Patient is an 89-year-old female with a PMH of lung cancer, COPD, AAA, thyroid nodule, bladder cancer, HTN, hypothyroidism presenting to the Emergency Department with a complaint of hoarse voice. Her ..
Patient is an 89-year-old female with a PMH of lung cancer, COPD, AAA, thyroid nodule, bladder cancer, HTN, hypothyroidism presenting to the Emergency Department with a complaint of hoarse voice. Her symptoms started five days prior. She was seen at an urgent care and diagnosed with laryngitis. The shortness of breath is worse when speaking. She denies fever, chills, chest pain, cough, recent URI symptoms, nausea, or vomiting.Vital signs upon arrival were stable. On physical exam the patient was resting comfortably in bed in no distress. Her physical exam was unremarkable with the exception of an airy, hoarse voice.CBC, BMP were unremarkable. Chest x-ray: no areas of acute disease. There was high suspicion for vocal cord paralysis, therefore, bedside laryngoscopy was performed showing left unilateral vocal cord paralysis. CT soft tissue neck and CT chest were then obtained with evidence of a soft tissue focal mass involving the left middle upper lobe/superior left mediastinum.She was diagnosed with unilateral vocal cord paralysis likely related to her mediastinal mass. She was provided with ENT follow-up for further management. She was also instructed to follow-up with her primary care for further management of the mediastinal mass. Discussion: Vocal cords are innervated by the recurrent laryngeal nerve. When this nerve becomes damaged or has mechanical fixation, it causes paralysis of the vocal cords. Symptoms of this include hoarseness, dysphonia, dyspnea, and aspiration. This can be related to malignancy related to the thyroid, lung, esophagus, and/or mediastinum invading the Vagus nerve or recurrent laryngeal nerve. Involvement of the left side is more common than the right because it travels a longer distance in the thoracic cavity through the mediastinal lymph nodes, and around the aortic arch. The most common cause for vocal cord paralysis in females is surgery; malignancy is the most common cause in male. Other factors may also cause vocal cord paralysis, including chronic exposure to heavy metals (arsenic, lead, and mercury), use of the drugs phenytoin and vincristine, history of a connective tissue disorder (such as Marfan syndrome), Lyme disease, sarcoidosis, diabetes, and alcoholism. One study by Toutounchi et al. evaluated the vocal cords with laryngoscopy with a 90-degree telescope as well as full endoscopic examination, CT scan, MRI, barium swallow and thyroid scan. Multiple studies showed greater left side involvement. The most common tumor sites were thyroid and lung tumors. Thyroidectomy and cardiac surgery were the most common surgical reason for vocal cord paralysis. Conclusion: When evaluating a patient with dysphonia, include in the differential diagnosis vocal cord paralysis. Take thorough history and physical exam. Consider the causes of vocal cord paralysis when completing your workup. Remember to ask about personal history of cancer or recent surgery when evaluating patient with dysphonia. Conduct a bedside laryngoscopy. The potential causes of and complications of vocal cord paralysis can life threatening. Provide these patients with Otolaryngology follow up.