Diagnosis

Vocal cord immobility

Etiology

Cause [h6a][4di][9wt]

• Congenital: Cardiovascular lesions that stretch the recurrent laryngeal nerve)

• Mechanical: Laryngeal cancer, large thyroid mass, rheumatoid arthritis, arytenoid dislocation, lymphadenopathy, inflammation and scarring (radiotherapy, intubation, inhalation injury, polychondritis)

• Neurological: Stroke, peripheral nerve injury, Guillain–Barré syndrome or myasthenia gravis, multiple sclerosis, ALS

• Infection: herpes simplex virus, Epstein-Barr virus, Varicella-Zoster, cytomegalovirus, HIV, West Nile virus, upper respiratory infection, syphilis and Lyme disease

• Iatrogenic: Birth trauma, thoracic surgery, thyroidectomy, carotid endarterectomy, cervical spine diskectomy

Pathophysiology [9wt]

1. The vocal cords open during breathing to allow passage of air

2. The vocal cords close during talking, swallowing and coughing

3. Prevention of the normal movement:

   • Mechanical tethering: inflammation, fibrosis/scar, tumor

   • Neurological paralysis: central (stroke), peripheral (recurrent laryngeal nerve)

4. Clinical manifestation of vocal cord immobility:

   • Dyspnea

   • Stridor

   • Weak voice

   • Problems with swallowing

   • Weak cough

Complications [sro]

• Aspiration pneumonia

• Respiratory distress

• Dysphagia

Epidemiology

Incidence per 100.000 [83e][tph][dwn]

Approach

• Panendoscopy

• Nasal endoscopy

• Laryngoscopy

• Bronchoscopy

• Larynx EMG

• Chest x-ray

• CT thorax

• CT abdomen

Treatment

1. Treat the underlying disease [9wt]

2. Voice therapy (some recovers with time depending on etiology) [frf]

3. Surgical medialization if no improvement after 9 months: Re-position the impaired vocal cord closer to the middle, so that the other vocal cord can close completely against it --> stronger voice and safe swallowing [tak]

   • Temporary injections (fillers): thicker vocal cords -> edge moves to the middle

   • Botulinum toxin

   • Permanent implants

   • Arytenoid re-positioning

   • Thyroplasty

   • Cordotomy

   • Vocal cord reinnervation

4. Tracheotomy to establish a secure airway if severe bilateral vocal cord immobility

Differential diagnoses

Acute laryngitis, Acute poliomyelitis, Allergy, Alport syndrome, Amyloidosis, Amyotrophic lateral sclerosis, Ankylosing spondylitis, Arnold-Chiari malformation, Asthma, Benign vocal cord lesion, Carotid aneurism, Charcot-Marie-Tooth disease, Costochondritis, Creutzfeldt-Jacob disease, Crohn disease, Croup, Diabetes mellitus, Epiglottitis, Foreign body, Gastroesophageal reflux disease, Gout, Hydrocephalus, Hypocalcemia, Hypokalemia, Laryngeal cancer, Laryngomalacia, Laryngopharyngeal reflux disease, Laryngospasm, Lyme disease, Meningocele, Moebius syndrome, Mumps, Myasthenia gravis, Pneumonia, Reactive arthritis, Reinkes edema, Rheumatoid arthritis, Sarcoidosis, Shy-Drager syndrome, Subglottic stenosis, Syphilis, Systemic lupus erythematosus, Tuberculosis, Wegener's granulomatosis