Unilateral Vocal Cord Paralysis Research Articles

Vocal cord paralysis following lithium button battery ingestion in children.

This study reports on vocal cord paralysis caused by esophageal button battery (BB) ingestion in children. Medical records of children with vocal cord paralysis and esophageal BB ingestion treated at a tertiary referral institute between January 2016 and March 2020 were reviewed. Five patients aged 9-58months were identified; three were male. Each patient had accidentally swallowed a 20-mm-diameter lithium battery (3 CR2032 type and 2 CR2025 type). One battery was removed within 4h after ingestion, and three batteries were removed within 12h. Removal of the battery was achieved with rigid esophagoscopy in four patients and direct laryngoscopy in one patient. Four patients had bilateral, and one had unilateral vocal cord paralysis. Three patients underwent tracheotomy; two were tracheotomy-dependent until follow-up, while the third patient died of multiple organ dysfunction syndrome a month after surgery. The two cases without tracheotomy remain under close follow-up.Conclusion: Accidentally ingested button batteries should be removed promptly to avoid severe complications. Respiratory support and neurotrophic treatment in the early stage of vocal cord paralysis may be beneficial for recovery of vocal cord movement. What is Known: • Button battery ingestion in children is extremely harmful, especially when the diameter of the button battery exceeds 20mm. • Esophageal button battery impaction can cause serious complications such as esophageal perforation, mediastinal infection, tracheoesophageal fistula, vocal cord paralysis, and life-threatening bleeding. What is New: • Vocal cord paralysis in children with button battery ingestion plays an early warning role for identifying the severity of the disease. • Early neurotrophic drugs and glucocorticoid therapy may be helpful for the recovery of vocal cord movement, thereby avoiding tracheotomy.

Long-term treatment outcome of type 1 thyroplasty using novel titanium medialization laryngoplasty implant combined with arytenoid adduction for unilateral vocal cord paralysis: single-arm interventional study at a single institution.

ObjectiveTo evaluate the long‐term treatment outcome of type 1 thyroplasty with novel rearrangeable titanium medialization laryngoplasty implant (TMLI) combined with arytenoid adduction (AA) for unilateral vocal cord paralysis (UVFP) in the authors' institution.MethodsA total of 16 Japanese patients with UVFP who received type 1 thyroplasty using TMLI with arytenoid adduction was enrolled in this single‐arm, non‐randomized interventional study. The results of the auditory perceptual assessment, aerodynamic examination, acoustic measurement, and patient‐based survey on these patients were evaluated preoperatively and at 3, 6, and 12 months postoperatively.ResultsType 1 thyroplasty using TMLI with arytenoid adduction for our patient series presented significant improvements in maximum phonation time, mean flow rates, GRBAS scale, the Voice Handicap Index and the Voice‐Related Quality of Life score over the 12‐month postoperative period.ConclusionType 1 thyroplasty using TMLI with arytenoid adduction was quite effective for obtaining satisfactory postoperative voice improvement without any surgical complication over the long‐term period.

A study of phonosurgeries in vocal dysfunction in Salem district

<p class="abstract"><strong>Background: </strong>Phonosurgery essentially is surgery defined to improve or restore the voice. The objective of the study was to analyze and categorize the various benign lesions of the vocal cord causing vocal dysfunction requiring phonosurgeries, to analyze the incidence and distribution of cases according to age, sex, and etiology among the patients who require intense medical and voice therapy with surgical intervention.<strong> </strong></p><p class="abstract"><strong>Methods: </strong>This prospective study was conducted in fifty patients with vocal dysfunction from the ear, neck and throat (ENT) outpatient department of Otorhinolaryngology, Mohan Kumaramangalam Government General Hospital, Salem in the year September 2018 to October 2019 who failed conservative medical and voice therapy requiring phonological procedure were included in this study. Phonomicrosurgery was done for the patients with benign vocal fold mucosal disorders and medialization laryngoplasty using Gore-Tex was done for the patients with unilateral vocal cord palsy causing vocal dysfunction.</p><p class="abstract"><strong>Results: </strong>The present study on phono surgery concludes vocal polyp is the commonest benign lesion of the vocal cord that constitutes 40% in our study population. Males are affected more than females. Proper investigation of voice and larynx provides the exact pathological nature of the lesion and determines the timing of surgical intervention.<strong></strong></p><p class="abstract"><strong>Conclusion: </strong>Most of the patients who underwent medialization laryngoplasty using Gore-Tex also had a good outcome at the end of the voice therapy.</p><p> </p>

Single-Stage Treatment of Extensive Aortic Pathology Using the Frozen Elephant Trunk Procedure.

Extensive pathology involving the aortic arch and descending aorta traditionally has been treated with two open procedures. We report our institutional experience with a single stage frozen elephant trunk procedure for treatment of extensive aortic pathology. Between June 2018 and October 2019, nine patients (eight males, 89%, mean age 61 ± 6 years) with extensive aortic pathology were operated using the frozen elephant trunk procedure. Five (56%) patients underwent primary operation for chronic arch and proximal descending aneurysm in two (22%) patients, chronic type B aortic dissection in two (22%) patients and penetrating aortic ulcer in one (11%) patient. The other four (44%) patients received reoperative surgery for chronic post-dissection aneurysms. For organ protection during the aortic arch procedure, we used selective antegrade cerebral perfusion and mild systemic hypothermia at 28°C. Early mortality was not observed. A single (11%) patient developed focal stroke. Unilateral vocal cord palsy was present in two (22%) patients. Spinal cord injury was not observed. Reexploration for bleeding was required in two (22%) patients. Prolonged ventilation, liver and kidney failure as well as cardiac morbidity were not observed. Two patients (22%) with anticipated Endoleak type Ib received TEVAR extension at follow up. Mid-term mortality was observed in two (22%) patients, due to pneumonia. The frozen elephant trunk procedure can be used for a single-stage treatment of patients with extensive aortic pathology, due to chronic degenerative aneurysms or post-dissection aneurysms involving the aortic arch and the descending aorta, with acceptable mortality and morbidity.

Voice outcome after type-1 thyroplasty for unilateral vocal cord paralysis: our experience at tertiary care hospital

<p class="abstract"><strong>Background:</strong> Vocal cord paralysis is a clinical sign caused by paralysis of intrinsic muscles of larynx due to dysfunction of recurrent laryngeal nerve or injury to the vagus nerve. One of the common and effective methods of medialization is by using silicone implants. This study was aimed at prospectively assessing and analysing the vocal outcomes and quality of life of patients in type 1 medialization thyroplasty using silicone implants.</p><p class="abstract"><strong>Methods:</strong> Prospective study of 18 months was done on 17 patients with unilateral vocal cord paralysis. Surgical procedure for the patients was standardized by using silicon implant to medialize the cord. The parameters used for the pre and post treatment objective analysis were stroboscopic analysis, psychoacoustic evaluation, maximum phonation time (MPT) and patient’s self-assessment. </p><p class="abstract"><strong>Results:</strong> In our study all 17 patients with unilateral vocal cord paralysis who were subjected to vocal cord medialization using silicone implant showed a statistically highly significant improvement in all the parameters of assessment. The mean preoperative MPT was 7.260 and post-operative MPT showed significant improvement and was 17.428 seconds. mean preoperative GRBAS score was 11.695 and post-operative was 3.826. Similarly, pre op vocal handicap index was 31.173 which decreased significantly after the procedure was 7.695.</p><p class="abstract"><strong>Conclusions:</strong> In the present study, we obtained favourable results of medialization thyroplasty as expressed by objective analysis of voice including GRABS score and acoustic analysis as well as maximum phonation time apart from traditional voice recording.</p><p> </p>

Hoarseness after spinal anesthesia: a case report

<p class="abstract">Hoarseness is a common entity encountered post intubation in cases operatively managed under general anaesthesia and during regional anaesthesia mainly in cervical/brachial plexus block as a consequence of involvement of phrenic nerve. Limited reports of hoarseness, associated with spinal anaesthesia (sub arachnoid block) in obstetric and gynecology cases have been documented by various authors. Here we document a case of hoarseness in 24-year-old parturient lasting for 10-14 days, after spinal anaesthesia with bupivacaine (H) for lower segment caesarean section. The hoarseness in this case can be due to unilateral vocal cord palsy as a consequence of high-level sympathetic blockade by administration of sub arachnoid block or vagal neuropathy due to intracranial hypotension, as a consequence of spinal fluid egress from dural puncture site<em>. </em>However, in our case no evidence of post dural puncture headache (PDPH) due to egress of cerebrospinal fluid from puncture site was noted, interestingly pointing towards lower pressure change threshold for occurrence of vagal nerve and vocal cord palsy viz PDPH.</p>

Two trajectories of functional recovery in thyroid surgery related unilateral vocal cord paralysis

BackgroundIatrogenic unilateral vocal fold paralysis caused by thyroid surgery induces profound physical and psychosocial distress in patients. The natural course of functional recovery over time differs substantially across subjects, but the mechanisms underlying this difference remain unclear. In this study, we examined whether the anatomic site of the lesion affected the trajectory of recovery. MethodsIn this prospective case series study in a single medical center, patients with thyroid surgery–related unilateral vocal fold paralysis were evaluated using quantitative laryngeal electromyography, videolaryngostroboscopy, voice acoustic analysis, the Voice Outcome Survey, and the Short Form-36 quality-of-life questionnaire. Patients with and without superior laryngeal nerve injuries were compared. ResultsForty-two patients were recruited, among whom 15 and 27 were assigned to the with and without superior laryngeal nerve injury groups, respectively. Compared with the group without superior laryngeal nerve injury, the group with superior laryngeal nerve injury group demonstrated less improvement in the recruitment of vocal fold adductors, and the group also had more severe impairment of vocal fold vibration, maximum phonation time, jitter, shimmer, and harmony-to-noise ratio at the first evaluation. This difference was also found in the glottal gap and maximum phonation time 12 months after the injury. ConclusionAmong patients with thyroid surgery–related unilateral vocal fold paralysis, superior laryngeal nerve injury induces a distinctively different recovery trajectory compared with those without superior laryngeal nerve injury characterized by less reinnervation of vocal fold adductors and worse presentation in terms of the glottal gap and maximum phonation time. This study emphasizes the importance of superior laryngeal nerve function and its preservation in thyroid surgery.

Acoustic Outcomes Comparison Injection Versus Medialization Laryngoplasty

Objectives: To determine whether injection laryngoplasty or medialization thyroplasty is more effective in the treatment of unilateral vocal fold paralysis. Methods: A prospective study of 75 patients with unilateral vocal cord paralysis who underwent autologous fat injection laryngoplasty or medialization laryngoplasty at the First Central Hospital of Mongolia between 15th Nov 2016 and 15th Jan 2020. The data analyzed included patient characteristics and type of intervention, along with the before treatment, 1 and 6 months after treatment voice parameters of electrogIottography and patients' subjective voice assessment. Results: Seventy-five patients were evaluated. The average time from intervention to post-treatment evaluation was 1 and 6 months. Improvements were demonstrated in all voice parameters (Maximum Foniation Time, Jitter, Shimmer, and Harmonic Noise Ratio) in both the injection and the medialization groups. Conclusions: In this study, objective and subjective voice analysis confirmed that injection and medialization laryngoplasty were effective in unilateral vocal cord paralysis. Both of these methods can be used to treat unilateral vocal cord paralysis.

Selective vagus-recurrent laryngeal nerve anastomosis in thyroidectomy with cancer invasion or iatrogenic transection.

Immediate recurrent laryngeal nerve (RLN) reconstruction at the time of thyroid cancer extirpation can provide excellent postoperative phonatory function. This study is to present our experience with the methods of RLN reconstruction, and to evaluate the role of selective vagus to RLN anastomosis (SVR) in thyroidectomy. Respective review of RLN reconstruction in thyroid surgery from January 2004 to October 2018 was conducted in two tertiary referral academic medical centers. Immediate RLN reconstruction was performed for primary thyroidectomy patients with intraoperative nerve tumor invasion or iatrogenic transection. Laryngofiberoscopic examination, voice evaluation of maximum phonation time, and GRBAS scale were performed preoperatively, on the second day after surgery, and monthly postoperatively for the first year. A total of 37 patients were enrolled. Twenty-nine RLNs were resected caused by tumor-associated trauma; the other nerves were inadvertently transected. Direct anastomosis (DA) was performed in eight patients, free nerve graft (FNG) was performed in four patients, ansa cervicalis to RLN anastomosis (ARA) was performed in eight patients, and SVR was performed in 17 patients. The mean periods from the reinnervation surgery of DA, SVR, ARA, and FNG to the phonation recovery were 46 ± 19 (days), 41 ± 29 (days), 83 ± 21 (days), and 137 ± 32 (days), respectively. There were improvements in the GRBAS scale of perceptual voice quality at 1 month for DA and SVR, 2months for ARA. Intraoperative SVR reinnervation demonstrated voice improvement postoperatively and might be an effective treatment for thyroidectomy-related permanent unilateral vocal cord paralysis.

Unilateral vocal cord paralysis following maxillofacial deformity correction

Genel anestezi, dusuk morbidite ve mortalite oranina sahip, guvenli bir islemdir. Tek seferde saglanan, girisimsel olmayan endotrakeal entubasyon sonrasi minor travma ile gelisen orta derecede ses kisikligi ve bogaz agrisi, erken postoperatif donemde normal kabul edilir. Ses kisikligi ile seyreden vokal kord paralizi ise endotrakeal entubasyonun cok nadir gorulen bir komplikasyonudur. Bu nedenle ozellikle ortognatik cerrahiden sonra ortaya cikarsa erken tani koymak zordur. Ortognatik cerrahi sonrasi bu komplikasyon, sadece bir vaka raporunda bildirilmistir. Bu olguda, 33 yasinda saglikli bir kadin hastada bimaksiller ortognatik cerrahi sonrasi gelisen, ses kisikligi ile seyreden tek tarafli vokal kord paralizi bildirildi. Ses kisikligi entubasyona bagli olarak kabul edildi ve hastada video laringoskopik inceleme yapilana kadar erken postop fazda vokal kord paralizi teshis edilemedi. Vokal kord paralizi bes ay surdu ve herhangi bir girisimsel tedavi uygulanmadan duzeldi. Cok nadir bir komplikasyon olmasina ragmen, vokal kord paralizi cerrahlar veya anestezi uzmanlari tarafindan goz ardi edilmemelidir ve ortognatik cerrahi sonrasi vokal kord fonksiyonlarina dikkat etmelidir. Aspirasyon riski yoksa, herhangi bir girisimsel tedavi yapmadan once en az 6 ay beklenmesi gerekir.

Unilateral vocal fold palsy & dysphagia: A review

ObjectivesUnilateral vocal fold palsy (UVFP) is the commonest neurological laryngeal disorder. Much of the research have focused on its implication on voice, with limited data on its impact on swallowing. The aim of this paper is to examine the current evidence on the pathophysiology, impact and management of UVFP and swallowing. MethodsA literature search was conducted on the PubMed, MedLine, and Embase databases based on the keywords “unilateral vocal cord palsy” and “dysphagia” for this narrative review. ResultsDysphagia is common in UVFP. A safe and effective swallow is more than just glottic competence but coordination of complex events within the aerodigestive tract's sensory and motor systems. It is an important secondary outcome which has short- and long-term impact on our patient's quality of life. It should be managed in a multi-disciplinary manner to optimise patient's outcome. ConclusionIt is important to consider the disease, patient and surgical factors when deciding on the type and timing of management options. There is increasing evidence of benefits with early surgical interventions, challenging the traditional conservative management to rule out spontaneous recovery and compensation.

Immediate Ansa Cervicalis-to-Recurrent Laryngeal Nerve Anastomosis for the Management of Recurrent Laryngeal Nerve Infiltration by a Differentiated Thyroid Carcinoma

Objectives: The optimal surgical approach to treat recurrent laryngeal nerve (RLN) infiltration by differentiated thyroid cancer (DTC) remains a subject of debate. This study explored the feasibility and efficiency of immediate ansa cervicalis nerve (ACN)-to-RLN anastomosis for the management of RLN infiltration by DTC. Material and Methods: Fifty-three patients who underwent immediate ACN-to-RLN anastomosis during DTC extirpation were enrolled in the present study. Thirty-seven cases presented with unilateral vocal cord paralysis before the operation (Group A), and another 16 patients presented with normal vocal cord mobility preoperatively (Group B). Multidimensional assessments, videostroboscopy, voice assessment, and laryngeal electromyography (LEMG) were performed preoperatively and postoperatively. Results: All videostroboscopy, voice assessment and LEMG parameters in Group A deteriorated 1 month after the operation and improved 1 year after the operation compared with preoperative data. In Group B, all parameters 1 year after the operation improved significantly compared with the corresponding parameters 1 month after the operation. LEMG in Group A and B provided substantial evidence for the maturation of neural regeneration from ACN and demonstrated that the laryngeal muscles were reinnervated successfully by this procedure. Conclusions: If the RLN is infiltrated by DTC, immediate ACN-to-RLN anastomosis during complete excision of DTC could restore satisfactory phonatory function and does not compromise oncological radicality.

Value of pathogenic diagnosis of 18F-FDG PET/CT imaging in non-traumatic unilateral vocal cord paralysis

Objective To evaluate the diagnostic value of 18F-fluorodeoxyglucose (FDG) PET/CT imaging in non-traumatic unilateral vocal cord paralysis (UVCP) and compare the radioactive uptake in different lesions. Methods Clinical data of 62 patients (49 males, 13 females; age: (61.7±12.8) years) with non-traumatic UVCP (43 cases of left vocal cord paralysis and 19 cases of right) admitted to Ji′an Hospital from January 2016 to December 2018 were analyzed retrospectively. Pathological results, imaging or follow-up results were considered as the standard of final diagnosis. The diagnostic efficacy of PET/CT imaging for the primary cause was analyzed. The maximum standardized uptake values (SUVmax) of vocal cord in patients with different etiology were compared by independent-sample t test. Results According to the final diagnosis, the primary causes of UVCP were as follows: malignant tumors (n=44), inflammation (n=16), glomus jugulare tumor (n=1) and idiopathic UVCP (n=1). The diagnostic accuracy of PET/CT imaging for the primary cause was 90.32%(56/62): 44 cases were correctly diagnosed as malignant tumors, while 11 cases as inflammation, and 1 case as glomus jugulare tumor. Among 62 patients, 29 patients had increased SUVmax in the affected side (direct invasion group; further divided into tumor group (n=12) and non-tumor group (n=17)), and other 33 patients had increased SUVmax in the healthy side (indirect invasion group). SUVmax of the affected vocal cord in direct invasion group was higher than that in the healthy side (9.97±5.21 vs 2.43±0.62; t=8.14, P 0.05). Conclusions 18F-FDG PET/CT imaging has high diagnostic value in pathogenic diagnosis of non-traumatic UVCP. The different radioactive uptake of vocal cords in the affected side and the healthy side provides more accurate etiological information for clinical analysis. Key words: Vocal cord paralysis; Positron-emission tomography; Tomography, X-ray computed; Deoxyglucose

Factors affecting outcomes of injection laryngoplasty: A systematic review

Vocal cord palsy is a common reason for visiting an otolaryngologist. In cases of unilateral involvement, patients primarily present with recurrent choking and aspiration, breathy voice, and inability to perform the Valsalva maneuver. Injection laryngoplasty (IL) is one of the least invasive and promising lines of treatment for unilateral vocal cord palsy (UVCP). The present study identified the existing evidence on factors that may affect the voice and swallowing outcomes of IL in adult patients with UVCP. This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and PRISMA checklist. The U.S. National Library of Medicine (PubMed) database was searched for studies on UVCP managed with IL. Sixteen articles investigated six distinct factors that affected the outcomes of IL. These six factors include early intervention, the approach used for injection, the degree of the posterior glottic gap, the number of irregular peaks, previous radiation therapy history, and the material used for injection.: This review is the first study to investigate all of the possible factors that affect IL. This review found six distinct factors that affected the outcomes of IL. Each of the retrieved studies investigated a different factor without considering the confounding effect of the other factors. This review guides future research for the development of a much more structured protocol to elucidate the weight of each factor in affecting outcomes.

Our Uncommon Experience with 6 Cases of Riedel's Thyroiditis (Woody Thyroiditis).

Riedel's thyroiditis is a rare form of thyroiditis. Estimated prevalence is 1.06/100,000 population and is reported in 0.05% of thyroidectomy specimens. It has 38% association with systemic fibrotic conditions. We retrospectively reviewed 6 cases of Riedel's thyroiditis at a tertiary care centre in south India, from 2011 through 2019 with special emphasis on demography, clinical presentation, workup, management, intraoperative findings, postoperative outcomes and follow up. There were 4 females and 2 males of which we reported a rare presentation in paediatric age group which was probably never reported before. Presenting symptoms included dysphagia and compressive symptoms in neck. 5 out of 6 cases underwent surgical management- 4 total thyroidectomy and 1 hemithyroidectomy. Postoperative complications noted were temporary hypoparathyroidism, unilateral vocal cord palsy and temporary bilateral vocal cord palsy One case was medically managed with oral corticosteroids. There was no evidence of extra cervical fibrosis on follow up in all patients. There was no cause-specific mortality, and the fibrotic process stabilized or resolved in all patients. Riedel's thyroiditis is a fibroinflammatory disorder presenting with compressive symptoms mandating surgical intervention mainly decompression in the form of isthmectomy. However since extensive interventions are associated with complications it is less favoured approach. Long term follow up of these cases are necessary for detecting evidence of extra cervical fibrosis.

Better Outcomes With Minimally Invasive Thyroidectomy Than Conventional Thyroidectomy

Introduction
 Aim of this study was to evaluate our results from conventional and minimally invasive thyroidectomy and compare their outcomes.
 Materials and Methods
 137 patients undergone conventional and minimally invasive thyroidectomy (video-assisted and open technique with mini-cervicotomy) were reviewed. Demographic data, blood loss, operative time, postoperative pain, cosmetic outcome and complications were examined and compared.
 Results
 Minimally invasive group consists of 53 cases(39%) and conventional group is composed of 84 cases(61%). No conversion from minimally invasive to conventional techniques was observed. In minimally invasive group, 25 patients(47%) had differantiated thyroid carcinoma and 28 patients(53%) had benign pathologies. Postoperative complications include transient hypocalcemia in 5 patients(3.6%) (4 in conventional, 1 in minimally invasive group), permanent hypocalcemia in 4 patients(3%) (3 in conventional, 1 in minimally invasive group), unilateral vocal cord paralysis in 2 patients(2%) (1 in conventional, 1 in minimally invasive group). Operative time was similar in both groups; however blood loss during surgery, postoperative pain was significantly lower in minimally invasive group.
 Conclusion
 Minimally invasive techniques could be implemented on selected carcinoma patients and results in equal safety and less surgical morbidity.
 Keywords: minimally invasive thyroidectomy, thyroid cancer, MIVAT

The Effect of Steroid Therapy for Idiopathic Unilateral Vocal Cord Palsy

The Effect of Steroid Therapy for Idiopathic Unilateral Vocal Cord Palsy

A closed claims analysis of vocal cord injuries related to endotracheal intubation between 2004 and 2015.

To provide a contemporary medicolegal analysis of claims brought against anesthesiologists for injuries related to endotracheal intubation. A retrospective study of closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database between 2004 and 2015. Closed claims that occurred in any surgical specialty in which the patient was undergoing general anesthesia and anesthesiology was named as the primary responsible service. Twenty claims were identified for analysis in 7 surgical specialties. Patient ages ranged from 45 to 76. Data regarding patient comorbidities and case history were obtained when available. None. Data collected includes patient demographics such as age, outcome severity, alleged complication, plaintiff allegations, contributing factors to the injury, the surgical specialty in which the injury occurred, and the ultimate result of the claim (dismissed/denied/settled). Out of 20 claims, settlement payments were made in 10% of claims with a mean payment amount of $7669. Mean patient age was 55.6years. Within severity of injuries, 65% of claims were classified as "Permanent Minor." The most common contributing factor in claims was "Technical Knowledge/Performance" and the most common plaintiff allegation was "Trauma from endotracheal tube placement." Bilateral vocal cord paralysis, unilateral (left-sided) vocal cord paralysis, and laryngeal nerve injury were the top alleged complications. The surgical specialty in which claims most often resulted was orthopedic surgery. Injuries related to endotracheal intubation remain an ongoing challenge to anesthesiologists. Their etiology is often multifactorial and was found in this study to stem most commonly from technical errors and patient co-morbidities. A detailed discussion of risks with patients during the consent process, careful documentation of such discussion, and prompt referral to specialists when needed are critical. Understanding the patterns related to injuries during intubation is essential in order to develop strategies for improved patient safety and outcomes.

Isolated unilateral palatal and vocal cord palsy as an initial presentation of chronic inflammatory demyelinating polyradiculoneuropathy

IntroductionChronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired autoimmune disease of the peripheral nervous system. Its clinical presentation and excellent response to steroids is a hallmark to the disease entity. It is usually a straight forward diagnosis in typical cases. Atypical CIDP often is of diagnostic concern and has been a challenge for practising neurologists.Case descriptionHere, we present a 56-year old female presented with isolated left palatal palsy preceded by a short febrile illness. Clinically consistent with post-infectious bulbar palsy, she was treated with intravenous pulse steroids and antibiotics. She had progressive disease and later developed quadriparesis with neck flexor weakness with progressive bulbar weakness and hypercapnic respiratory failure.Discussion and evaluationMRI whole spine with contrast showed nerve root enhancement. Nerve conduction studies of all four limbs and LP and CSF analysis were consistent with CIDP. She was treated with intravenous immunoglobulin (0.4 g/kg for five consecutive days). She showed mild improvement of symptoms initially and later had deterioration of symptoms within a week interval. She received two doses of Rituximab of 1 gram each within 3 weeks apart, after which she has gradual improvement. She was able to tolerate orally and able to walk without support following 1 month after treatment, and there were no further relapses except for the persistence of minor sensory symptoms after 6 months of follow-up.ConclusionIsolated cranial nerve involvement presenting as CIDP is a rare entity. Intravenous immunoglobulin and newer immunosuppressants like CD-20 monoclonal antibodies like rituximab have a significant role in the treatment.

Main branch of ACN-to-RLN for management of laryngospasm due to unilateral vocal cord paralysis.

This study explored the feasibility and efficiency of main branch of ansa cervicalis nerve (ACN)-to-recurrent laryngeal nerve (RLN) anastomosis for management of paroxysmal laryngospasm due to unilateral vocal cord paralysis (UVCP). Thirteen patients who underwent main branch of ACN-to-RLN anastomosis for management of paroxysmal laryngospasm due to UVCP were enrolled in the present study. Multidimensional assessments, including videostroboscopy, voice assessment, and laryngeal electromyography (LEMG), were performed preoperatively and postoperatively. This series was limited to UVCP with iatrogenic causes, including thyroidectomy, cervical spine surgery, and thoracic surgery. After main branch of ACN-to-RLN anastomosis, all cases showed significant airway improvement, and laryngospasm was completely abolished in 92.3% (12 of 13) of cases. Videostroboscopy showed that the bulging and paradoxical adduction of the affected vocal cord during a sniff were abolished immediately after operation, and there was no significant difference in vocal fold position or glottal closure before versus after the operation. LEMG showed that the postoperative recruitment and amplitude of voluntary motor unit potential in the affected thyroarytenoid muscle during a sniff were significantly decreased compared to preoperative values, and postoperative recruitment showed significant improvement during phonation compared to that preoperatively. Voice assessment showed that there were no significant differences in overall grade, roughness, breathiness, jitter (local), shimmer (local), noise-to-harmonics ratio, or maximum phonation time after the operation compared to the preoperative values. Main branch of ACN-to-RLN anastomosis could have long-lasting efficacy in the management of paroxysmal laryngospasm due to UVCP, with no apparent compromise of voice quality. 4 Laryngoscope, 130:2412-2419, 2020.