My former classmate in elementary referred his father to me for evaluation and management because of two-months history of hoarseness and nonproductive cough. He has a 30 pack-years smoking history but apparently had quit smoking a few months earlier. He denied chest pain and dysphagia. On laryngoscopy, the left vocal fold was paralyzed. No laryngeal mass noted. I requested for a computed tomography (CT) scan of the neck and chest and a 6 x 7 cm mass was noted at the left hilar area. I referred him for CT scan guided biopsy of the mass.
This is the normal vocal fold movements.
Unilateral vocal cord paralysis occurs secondary to dysfunction of the recurrent laryngeal or vagus nerve innervating the larynx. Patients typically present with a fairly sudden onset of a “breathy” voice because of incomplete adduction of the paralyzed vocal cord. In addition, the patient may complain of his or her “voice going away” and shortness of breath. Normally, upon speaking, both vocal cords adduct to allow for glottal closure and subsequent induction of vocal cord vibration.
The etiology of unilateral vocal cord paralysis can be categorized into 3 main groups: surgical iatrogenic injuries, malignant invasion, and idiopathic paralysis. Surgical iatrogenic injuries may be a complication of thyroidectomy, carotid endarterectomy, anterior cervical disc surgery, and thoracic or mediastinal surgery. Malignant invasion of the vagus or recurrent laryngeal nerves can also occur with skull base tumors, thyroid neoplasms, carcinoma of the lung, esophageal carcinoma, and metastases to the mediastinum (well illustrated in this case). A third etiology is idiopathic—when a definite etiology for the paralysis cannot be determined. These cases may be attributed to a recent viral infection or inflammatory process.
This is how a vocal fold paralysis looks like.
A physician investigating vocal cord paralysis follows the route of the vagus and recurrent laryngeal nerve on CT scans from the skull base to the superior mediastinum. The vagus nerve originates in the brain stem, then travels along the carotid sheath with the jugular vein and internal carotid artery. The left vagus nerve gives rise to the left recurrent laryngeal nerve as the vagus nerve descends just lateral and anterior to the arch of the aorta. The left recurrent laryngeal nerve then loops under the aortic arch adjacent to the ligamentum arteriosum and ascends in the tracheoesophageal groove until penetrating the larynx, supplying the intrinsic muscles of the larynx. In contrast, the right recurrent laryngeal nerve loops under the right subclavian artery before ascending to innervate the larynx. Any mass therefore along this route can directly affect the nerve and may cause paralysis of the muscles it supplies, in this case, the intrinsic muscles of the larynx.
Various treatments are available for unilateral vocal cord paralysis. The 2 main approaches are voice therapy and surgical therapy. Voice therapy is used primarily when the paralyzed vocal cord is in a favorable position or when the patient is unable to have surgery because of medical limitations. The most common voice therapy techniques involve avoidance of irritants such as tobacco and alcohol, proper use of respiratory support for phonation, phrase and word timing, and pitch alteration. Surgical procedures aim to medialize the paralyzed vocal cord. Temporary treatment utilizes the Gelfoam vocal cord injection, which effectively medializes the cord for 4 to 12 weeks. Two options are available for permanent surgical therapy. Fat injection of the vocal cord (lipoinjection) involves collecting a small amount of the patient's fat—usually via liposuction or open incision in the abdomen-and injecting it into the deep portion of the vocal cord. A more advanced surgical method, known as laryngeal framework surgery, involves manipulating the paralyzed vocal cord through an external approach and repositioning the arytenoid cartilage.
In our case however, management will be focused primarily on the pulmonary mass and treatment of the vocal fold paralysis will just be secondary, if any.
This is the normal vocal fold movements.
Unilateral vocal cord paralysis occurs secondary to dysfunction of the recurrent laryngeal or vagus nerve innervating the larynx. Patients typically present with a fairly sudden onset of a “breathy” voice because of incomplete adduction of the paralyzed vocal cord. In addition, the patient may complain of his or her “voice going away” and shortness of breath. Normally, upon speaking, both vocal cords adduct to allow for glottal closure and subsequent induction of vocal cord vibration.
The etiology of unilateral vocal cord paralysis can be categorized into 3 main groups: surgical iatrogenic injuries, malignant invasion, and idiopathic paralysis. Surgical iatrogenic injuries may be a complication of thyroidectomy, carotid endarterectomy, anterior cervical disc surgery, and thoracic or mediastinal surgery. Malignant invasion of the vagus or recurrent laryngeal nerves can also occur with skull base tumors, thyroid neoplasms, carcinoma of the lung, esophageal carcinoma, and metastases to the mediastinum (well illustrated in this case). A third etiology is idiopathic—when a definite etiology for the paralysis cannot be determined. These cases may be attributed to a recent viral infection or inflammatory process.
This is how a vocal fold paralysis looks like.
A physician investigating vocal cord paralysis follows the route of the vagus and recurrent laryngeal nerve on CT scans from the skull base to the superior mediastinum. The vagus nerve originates in the brain stem, then travels along the carotid sheath with the jugular vein and internal carotid artery. The left vagus nerve gives rise to the left recurrent laryngeal nerve as the vagus nerve descends just lateral and anterior to the arch of the aorta. The left recurrent laryngeal nerve then loops under the aortic arch adjacent to the ligamentum arteriosum and ascends in the tracheoesophageal groove until penetrating the larynx, supplying the intrinsic muscles of the larynx. In contrast, the right recurrent laryngeal nerve loops under the right subclavian artery before ascending to innervate the larynx. Any mass therefore along this route can directly affect the nerve and may cause paralysis of the muscles it supplies, in this case, the intrinsic muscles of the larynx.
Various treatments are available for unilateral vocal cord paralysis. The 2 main approaches are voice therapy and surgical therapy. Voice therapy is used primarily when the paralyzed vocal cord is in a favorable position or when the patient is unable to have surgery because of medical limitations. The most common voice therapy techniques involve avoidance of irritants such as tobacco and alcohol, proper use of respiratory support for phonation, phrase and word timing, and pitch alteration. Surgical procedures aim to medialize the paralyzed vocal cord. Temporary treatment utilizes the Gelfoam vocal cord injection, which effectively medializes the cord for 4 to 12 weeks. Two options are available for permanent surgical therapy. Fat injection of the vocal cord (lipoinjection) involves collecting a small amount of the patient's fat—usually via liposuction or open incision in the abdomen-and injecting it into the deep portion of the vocal cord. A more advanced surgical method, known as laryngeal framework surgery, involves manipulating the paralyzed vocal cord through an external approach and repositioning the arytenoid cartilage.
In our case however, management will be focused primarily on the pulmonary mass and treatment of the vocal fold paralysis will just be secondary, if any.
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