Neuropatía laríngea y movimiento paradojal de cuerdas vocales en la edad pediátrica: reporte de un caso / Laryngeal neuropathy and paradoxical vocal fold motion in the pediatric age: case report

Resumen La neuropatía laríngea es una condición de hipersensibilidad, hiperreactividad e hiper-función laríngea secundaria a un desequilibrio entre las aferencias y eferencias laríngeas. La respuesta individual y exagerada frente a diversos gatillantes específicos puede generar síntomas como tos crónica, parestesia laríngea, carraspera, disfonía, estridor, sensación de globus faríngeo, movimiento paradojal de las cuerdas vocales (también conocido como disfunción cordal) y/o laringoespasmo. Existe abundante literatura sobre neuropatía laríngea en adultos, sin embargo, en niños es limitada. El objetivo de este artículo es dar a conocer un caso de neuropatía laríngea en la edad pediátrica y la importancia de su consideración en el enfrentamiento de estos pacientes. Se presenta caso clínico de un paciente de 13 años, con antecedente de cirugía cardiaca reciente, evoluciona con disfonía severa evidenciándose aparente inmovilidad cordal bilateral con resultados discordantes entre nasofibrolaringoscopía y electromiografía laríngea. Posteriormente presenta mejorías en su voz, sin embargo, se agregan otros síntomas laringológicos como carraspera, globus faríngeo y estridor no explicados por causas anatómicas. Se expone la evaluación y abordaje otorrinolaringológico-fonoaudiológico para el caso. Se concluye que el diagnóstico de neuropatía laríngea requiere un alto índice de sospecha clínica ante signos laringológicos sugerentes, debiendo descartarse causas orgánicas y estructurales. El abordaje otorrinolaringológico-fonoaudiológico constituye el pilar terapéutico asociado al uso de neuromoduladores en casos seleccionados.

Abstract Laryngeal neuropathy is a condition of hypersensitivity, hyperresponsiveness and laryngeal hyperfunction secondary to an imbalance between laryngeal afferent and efferent information. The individual and exaggerated response to diverse specific triggers can lead to symptoms such as chronic cough, laryngeal paresthesia, throat clearing, dysphonia, stridor, globus pharyngeus, vocal cord dysfunction, and/or laryngospasm. There is plentiful literature on laryngeal neuropathy in adults, however, in children, it is limited. Here, we present a case report of laryngeal neuropathy in the pediatric age and discuss the importance of its consideration in the approach of these patients. A case of a 13-year-old patient, recently intervened with cardiac surgery that evolves with severe dysphonia is presented. Nasofibrolaryngoscopy shows apparent bilateral vocal fold immobility with discordant results in laryngeal electromyography. Later, his voice improves but other laryngological symptoms appeared, such as throat clearing, globus pharyngeus and stridor, not explained by anatomical causes. The otolaryngological-speech therapy evaluation and approach for the case is exposed. We conclude that for the diagnosis of laryngeal neuropathy, a high index of clinical suspicion is required in the presence of suggestive laryngological symptoms, and organic and structural causes must be previously ruled out. The otorhinolaryngological-logopedic approach constitutes the mainstay of treatment associated with the use of neuromodulators in selected cases.

Vocal cord dysfunction: analysis of 27 cases and updated review of pathophysiology & management

Introduction: Vocal cord dysfunction is characterized by unintentional paradoxical vocal cord movement resulting in abnormal inappropriate adduction, especially during inspiration; this predominantly manifests as unresponsive asthma or unexplained stridor. It is prudent to be well informed about the condition, since the primary presentation may mask other airway disorders. Objective: This descriptive study was intended to analyze presentations of vocal cord dysfunction in a tertiary care referral hospital. The current understanding regarding the pathophysiology and management of the condition were also explored. Methods: A total of 27 patients diagnosed with vocal cord dysfunction were analyzed based on demographic characteristics, presentations, associations and examination findings. The mechanism of causation, etiological factors implicated, diagnostic considerations and treatment options were evaluated by analysis of the current literature. Results: There was a strong female predilection noted among the study population ( n = 27), which had a mean age of 31. The most common presentations were stridor (44%) and refractory asthma (41%). Laryngopharyngeal reflux disease was the most common association in the majority (66%) of the patients, with a strong overlay of anxiety, demonstrable in 48% of the patients. Conclusion: Being aware of the condition is key to avoid misdiagnosis in vocal cord dysfunction. Fiberoptic laryngoscopy is the diagnostic gold standard to demonstrate paradoxical vocal cord adduction during an attack. A multidisciplinary approach should be adapted for the management, which should be specific and tailored for individual patients (AU)

Evaluación de la disnea asociada al ejercicio / Exercise-induced dyspnea evaluation

Exercise-induced dyspnea is a common pediatric question but difficult to address since usually symptoms are described ambiguously by the child or parents. Most of times dyspnea is secondary to poor training but sometimes may be due to an underlying condition like exercise-induced bronchoconstriction or vocal cord dysfunction. To provide clinicians with a practical approach about exercise-induced dyspnea we have review pathogenesis and clinical characteristics of respiratory diseases and proposed an algorithm for study.

Frecuentemente nos vemos enfrentados a evaluar un niño con síntomas vagos asociados al ejercicio que el mismo paciente o sus padres describen como ahogo o sensación de pecho apretado. La mayoría de las veces se trata de cansancio atribuible al ejercicio normal que solo refleja pobre condicionamiento físico del individuo; sin embargo, este cansancio puede ser desproporcionado al esfuerzo, lo que obliga a considerar enfermedades comunes como asma o poco comunes como disfunción de cuerdas vocales. El objetivo de esta revisión es actualizar el conocimiento aquellas enfermedades respiratorias que forman parte del diagnóstico diferencial de la disnea asociada al ejercicio y proponer un algoritmo de estudio que permita un acercamiento práctico según causas de origen.