Bilateral vocal cord paralysis following blunt trauma to the neck

Post-traumatic Delayed Bilateral Vocal Cord Paralysis Caused by Cervical Osteophytes: A Case Report

Vocal fold paralysis occurs when the function of the vagus nerve or its distal branch, the recurrent laryngeal nerve, is diminished or absent. Bilateral vocal fold paralysis can present with varying degrees of severity and is sometimes fatal. Cervical osteophytes are a rare cause of bilateral vocal fold paralysis, with only a few cases reported. A 68-year-old man was brought to the emergency department because of a disturbance in consciousness following a fall. A CT scan of the head showed multiple cranium and brain injuries, and the patient was treated conservatively by neurosurgery. The day after the injury, dysphagia and dysarthria appeared. On the third day of admission, both vocal cords were fixed bilaterally in the paramedian position, and the patient was nearly choking on sputum. A CT scan showed that the intracranial lesions gradually improved, but the vocal cord paralysis remained. A cervical CT scan was performed to investigate the cause of the vocal cord paralysis, which revealed that cervical vertebral osteophytes were compressing the tracheoesophageal groove and the glottis. The patient was transferred to the hospital for rehabilitation, although bilateral vocal cord paralysis remained. Although rare, clinicians need to be aware that cervical osteophytes can cause vocal fold paralysis, which may be manifested when combined with further trauma. It is also important to note that traumatic vocal cord paralysis can be delayed.

Laryngeal Trauma

Laryngeal trauma is rare but potentially fatal. Initial evaluation includes efficient history and physical examination, imaging, bedside flexible laryngoscopy, and if necessary, operative endoscopic evaluation. Multiple classification systems exist for laryngeal trauma, and each has its merits. We recommend a patient-centered approach, rather than using the classification alone. Secure airways are the primary goal of acute management, with awake tracheostomy more often indicated over oral intubation compared with traumas not involving the larynx. More severe injuries typically require surgical intervention. Early intervention results in optimal voice and airway outcomes.

Delayed Bilateral Vocal Cord Paralysis Following Cervical Spine Trauma

Bilateral vocal cord paralysis is a potentially life-threatening condition, depending on the position in which the vocal cords are paralyzed. When the vocal cords are fixed in adduction, patients develop respiratory distress, inspiratory stridor, aspiration, and minimal phonation deficits. This condition can result from acute injuries to the right and left recurrent laryngeal nerves, or from chronic bilateral recurrent laryngeal nerve palsy. The clinical presentation is variable with such nerve injuries. Traumatic injuries to the cervical spine are an uncommon cause of this condition. In this report, we describe a patient who developed progressive respiratory distress, inspiratory stridor, and dysphagia to liquids several weeks after suffering major trauma to the head and neck. Laryngoscopy revealed immobile bilateral vocal cords fixed in the paramedian position, resulting in severe airway obstruction that warranted an emergency tracheostomy.

Laryngeal Trauma, Its Types, and Management

Laryngotracheal wounds are rare; however, they have a significant mortality rate. These wounds can be blunt or penetrating. Usually, the larynx is protected from blunt trauma by the sternum and jaw. A "clothesline" injury happens when the exposed neck is struck by a hard object, such as a wall wire or tree branch, or when an attack is intended to damage the larynx. Additionally, injuries may occur when the neck is stressed due to damage, such as in a rear-end accident that causes a whiplash-like injury or when the larynx is intentionally targeted for harm. Penetrating neck trauma may result in injury to the larynx. Assume a patient has suffered a penetrating or severe neck injury. It is usually evident from their medical history or a quick trauma evaluation in that case. However, it is recommended to be cautious for anterior neck injuries in general and to have a low threshold for establishing a surgical airway. The priority is securing an airway when a patient with a laryngeal injury arrives in the emergency room. The operating surgeon may request any flexible laryngoscopy, computed tomography (CT), esophagram, and chest X-ray for additional examination, depending on the nature of the damage and the patient's health. After the examination, the initial step in treating laryngeal injuries should be to locate and secure the airway. According to the evaluation and management based on the Schaefer classification system for laryngeal injury, the patient is treated based on whether the patient has impending airway obstruction or a stable airway. Medical management or observation and surgical management depend on the site and severity of the injury, patient condition, and type of injury. There are several complications related to laryngotracheal trauma, which can be minor or even fatal. Following successful treatment, postoperative and rehabilitative care, vocal rest, speech therapy, and swallowing therapy may be necessary.

Cricotracheal separation: do not get fooled by what you see

INTRODUCTION

Laryngeal involvement in neck trauma is quite considerable. The presence of a cricotracheal separation type of injury can be easily missed and overlooked, especially if the neck does not show any external signs. Blunt trauma to the neck affects many anatomical structures inside the intact-looking neck that threatens the victim's life. At exploration, the surgeon must be aware of the full impact of the injury on different neck structures.

AIM OF WORK

Raise the attention on the proper management of laryngeal trauma victims.

PATIENTS AND METHOD

This is a retrospective study carried out on 23 patients who suffered from cricotracheal separation as a result of laryngeal trauma.

RESULTS

Cricotracheal separation is a frequent finding in an innocent-looking neck. The mechanism of the trauma itself is an excellent clue to suspect its presence.

CONCLUSION

This type of laryngeal injury must be kept in mind and must be suspected. Some recommendations and guidelines are presented on the proper handling of such patients.

Bilateral vocal cord paralysis in a hanging survivor: a case report

BACKGROUND

Complications in survivors after typical hanging have not been well characterized because of the high mortality rate.

CASE PRESENTATION

We present a patient with bilateral vocal cord paralysis following typical hanging. A 39-year-old man with depression attempted suicide by hanging. He was in a coma and was transported to our hospital. Emergency endotracheal intubation was carried out. After 10 days of mechanical ventilation, he was extubated. After extubation, his voice was hoarse and stridor was heard. Vocal cord paralysis became apparent by laryngeal fiberscopy, and a tracheotomy was carried out. It resolved gradually 2 months after injury without surgery or drug treatment.

CONCLUSION

Although vocal cord paralysis after typical hanging is rare, there is a need for adequate assessment of the airways in survivors of typical hanging as a differential diagnosis of airway edema after extubation.

Bilateral vocal cord palsy after a posterior cervical laminoplasty

PURPOSE

To report a patient with bilateral vocal cord palsy following cervical laminoplasty, who survived following a tracheotomy and intensive respiratory care.

METHODS

Acute respiratory distress is a fatal complication of cervical spinal surgery. The incidence of bilateral vocal cord palsy after posterior cervical decompression surgery is extremely rare. The authors report a 71-year-old woman who suffered from cervical myelopathy due to ossification of the posterior longitudinal ligament. Open-door laminoplasty from C2 to C6 and laminectomy of C1 were performed. Following surgery, extubation was successfully conducted. Acute-onset dysphagia and stridor had occurred 2 h following extubation. A postoperative fiber optic laryngoscope revealed bilateral vocal cord palsy. After a tracheotomy and intensive respiratory care, she had completely recovered 2 months after surgery.

DISCUSSION

One potential cause of this pathology was an intraoperative hyper-flexed neck position, which likely induced mechanical impingement of the larynx, resulting in swelling and edema of the vocal cords and recurrent laryngeal nerve paresis. Direct trauma of the vocal cords during intubation and extubation could have also induced vocal cord paralysis.

CONCLUSIONS

We reported a case of bilateral vocal cord palsy associated with posterior cervical laminoplasty. Airway complications following posterior spinal surgery are rare, but they do occur; therefore, spine surgeons should be aware of them and take necessary precautions against intraoperative neck position, intubation technique, even positioning of the intratracheal tube.

Acute traumatic injury of the larynx

Laryngeal trauma is rare but serious and potentially deadly injury. The prompt diagnosis and management of acute laryngeal trauma is necessary because the clinical presentation is variable depending on the location, severity, and mechanism of injury. Two case histories are presented: (1) case history A: a 53-year-old male, after motor vehicle accident, fractured the mid anterior thyroid cartilage and both aspects of the cricoid cartilage; however, this patient was asymptomatic from the above fractures; and (2) case history B: a 41-year-old male who sustained trauma to the chest, neck, and left arm after being struck by a large lead pipe which fractured the left aspect of the cricoid cartilage was symptomatic. The type rather than the severity of acute laryngeal injury and the mechanism of injury may be related to symptomatology. Acute laryngeal trauma should be recognized by trauma radiologists and emergency room physicians. Early diagnosis and management of acute laryngeal trauma may prevent unnecessary specialty consults and long-term complications.

Laryngeal trauma in sport

The larynx and surrounding soft tissues are vulnerable to injury during athletics despite protective equipment and rule modifications. Laryngeal injuries are uncommon but potentially fatal conditions that pose risks to the voice, airway, and esophagus of athletes who sustain blunt or penetrating neck trauma. Common symptoms and signs of laryngeal trauma include hoarseness, dyspnea, hemoptysis, dysphonia, respiratory distress, anterior neck tenderness, subcutaneous emphysema, and loss of normal laryngeal architecture. Diagnostic evaluation includes plain radiographs, computed tomography, and fibroscopic endoscopy. Most athletes with laryngeal injuries will require surgical treatment to restore normal regional anatomy and vocal quality. Less severe injuries may be treated with close observation, serial endoscopy, medications, and vocal rest.

Bilateral recurrent laryngeal nerve palsy following blunt neck trauma

Blunt trauma neck to larynx is an uncommon injury that results in a wide spectrum of damage to endolaryngeal soft tissues as well as underlying cartilaginous skeleton leading to upper airway obstruction requiring emergency tracheostomy. A case report of blunt trauma neck anterior is presented who developed upper airway obstruction necessitating tracheostomy. Indirect Laryngoscopy and fibre optic examination identified vocal cord paralysis as primary cause of upper airway obstruction although X ray soft tissue neck and CT neck revealed fracture hyoid as well as hematoma surrounding the laryngeal frame work. Emergency tracheostomy was done and patient recovered uneventfully.

The evolving etiology of bilateral vocal fold immobility

In the past, bilateral vocal fold immobility (BVFI) occurred most commonly after thyroidectomy. However, no large series documenting the etiology of adult BVFI has been published within the past fifteen years. This study reviews the etiologic patterns of BVFI at our institutions. We compare BVFI from before and after 1980. We also review combined studies of unilateral vocal fold immobility (UVFI) to compare and unilateral versus bilateral etiologic trends. In comparison with previously published series, fewer cases of BVFI present today as a complication of thyroid surgery and more as the result of malignancies and nonsurgical trauma. Unfortunately, BVFI caused by malignancy is not usually an initial sign of local disease, but an ominous sign of recurrence or metastases. In comparing UVFI and BVFI we found that thyroidectomy causes a higher percentage of BVFI than of UVFI. Over one-third of UVFI cases were caused by neoplasm which further underscores the potential seriousness of immobile vocal folds and the need for careful investigation.

The contralateral injury in blunt laryngeal trauma

OBJECTIVES

To present the unique case of a patient who sustained an ipsilateral and contralateral injury after external laryngeal trauma. The authors also explain the dynamics behind this type of injury.

STUDY DESIGN

Case report and brief literature review.

METHODS

A case report is presented of a patient who sustained both an ipsilateral and a contralateral injury after blunt laryngeal trauma. A brief review of the literature follows, including a description of proper management of this injury.

CONCLUSION

The reader should garner an understanding of the dynamics of this type of injury and learn the basic management of a similar injury.

Traumatic retropharyngeal haematoma treated by embolization of the thyrocervical trunk

Trauma involving the retropharyngeal space is relatively infrequent. Upper airway obstruction due to a retropharyngeal haematoma can be life threatening and requires immediate intervention. We present a well-documented case that illustrates the unexpected clinical course of such a haematoma and its management.

Idiopathic bilateral vocal fold weakness

OBJECTIVE

To describe an unrecognized clinical entity, idiopathic bilateral vocal fold weakness, and propose recommendations regarding the diagnosis and management of these cases.

STUDY DESIGN

Retrospective, nonrandomized case study.

METHODS

All cases of bilateral vocal fold weakness evaluated at the University of Washington Voice Disorders Clinic between 1991 to 1998 were reviewed.

RESULTS

Four patients with bilateral laryngeal weakness were determined to have idiopathic bilateral vocal fold paresis following exhaustive workups, including videostroboscopy, bilateral laryngeal electromyography (EMG), neurological consultation, and other pertinent studies.

CONCLUSIONS

Performing bilateral laryngeal EMG is an essential aspect of the workup of any laryngeal weakness case, particularly if the etiology is unknown on presentation. Idiopathic bilateral vocal fold weakness is an underrecognized but real clinical diagnosis that will become more familiar with the increasing utilization of laryngeal EMG in clinical situations.

Cisplatin induced reversible bilateral vocal cord paralysis: an undescribed complication of cisplatin

BACKGROUND

Bilateral vocal cord paralysis is uncommon. Most cases occur secondary to trauma, malignancy, surgery, or intubation. Also, it was reported as a side effect of Vinca alkaloids.

METHODS

We report a patient with small cell lung cancer who developed bilateral vocal cord paralysis and needed to be intubated after treatment with cisplatin and etoposide. All workups excluded metastases as a cause of bilateral vocal cord paralysis. The patient required tracheostomy; she did not receive any further chemotherapy. After 11 weeks, vocal cord paralysis disappeared, tracheostomy was reversed, and the patient remained symptom free; however, 6 months later, the patient developed brain and liver metastases and died from her disease with no evidence of vocal cord paralysis.

RESULTS

We report a case of reversible bilateral vocal cord paralysis that we believe to be secondary to cisplatin toxicity, which is an undescribed complication of this drug.

CONCLUSION

Cisplatin can induce reversible bilateral vocal cord paralysis. The concurrent use of cisplatin and etoposide might have contributed to this complication in our patient.