation after surgery for lung cancer

The patient was a 64-year-old woman with no history of laryngeal disorders. She underwent video-assisted right lower lobectomy and node dissection for lung cancer. Using a stylet while the patient was under general anesthesia, tracheal intubation with a 35-French gauge left-sided double-lumen endobronchial tube was successfully performed on the first attempt. The patient developed slight hoarseness on postoperative day 1, and we initially suspected recurrent laryngeal nerve paralysis caused by the surgery, which we elected to treat conservatively. However, because her hoarseness had not improved 4months after surgery, we evaluated her vocal cords using laryngoscopy. This revealed severe dysfunction of the right vocal cord and arytenoid dislocation, which we treated through reduction using a balloon catheter. By 6months, the patient's vocal cord mobility had improved. Arytenoid dislocation is a rare complication, but should be suspected when patients have right vocal fold paralysis after lung cancer surgery.

Idiopathic bilateral vocal cord paralysis in infants: Case series and literature review.

Vocal fold paralysis is the second most common congenital laryngeal anomaly in newborns. Bilateral paralysis is a severe condition and often remains of unknown etiology. We report our experience of congenital idiopathic bilateral vocal fold paralysis in newborns and infants, and discuss the therapeutic options. Retrospective review. A retrospective review was carried out at a single tertiary referral center over a 15-year period of children presenting with congenital idiopathic bilateral laryngeal paralysis (CIBP). Twenty-six patients were identified and managed over period of the study (mean follow-up, 6.7 years). A tracheostomy was eventually performed in 14 patients, 12 during the neonatal period. Endoscopic treatment was performed in 16 patients and an external approach in five patients after endoscopic failure. Three patients were managed by watchful waiting. Spontaneous recovery occurred in 16 patients (median age, 14.5 months), including nine with a tracheostomy. Decannulation was achieved in 12 patients (median age, 42 months), and noninvasive positive pressure ventilation (NPPV) was applied in six patients. Only inhomogeneous series of pediatric bilateral laryngeal palsies have been published so far, making it difficult to identify prognostic and predictive markers, as well as therapeutic guidelines. Focusing on CIBP, our data suggest that the management strategy must take into account the possibility of a delayed spontaneous recovery. NPPV is an interesting therapeutic tool in this situation. A systematic somatic assessment is mandatory to look for associated conditions.

Clinical features and surgical outcomes following closed reduction of arytenoid dislocation.

Arytenoid dislocation is a rare condition characterized by vocal fold immobility and is easily mistaken as recurrent laryngeal nerve paralysis. To describe the presenting features, multimodal diagnostic evaluation, and surgical outcomes following closed reduction (CR) of arytenoid dislocation. Prospective case series at a single academic medical center. Evaluation and treatment data were obtained from 22 consecutive patients with arytenoid dislocation over a 7-year period. Patients underwent direct laryngoscopy and CR of the dislocated arytenoid, with adjunct injection laryngoplasty or botulinum toxin administration in select cases. Initial diagnosis was confirmed using flexible laryngeal endoscopy with stroboscopy, computed tomography, electromyography, and interoperative palpation. Arytenoid motion (primary outcome measure) and vocal function data (secondary outcome measures) were collected before treatment and up to 6 months after treatment. Key history features included emergent intubation, elective intubation, and external laryngeal trauma. Sixteen patients (73%) had anterior and 6 patients (27%) posterior dislocation. One patient experienced spontaneous recovery. Following CR, with or without adjunct therapy, 18 of the remaining patients (86%) exhibited arytenoid motion recovery with concomitant voice improvement. Recovery was sustained at 6 months after CR. Closed reduction performed within 21 days of the presumed dislocation event was associated with a superior arytenoid motion recovery rate. These data represent the largest clinical series on arytenoid dislocation with complete vocal function data and follow-up at 6 months after CR. These findings also corroborate existing evidence for early surgical intervention.

Brachycephalic obstructive airway syndrome: a growing problem

Brachycephalic obstructive airway syndrome: a growing problem

That’s Pretty Hard to Swallow: A Rare Case of Dysphagia Due to Myasthenia Gravis

Introduction: An 89-year-old woman with GERD and hypothyroidism presented with a 7-month history of dysphagia and odynophagia to both solids and liquids. She was admitted 1 month prior to this admission for similar symptoms and underwent an EGD, which revealed a hiatal hernia. Despite compliance with omeprazole 40 mg daily, she returned to the emergency room with worsening symptoms. She denied abdominal pain, nausea, vomiting, diarrhea, constipation, dark stools, blood per rectum, or jaundice. Physical exam revealed an elongated face with bitemporal wasting, bilateral partial ptosis, and dysarthria. Motor strength was 4/5 in both upper and lower extremities. The abdominal exam was benign. Evaluation for gastrointestinal causes of dysphagia included a video esophagram showing decreased peristalsis and a repeat EGD revealing no resistance to a balloon dilator nor evidence of stricture, rings, or masses. Due to negative GI imaging, evaluation for neurological causes of dysphagia was completed. This included MRI brain and MRA of the head & neck which were negative for infarction or stenosis of vessels. CT scan of the neck was negative for right recurrent laryngeal nerve paralysis. By hospital admission day 4, she was intubated for inability to swallow her secretions and given an NG tube for feeds. Labs revealed elevated aldolase level of 7.9. Due to suspicion for neuromuscular causes of dysphagia, electromyography was completed, revealing a neuromuscular junction abnormality. Voltage-gated Ca-channel antigen and anti-MuSK antibody were negative while acetylcholine receptor-binding antibody level was 5.63 (high), acetylcholine receptor-modulating antibody level was 30 (high), and acetylcholine receptor-blocking antibody was 83 (high), thus confirming the diagnosis of myasthenia gravis as the cause of dysphagia. Repetitive nerve stimulation showed a decremental response further solidifying the diagnosis. CT scan of the chest did not reveal presence of a thymoma. She was started on IV immunoglobulins for 5 days, prednisone 50 mg daily, and pyridostigmine 60 mg three times a day with improvement in her muscle weakness, ptosis, and dysphagia. Dysphagia as the primary presenting symptom of myasthenia gravis is very rare and has only been reported in 6-15% of cases of myasthenia gravis. Myasthenia gravis is more commonly reported as a paraneoplastic phenomenon associated with a thymoma/thymic tumor, which was absent in our case. Late-onset myasthenia gravis is more common in men and is often acetylcholine-receptor antibody negative. The age of onset along with the gender and antibody profile of our patient makes this case very unique. Our case truly increases awareness of nongastrointestinal causes of dysphagia. Disclosure - 1. Dr. Kumkum Patel--no financial relationships. 2. Dr. Jacqueline Forman--no financial relationships. 3. Dr. Bhawna Halwan--no financial relationships. 3. Dr. James Grendell-Consultant: NPS Pharmaceuticals Advisory Board.

Aspiration pneumonia in the Irish wolfhound: a possible breed predisposition

Anecdotal reports suggest a recent high prevalence of aspiration pneumonia in Irish wolfhounds, prompting further investigation into the incidence of the disease in this breed. To investigate the possibility that Irish wolfhounds have an increased incidence of aspiration pneumonia, and to consider possible predisposing causes in this breed. Retrospective review of medical records from the Small Animal Specialist Hospital, Sydney, from January 2008 to December 2012 inclusive to determine the total hospital incidence and individual breed incidences of aspiration pneumonia. The total hospital incidence of aspiration pneumonia was 0 · 5%. The Irish wolfhound had the highest breed incidence, with 9 of 25 dogs (36%) diagnosed with aspiration pneumonia. Four of the Irish wolfhounds had a predisposing cause identified; one having a choking episode, one having gastric bloat, while two were diagnosed with laryngeal paralysis after it was specifically investigated because of clinical suspicion. Five had no underlying cause of their aspiration pneumonia determined. On the basis of the hospital population studied, the Irish wolfhound has a high incidence of aspiration pneumonia. Further investigation into the possible predisposing cause(s) in this breed is warranted.

Intraoperative Nerve Monitoring Crisis: Sounding the Alarm

Objectives: Otolaryngology was one of the first specialties to use intraoperative nerve monitoring (IOM) to reduce the risk of facial and recurrent laryngeal nerve paralysis. Unfortunately, many external changes have occurred in the field that impact standards of care and correct coding. The objective is to identify these new external standards so AAO members can describe and apply new regulations to reduce adverse medicolegal and coding abuse risks. Methods: Rigorous, newly published standards in neurophysiologic monitoring created by neurologic and electrodiagnostic associations are reviewed and compared with the more lax procedures commonly used by otolaryngologists with informal, on-the-job IOM training. Similarly, new third party payor changes in billing and coding are reviewed and compared to common IOM coding practices. Results: A comparison of routine IOM methods performed by otolaryngologists reveals marked differences in procedure and documentation compared to published standards in neurophysiological monitoring. In addition, many otolaryngologists have failed to change their IOM coding strategies to comply with new third party payor guidelines. Conclusions: (1) The absence of specialty-specific American Academy of Otolaryngology Practice Guidelines on IOM places otolaryngologists at risk for noncompliance with external standards published in the neurophysiology field. Failure to observe national standards of IOM also compromises the quality of the monitoring provided to our patients. (2) Because “ignorance of the law is no excuse,” failure to identify and comply with new IOM coding regulations places the otolaryngologist at risk for charges of “fraud and abuse” billing. Implementing both clinical and coding changes will benefit patient and physician alike.

Total Versus Hemithyroidectomy for Well Differentiated Thyroid Cancer

ABSTRACT Aim: United States and European guidelines recommend total thyroidectomy for well-differentiated thyroid cancer (WDTC) >1 cm. On the other hand, in Japan, lobectomy is the preferred treatment for patients with WDTC without high risk. The selection criteria used for lobectomy and whether lobectomy should be performed on patients without high risk WDTC are still unclear. This study compared the outcome of patients with WDTC treated with either a total thyroidectomy or lobectomy. Methods: We reviewed records of patients with tumors smaller than 5 cm, cN0 and cM0 WDTC treated at Nagasaki University between 1994 and 2007. Data on clinicopathological features and adverse events were compared between total thyroidectomy and lobectomy-treated patients. Recurrence-free survival (RFS) and disease-specific survival (DSS) were determined using the Kaplan-Meier method. Results: Of 268 patients with WDTC, 190 had available detailed data and were eligible for this study. The median follow-up period was 9.2 years. Total thyroidectomy was carried out in 58 (31%) and lobectomy in 132 (69%) patients. The proportion of patients over 45 years old, with papillary carcinoma and who had undergone lymph node dissection (total thyroidectomy, 86%; lobectomy, 58%) was significantly higher in the total thyroidectomy group than in the lobectomy group. Gender, tumor size and incidence of pathological lymph node metastases in patients who underwent lymph node dissection did not significantly differ with the extent of surgical resection. Adverse events differed by total thyroidectomy and lobectomy; permanent or temporary hypocalcemia with use of medicine was 43% and 0%, respectively, and permanent or temporary recurrent laryngeal nerve paralysis was 16% and 4%, respectively. The 10-year RFS and DSS were 96% and 100%, respectively. There was no significant difference in RFS with the extent of surgical resection. RFS varied between patients with multiple and single lesions, 88% and 99%, respectively (p = 0.002). Conclusions: Equivalent prognoses were observed for patients with tumors smaller than 5cm, cN0 and cM0 WDTC treated with lobectomy or total thyroidectomy. Adverse events were fewer in patients who underwent lobectomy than in those who underwent total thyroidectomy. Disclosure: All authors have declared no conflicts of interest.

Acquired bilateral adductor laryngeal paralysis in neonates and children: A case series and a systematic review

ObjectivesTo present a series of acquired bilateral adductor laryngeal paralysis (BAdLP) and review the literature on clinical manifestations and management. MethodsA retrospective review of a single tertiary care practice of pediatric otolaryngology was conducted. Patients were identified from a surgical database spanning twelve years of practice (2002–2013). The variables documented included gender, age at presentation, co-morbid conditions, documented laryngeal findings on endoscopy, management and outcome. A systematic review of the literature was conducted to identify reports on BAdLP in children and associated conditions. ResultsFive cases (four girls and one boy) ranging from 3 months to 16 years of age were identified. All cases were documented using rigid and/or flexible laryngoscopy. In four cases, the onset was after major cardiac surgery complicated by cerebral vascular accidents, while one followed a thalamic stroke. Four were managed with tube feeding. Only three papers reported BAdLP in children. ConclusionsThe cases identified were all acquired after a central neurological insult. The profile is distinct from the congenital adductor form of laryngeal paralysis previously described. However, the symptom complex is identical. We believe this is the largest case series from one center to be reported.

Outcome of 45 dogs with laryngeal paralysis treated by unilateral arytenoid lateralization or bilateral ventriculocordectomy.

The purpose of this retrospective study was to assess risk factors and complications affecting postoperative outcome of dogs with laryngeal paralysis treated by either unilateral arytenoid lateralization (UAL) or bilateral ventriculocordectomy (VCC). Medical records of all dogs having either UAL or VCC between 2000 and 2011 were analyzed. Twenty-five dogs had VCC and 20 dogs had UAL. The overall postoperative complications rates for VCC and UAL were similar (52% and 60%, respectively; P = .0887). Dogs that had UAL were more likely to have acute postoperative respiratory distress and aspiration pneumonia (P = .0526). Dogs with VCC were more likely to have chronic postoperative respiratory distress and aspiration pneumonia (P = .0079). Revision surgery was required in 6 dogs (24%) following VCC and 2 dogs (10%) following UAL. Sex, breed, presenting complaint, type of service provided, and concurrent diseases were not significantly associated with higher risk of either death or decreased survival time postoperatively with either procedure. Overall postoperative complication rates, required revision surgeries, and episodes of aspiration pneumonia were similar in dogs undergoing UAL and VCC surgeries. Dogs that had VCC appeared to have an increased risk of lifelong complications postoperatively compared with UAL; therefore, VCC may not be the optimal choice for treatment of laryngeal paralysis.