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Unilateral vocal cord palsy: Finding the culprit
Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Egyptian Journal of Ear, Nose, Throat and Allied Sciences journal homepage: www.ejentas.com
Unilateral vocal cord palsy: Finding the culprit Chew Shiun Chuen a,⇑, Hazama Mohamad a, Nik Fariza Husna Nik Hassan b a b
Department of Otorhinolaryngology-Head & Neck Surgery, School of Health Sciences, Universiti Sains Malaysia Health Campus, 16150 Kota Bharu, Kelantan, Malaysia Audiology and Speech Programme, School of Health Sciences, Universiti Sains Malaysia Health Campus, 16150 Kota Bharu, Kelantan, Malaysia
a r t i c l e
i n f o
Article history: Received 31 October 2016 Accepted 12 December 2016 Available online xxxx Keywords: Unilateral vocal cord palsy Varicella zoster virus Computed tomography Mediastinum
a b s t r a c t Unilateral vocal cord palsy after recent chicken pox or varicella zoster virus infection is indeed rare. Viral neuronitis is a self-limiting disease; with complete or partial recovery. However, any lesions, which could compress the laryngeal nerve along its course causing unilateral vocal cord palsy, should be excluded. Imaging studies; i.e. computed tomography (CT) scan should be done to address this problem. CT scans enable us to image the entire course of the laryngeal nerve as well as any lesion in the mediastinum which could compress on it. Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).
1. Introduction A patient presented with voice change and the clinical finding of unilateral vocal cord palsy preceded by an upper respiratory tract infection or any air borne viral infection is rare. The common causes of unilateral vocal cord palsy are blunt neck or chest trauma, tumours of the skull base, neck, and chest or iatrogenic; i.e. post intubation or thyroid surgeries. Chicken pox or varicella zoster virus (VZV) infection is an airborne viral infection, it is one of the cause of unilateral vocal cord palsy.1 We reported a patient with post VZV virus infection with a huge mediastinum node complicated with a temporary vocal cord paresis.
2. Case report A sixteen-year-old malay boy was referred to the otorhinolaryngology (ORL) clinic with complaint of voice change for one month duration. He denied any associated aspiration symptom, or recent upper respiratory tract infection. He also denied laryngopharyngeal reflux symptoms, no history of recent trauma and no neck mass. He has no previous voice problems, no vocal cord abusive behaviour: non-smoker, not a professional voice user and no shouting events. However, one week prior to the voice change, he had a varicella zoster virus infection. Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied Sciences. ⇑ Corresponding author. E-mail address: [email protected] (S.C. Chew).
During the clinical examination, he was not in respiratory distress and there was no stridor. However, he had a breathy and hoarse voice. No neck nodes or other neck swellings palpable. He had bilateral grade II tonsillar enlargement. He had no facial asymmetry and other cranial nerves were intact. Flexible nasopharyngolaryngoscopy revealed a left vocal cord paresis. It was compensated by the right vocal cord with a small phonation gap. Otherwise, other laryngeal structures were normal. There were no vesicular or ulcerative lesions noted. A computed tomography (CT) scan of the base of skull till mid thorax was performed, it revealed a huge anterior mediastinum node located superior to the left brachiocephalic vein and anterior to the left common carotid artery (Fig. 1). It measured 1.6 cm 1.9 cm 2.8 cm. There were also multiple subcentimeter cervical nodes. There was no other abnormality noted along the course of the left recurrent laryngeal nerve. The impression given by the radiologist was; left laryngeal nerve palsy due to compression by the mediastinal node. One month later, during the consecutive follow up, the patient’s voice was completely normal and the left vocal palsy was resolved. A surveillance ultrasound was performed and noted complete resolution of the previous seen anterior mediastinal node.
3. Discussion Chickenpox or varicella is an airborne disease and it is highly contagious disease caused by varicella zoster virus (VZV). An infected patient may presented with symptoms such as fever, fatigue, sorethroat, or cough. Maculopapular or vesicular rash which may arise from chest, face, back and limbs. There were reported
http://dx.doi.org/10.1016/j.ejenta.2016.12.008 2090-0740/Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Chew S.C., et al. Unilateral vocal cord palsy: Finding the culprit. Egypt J Ear Nose Throat Allied Sci (2016), http://dx.doi. org/10.1016/j.ejenta.2016.12.008
2
S.C. Chew et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2016) xxx–xxx
Chest X-ray (CXR) can be used as a screening study, however, it is not sufficient for the full evaluation of vocal cord palsy.5 It is very important to investigate the pathologies in the mediastinum, especially those involving the aortopulmonary window and the paratracheal region.6 Computed tomography (CT) scan is one of the useful methods for the diagnosis of unilateral vocal cord palsy. CT scans enable us to image the entire course of the laryngeal nerves. It is more superior compared to CXR as it can more accurately detect the extent and location of the responsible pathology.7 Magnetic resonance imaging is one of the other available options. 4. Summary
Fig. 1. Anterior mediastinum node enlargement (yellow arrow).
cases of vocal cords palsy after a recent VZV infection. Direct invasion of the virus or by immunological mechanisms may cause neurological complications. Hence, VZV is known to be a common cause of vocal cord paralysis presently defined as idiopathic.2 In this case, the patient had history of chicken pox one week prior to voice change and the clinical finding revealed left vocal cord palsy. Incidentally, the patient’s CT finding showed a large anterior mediastinum node that was at the course of the left laryngeal nerve which highly suggestive to cause the left vocal cord palsy. As the vocal cords are supplied by the recurrent laryngeal nerve, tumour, mass or lymphnodes enlargement in the mediastinum is able to compress and causes direct invasion to the recurrent laryngeal nerve along its course. The left recurrent laryngeal nerve is more susceptible to injuries than the right because of its longer and more extensive course. Reactive lymphadenopathy has a significant proportion of the patients with isolated mediastinal and hilarlymphadenopathy,3 Varicella-zoster virus is known to be one of the infectious causes.4 Other causes, eg: sarcoidosis, tuberculosis, carcinoma and lymphoma, which could cause isolated mediastinal and hilar lymphadenopathy.
This is a very unique case of a patient presented with hoarseness with left vocal cord paresis post VSV infection with a huge mediastinal node. Proper history regarding the presenting illness helps to narrow down the differential diagnosis. The clinical finding of left unilateral vocal cord palsy which later resolve mimicry of a time-limiting viral neuronitis. Nevertheless imaging study, i.e. CT scan, is important to rule out any other cause of vocal cord palsy such as compressive cause along the course of the laryngeal nerve; for example occult tumour compression that can be missed.
References 1. Fujiwara K, Furuta Y, Fukuda S. A case of associated laryngeal paralysis caused by varicella zoster virus without eruption. Case Rep Med. 2014;2014:1–3. 2. Pahor AL. Herpes zoster of the larynx-How common? J Laryngol Otol. 1979;93:93–98. 3. Evison M, Crosbie P, Morris J, Martin J, Barber P, Booton R. A study of patients with isolated mediastinal and hilar lymphadenopathy undergoing EBUS-TBNA. BMJ Open Resp Res. 2014;1(1):e000040. 4. Ellis M. Infectious diseases of the respiratory tract. Cambridge: Cambridge University Press; 1998. 5. Altman JS, Benninger MS. The evaluation of unilateral vocal fold immobility: is chest X-ray enough? J Voice. 1997;11:364–367. 6. Bando H, Nishio T, Bamba H, Uno T, Hisa Y. Vocal fold paralysis as a sign of chest diseases: a 15-year retrospective study. World J Surg. 2006;30(3):293–298. 7. Song S, Jun B, Cho K, Lee S, Kim Y, Park S. CT evaluation of vocal cord paralysis due to thoracic diseases: a 10-year retrospective study. Yonsei Med J. 2011;52 (5):831.
Please cite this article in press as: Chew S.C., et al. Unilateral vocal cord palsy: Finding the culprit. Egypt J Ear Nose Throat Allied Sci (2016), http://dx.doi. org/10.1016/j.ejenta.2016.12.008
Contents lists available at ScienceDirect
Egyptian Journal of Ear, Nose, Throat and Allied Sciences journal homepage: www.ejentas.com
Unilateral vocal cord palsy: Finding the culprit Chew Shiun Chuen a,⇑, Hazama Mohamad a, Nik Fariza Husna Nik Hassan b a b
Department of Otorhinolaryngology-Head & Neck Surgery, School of Health Sciences, Universiti Sains Malaysia Health Campus, 16150 Kota Bharu, Kelantan, Malaysia Audiology and Speech Programme, School of Health Sciences, Universiti Sains Malaysia Health Campus, 16150 Kota Bharu, Kelantan, Malaysia
a r t i c l e
i n f o
Article history: Received 31 October 2016 Accepted 12 December 2016 Available online xxxx Keywords: Unilateral vocal cord palsy Varicella zoster virus Computed tomography Mediastinum
a b s t r a c t Unilateral vocal cord palsy after recent chicken pox or varicella zoster virus infection is indeed rare. Viral neuronitis is a self-limiting disease; with complete or partial recovery. However, any lesions, which could compress the laryngeal nerve along its course causing unilateral vocal cord palsy, should be excluded. Imaging studies; i.e. computed tomography (CT) scan should be done to address this problem. CT scans enable us to image the entire course of the laryngeal nerve as well as any lesion in the mediastinum which could compress on it. Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).
1. Introduction A patient presented with voice change and the clinical finding of unilateral vocal cord palsy preceded by an upper respiratory tract infection or any air borne viral infection is rare. The common causes of unilateral vocal cord palsy are blunt neck or chest trauma, tumours of the skull base, neck, and chest or iatrogenic; i.e. post intubation or thyroid surgeries. Chicken pox or varicella zoster virus (VZV) infection is an airborne viral infection, it is one of the cause of unilateral vocal cord palsy.1 We reported a patient with post VZV virus infection with a huge mediastinum node complicated with a temporary vocal cord paresis.
2. Case report A sixteen-year-old malay boy was referred to the otorhinolaryngology (ORL) clinic with complaint of voice change for one month duration. He denied any associated aspiration symptom, or recent upper respiratory tract infection. He also denied laryngopharyngeal reflux symptoms, no history of recent trauma and no neck mass. He has no previous voice problems, no vocal cord abusive behaviour: non-smoker, not a professional voice user and no shouting events. However, one week prior to the voice change, he had a varicella zoster virus infection. Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied Sciences. ⇑ Corresponding author. E-mail address: [email protected] (S.C. Chew).
During the clinical examination, he was not in respiratory distress and there was no stridor. However, he had a breathy and hoarse voice. No neck nodes or other neck swellings palpable. He had bilateral grade II tonsillar enlargement. He had no facial asymmetry and other cranial nerves were intact. Flexible nasopharyngolaryngoscopy revealed a left vocal cord paresis. It was compensated by the right vocal cord with a small phonation gap. Otherwise, other laryngeal structures were normal. There were no vesicular or ulcerative lesions noted. A computed tomography (CT) scan of the base of skull till mid thorax was performed, it revealed a huge anterior mediastinum node located superior to the left brachiocephalic vein and anterior to the left common carotid artery (Fig. 1). It measured 1.6 cm 1.9 cm 2.8 cm. There were also multiple subcentimeter cervical nodes. There was no other abnormality noted along the course of the left recurrent laryngeal nerve. The impression given by the radiologist was; left laryngeal nerve palsy due to compression by the mediastinal node. One month later, during the consecutive follow up, the patient’s voice was completely normal and the left vocal palsy was resolved. A surveillance ultrasound was performed and noted complete resolution of the previous seen anterior mediastinal node.
3. Discussion Chickenpox or varicella is an airborne disease and it is highly contagious disease caused by varicella zoster virus (VZV). An infected patient may presented with symptoms such as fever, fatigue, sorethroat, or cough. Maculopapular or vesicular rash which may arise from chest, face, back and limbs. There were reported
http://dx.doi.org/10.1016/j.ejenta.2016.12.008 2090-0740/Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Chew S.C., et al. Unilateral vocal cord palsy: Finding the culprit. Egypt J Ear Nose Throat Allied Sci (2016), http://dx.doi. org/10.1016/j.ejenta.2016.12.008
2
S.C. Chew et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2016) xxx–xxx
Chest X-ray (CXR) can be used as a screening study, however, it is not sufficient for the full evaluation of vocal cord palsy.5 It is very important to investigate the pathologies in the mediastinum, especially those involving the aortopulmonary window and the paratracheal region.6 Computed tomography (CT) scan is one of the useful methods for the diagnosis of unilateral vocal cord palsy. CT scans enable us to image the entire course of the laryngeal nerves. It is more superior compared to CXR as it can more accurately detect the extent and location of the responsible pathology.7 Magnetic resonance imaging is one of the other available options. 4. Summary
Fig. 1. Anterior mediastinum node enlargement (yellow arrow).
cases of vocal cords palsy after a recent VZV infection. Direct invasion of the virus or by immunological mechanisms may cause neurological complications. Hence, VZV is known to be a common cause of vocal cord paralysis presently defined as idiopathic.2 In this case, the patient had history of chicken pox one week prior to voice change and the clinical finding revealed left vocal cord palsy. Incidentally, the patient’s CT finding showed a large anterior mediastinum node that was at the course of the left laryngeal nerve which highly suggestive to cause the left vocal cord palsy. As the vocal cords are supplied by the recurrent laryngeal nerve, tumour, mass or lymphnodes enlargement in the mediastinum is able to compress and causes direct invasion to the recurrent laryngeal nerve along its course. The left recurrent laryngeal nerve is more susceptible to injuries than the right because of its longer and more extensive course. Reactive lymphadenopathy has a significant proportion of the patients with isolated mediastinal and hilarlymphadenopathy,3 Varicella-zoster virus is known to be one of the infectious causes.4 Other causes, eg: sarcoidosis, tuberculosis, carcinoma and lymphoma, which could cause isolated mediastinal and hilar lymphadenopathy.
This is a very unique case of a patient presented with hoarseness with left vocal cord paresis post VSV infection with a huge mediastinal node. Proper history regarding the presenting illness helps to narrow down the differential diagnosis. The clinical finding of left unilateral vocal cord palsy which later resolve mimicry of a time-limiting viral neuronitis. Nevertheless imaging study, i.e. CT scan, is important to rule out any other cause of vocal cord palsy such as compressive cause along the course of the laryngeal nerve; for example occult tumour compression that can be missed.
References 1. Fujiwara K, Furuta Y, Fukuda S. A case of associated laryngeal paralysis caused by varicella zoster virus without eruption. Case Rep Med. 2014;2014:1–3. 2. Pahor AL. Herpes zoster of the larynx-How common? J Laryngol Otol. 1979;93:93–98. 3. Evison M, Crosbie P, Morris J, Martin J, Barber P, Booton R. A study of patients with isolated mediastinal and hilar lymphadenopathy undergoing EBUS-TBNA. BMJ Open Resp Res. 2014;1(1):e000040. 4. Ellis M. Infectious diseases of the respiratory tract. Cambridge: Cambridge University Press; 1998. 5. Altman JS, Benninger MS. The evaluation of unilateral vocal fold immobility: is chest X-ray enough? J Voice. 1997;11:364–367. 6. Bando H, Nishio T, Bamba H, Uno T, Hisa Y. Vocal fold paralysis as a sign of chest diseases: a 15-year retrospective study. World J Surg. 2006;30(3):293–298. 7. Song S, Jun B, Cho K, Lee S, Kim Y, Park S. CT evaluation of vocal cord paralysis due to thoracic diseases: a 10-year retrospective study. Yonsei Med J. 2011;52 (5):831.
Please cite this article in press as: Chew S.C., et al. Unilateral vocal cord palsy: Finding the culprit. Egypt J Ear Nose Throat Allied Sci (2016), http://dx.doi. org/10.1016/j.ejenta.2016.12.008