Hoarseness due to aortic arch aneurysms

Abstract Objective: To give an overview of the Ortner's syndrome caused by an aortic arch aneurysm. Methods: By comprehensive retrieval of the pertinent literature published in the past two decades, 75 reports including 86 patients were collected and recruited into this study along with a recent case of our own. Results: The aortic arch aneurysms causing hoarseness were most commonly mycotic aneurysms. In this patient setting, in addition to the left recurrent laryngeal nerve, trachea was the most commonly affected structure by the aortic arch aneurysm. Surgical/interventional/hybrid treatments led to a hoarseness-relieving rate of 64.3%, much higher than that of patients receiving conservative treatment. However, hoarseness recovery took longer time in the surgically treated patients than in the interventionally treated patients. Conclusion: The surgical and interventional treatments offered similar hoarseness-relieving effects. Surgical or interventional treatment is warranted in such patients for both treatment of arch aneurysms and relief of hoarseness.

Laryngeal and vocal alterations after thyroidectomy / Alterações laríngeas e vocais após tireoidectomia

Abstract Introduction: Dysphonia is a common symptom after thyroidectomy. Objective: To analyze the vocal symptoms, auditory-perceptual and acoustic vocal, videolaryngoscopy, the surgical procedures and histopathological findings in patients undergoing thyroidectomy. Methods: Prospective study. Patients submitted to thyroidectomy were evaluated as follows: anamnesis, laryngoscopy, and acoustic vocal assessments. Moments: pre-operative, 1st post (15 days), 2nd post (1 month), 3rd post (3 months), and 4th post (6 months). Results: Among the 151 patients (130 women; 21 men). Type of surgery: lobectomy + isthmectomy n = 40, total thyroidectomy n = 88, thyroidectomy + lymph node dissection n = 23. Vocal symptoms were reported by 42 patients in the 1st post (27.8%) decreasing to 7.2% after 6 months. In the acoustic analysis, f0 and APQ were decreased in women. Videolaryngoscopies showed that 144 patients (95.3%) had normal exams in the preoperative moment. Vocal fold palsies were diagnosed in 34 paralyzes at the 1st post, 32 recurrent laryngeal nerve (lobectomy + isthmectomy n = 6; total thyroidectomy n = 17; thyroidectomy + lymph node dissection n = 9) and 2 superior laryngeal nerve (lobectomy + isthmectomy n = 1; Total thyroidectomy + lymph node dissection n = 1). After 6 months, 10 patients persisted with paralysis of the recurrent laryngeal nerve (6.6%). Histopathology and correlation with vocal fold palsy: colloid nodular goiter (n = 76; palsy n = 13), thyroiditis (n = 8; palsy n = 0), and carcinoma (n = 67; palsy n = 21). Conclusion: Vocal symptoms, reported by 27.8% of the patients on the 1st post decreased to 7% in 6 months. In the acoustic analysis, f0 and APQ were decreased. Transient paralysis of the vocal folds secondary to recurrent and superior laryngeal nerve injury occurred in, respectively, 21% and 1.3% of the patients, decreasing to 6.6% and 0% after 6 months.

Resumo Introdução: A disfonia é um sintoma comum após a tireoidectomia. Objetivo: Analisar os sintomas vocais, auditivo-perceptivos e acústica vocal, videolaringoscopia, procedimento cirúrgico e achados histopatológicos em pacientes submetidos à tireoidectomia. Método: Estudo prospectivo. Pacientes submetidos à tireoidectomia foram avaliados da seguinte forma: anamnese, laringoscopia e avaliações vocais acústicas. Momentos: pré-operatório, 1ª avaliação pós (15 dias), 2ª avaliação pós (1 mês), 3ª avaliação pós (3 meses) e 4ª avaliação pós-operatória (6 meses). Resultados: Dos 151 pacientes, 130 eram mulheres e 21, homens. Tipos de cirurgia: lobectomia + istmectomia n = 40, tireoidectomia total n = 88, tireoidectomia + dissecção de linfonodo n = 23. Sintomas vocais foram relatados por 42 pacientes na 1ª avaliação pós-operatória (27,8%), reduzidos para 7,2% após 6 meses. Na análise acústica, f0 e APQ estavam diminuídos nas mulheres. As videolaringoscopias mostraram que 144 pacientes (95,3%) tiveram exames normais no momento pré-operatório. Paralisia das cordas vocais foi diagnosticada em 34 pacientes na 1ª avaliação pós-operatória, 32 do nervo laríngeo recorrente (lobectomia + istmectomia - n = 6; tireoidectomia total - n = 17; tireoidectomia total + dissecção de linfonodos - n = 9) e 2 do nervo laríngeo superior (lobectomia + istmectomia - n = 1; tireoidectomia total + dissecção de linfonodos - n = 1). Após 6 meses, 10 pacientes persistiram com paralisia do nervo laríngeo recorrente (6,6%). Histopatologia e correlação com paralisia das cordas vocais: bócio coloide nodular (n = 76; paralisia n = 13), tireoidite (n = 8; paralisia n = 0) e carcinoma (n = 67; paralisia n = 21). Conclusão: Os sintomas vocais, relatados por 27,8% dos pacientes na 1ª avaliação pós-operatória, diminuíram para 7% em 6 meses. Na análise acústica, f0 e APQ diminuíram. A paralisia transitória de cordas vocais secundária à lesão do nervo laríngeo recorrente e nervo laríngeo superior ocorreu, respectivamente, em 21% e 1,3% dos pacientes, reduziu-se para 6,6% e 0% após 6 meses.

Vocal cord paralysis after endotracheal intubation: an uncommon complication of general anesthesia / Paralisia de cordas vocais após intubação endotraqueal: uma complicação incomum da anestesia geral

Abstract Background: General anesthesia is a safe, frequent procedure in clinical practice. Although it is very unusual in procedures not related to head and or neck surgery, vocal cord paralysis is a serious and important complication. Incidence has been associated with patient age and comorbidities, as well as the position of the endotracheal tube and cuff. It can become a dangerous scenario because it predisposes aspiration. Objectives: To present a case and analyze the risk factors associated with increased risk of vocal cord paralysis described in the literature. Case report: 53 year-old diabetic man, who developed hoarseness in the postoperative period after receiving general anesthesia for an elective abdominal laparoscopic surgery. Otolaryngological evaluation showed left vocal cord paralysis. Conclusions: Vocal cord paralysis can be a serious complication of general anesthesia because of important voice dysfunction and risk of aspiration. The management is not yet fully established, so prevention and early diagnosis is essential.

Resumo Justificativa: A anestesia geral é um procedimento seguro e frequente na prática clínica. Embora seja muito rara em procedimentos não relacionados à cirurgia de cabeça ou pescoço, a paralisia das cordas vocais é uma complicação séria e importante. Sua incidência tem sido associada à idade e comorbidades do paciente, bem como à posição do tubo endotraqueal e seu balonete. A paralisia das cordas vocais pode ser uma condição perigosa porque predispõe à aspiração. Objetivos: Apresentar um caso e analisar os fatores de risco associados ao aumento do risco de paralisia das cordas vocais descritos na literatura. Relato de caso: Paciente do sexo masculino, 53 anos, diabético, que desenvolveu rouquidão no pós-operatório após anestesia geral para cirurgia laparoscópica abdominal eletiva. A avaliação otorrinolaringológica mostrou paralisia da corda vocal esquerda. Conclusão: A paralisia de cordas vocais pode ser uma complicação séria da anestesia geral devido ao risco grave de disfunção da voz e aspiração. O manejo dessa condição ainda não está totalmente estabelecido, de modo que a prevenção e o diagnóstico precoce são essenciais.

Multidimensional effects of voice therapy in patients affected by unilateral vocal fold paralysis due to cancer / Efeitos multidimensionais da terapia vocal em pacientes com paralisia unilateral daprega vocal por câncer

Abstract Introduction: Patients with unilateral vocal fold paralysis may demonstrate different degrees of voice perturbation depending on the position of the paralyzed vocal fold. Understanding the effectiveness of voice therapy in this population may be an important coefficient to define the therapeutic approach. Objective: To evaluate the voice therapy effectiveness in the short, medium and long-term in patients with unilateral vocal fold paralysis and determine the risk factors for voice rehabilitation failure. Methods: Prospective study with 61 patients affected by unilateral vocal fold paralysis enrolled. Each subject had voice therapy with an experienced speech pathologist twice a week. A multidimensional assessment protocol was used pre-treatment and in three different times after voice treatment initiation: short-term (1-3 months), medium-term (4-6 months) and long-term (12 months); it included videoendoscopy, maximum phonation time, GRBASI scale, acoustic voice analysis and the portuguese version of the voice handicap index. Results: Multiple comparisons for GRBASI scale and VHI revealed statistically significant differences, except between medium and long term (p < 0.005). The data suggest that there is vocal improvement over time with stabilization results after 6 months (medium term). From the 28 patients with permanent unilateral vocal fold paralysis, 18 (69.2%) reached complete glottal closure following vocal therapy (p = 0.001). The logistic regression method indicated that the Jitter entered the final model as a risk factor for partial improvement. For every unit of increased Jitter, there was an increase of 0.1% (1.001) of the chance for partial improvement, which means an increase on no full improvement chance during rehabilitation. Conclusion: Vocal rehabilitation improves perceptual and acoustic voice parameters and voice handicap index, besides favor glottal closure in patients with unilateral vocal fold paralysis. The results were also permanent during the period of 1 year. The Jitter value, when elevated, is a risk factor for the voice therapy success.

Resumo Introdução: Pacientes com paralisia unilateral de prega vocal podem apresentar diferentes graus de distúrbios da voz, dependendo da posição da prega vocal paralisada. A compreensão da eficácia da terapia vocal nesta população pode ser um coeficiente importante para definir a abordagem terapêutica. Objetivo: Avaliar a eficácia da terapia vocal em curto, médio e longo prazos em pacientes com paralisia unilateral de prega vocal e determinar os fatores de risco para falha na reabilitação da voz. Método: Estudo prospectivo, no qual 61 pacientes com paralisia unilateral de prega vocal foram recrutados. Cada participante foi submetido a terapia vocal com um fonoaudiólogo experiente duas vezes por semana. Um protocolo de avaliação multidimensional foi utilizado no pré-tratamento e em três momentos após o início da terapia da voz: curto prazo (1-3 meses), médio prazo (4-6 meses) e longo prazo (12 meses); incluiu videoendoscopia, tempo máximo de fonação, escala GRBASI, análise de voz acústica e a versão em português do Voice Handicap Index. Resultados: Os dados comparativos temporais das avaliações revelaram diferenças estatisticamente significativas, exceto entre médio e longo prazo (p < 0,005). Os dados sugerem que há melhora vocal ao longo do tempo com resultados de estabilização após seis meses (médio prazo). Dos 28 pacientes com paralisia unilateral permanente da prega vocal, 18 (69,2%) atingiram o fechamento glótico completo após a terapia vocal (p = 0,001). O método de regressão logística indicou que o Jitter entrou no modelo final como um fator de risco para melhora parcial. Para cada unidade de aumento de Jitter, houve um aumento de 0,1% (1,001) da chance de melhora parcial, o que significa um aumento na chance de não ocorrer melhora completa durante a reabilitação. Conclusão: A reabilitação vocal melhora os parâmetros de voz perceptiva e acústica e o índice de incapacidade vocal, além de favorecer o fechamento glótico em pacientes com paralisia unilateral da prega vocal. Além disso, os resultados também foram permanentes durante o período de um ano. O valor de Jitter, quando elevado, é um fator de risco para sucesso parcial da terapia vocal.

Parálisis de cuerda vocal secundaria a intubación endotraqueal y su manejo: revisión en relación a dos casos clínicos / Vocal cord paralysis secondary to endotracheal intubation and its management: review in relation to two clinical cases

La parálisis de cuerda vocal secundaria a intubación endotraqueal es una complicación poco frecuente de la anestesia general. Se manifiesta con disfonía precoz luego de la extubación, y en ocasiones se asocia a aspiración. A continuación se presenta el reporte de dos pacientes sometidos a cirugía abdominal con anestesia general e intubación endotraqueal, que presentan una parálisis cordal unilateral en el posoperatorio inmediato. En ambos pacientes se realiza una laringoplastía de inyección con ácido hialurónico (Restylane®), con buenos resultados vocales. Uno de los casos tiene seguimiento a lo largo de dos años. Se describe esta patología y su manejo mediante una revisión bibliográfica.

Vocal fold paralysis posterior to endotracheal intubation is a very uncommon complication of the general anestesia. The symptoms includes hoarseness posterior to the extubation, and some times aspiration occurs. In this paper we present the report of two cases of abdominal surgery with general anesteshia and endotraqueal intubation procedures. Both subjects developed unilateral vocal fold paralysis after the process. The patients were treated with wedilization injection with Restylane ®, satisfactory voice's results were achieved. One of them has an observational time of two years. We describe this infrequent pathology and the treatment through literature review.

Severe microscopic polyangiitis with unilateral vocal cord paralysis as initial manifestation / Parálisis unilateral de cuerda vocal como manifestación inicial de poliangitis microscópica grave

Abstract Case Description: A 16 year-old female who presented with initial ear, nose and throat manifestations who later progressed to severe renal disease, requiring hemodialysis after 11 months of unique laryngeal involvement. Clinical Findings: Unilateral vocal cord paralysis without other symptoms or signs, but with positive perinuclear anti-neutrophil cytoplasmic antibodies (ANCA) and anti-myeloperoxidase autoantibodies, followed an unfavorable course months later with rapidly progressive glomerulonephritis. Renal biopsy confirmed an ANCA-associated vasculitis. She was diagnosed with microscopic polyangiitis. Treatment and Outcome: High-dose glucocorticoids, intravenous cyclophosphamide, plasma exchange and finally, hemodialysis and renal transplantation. Clinical Relevance: In contrast to granulomatosis with polyangiitis (Wegener), ear, nose and throat manifestations in microscopic polyangiitis are uncommon, while involvement of the lungs and kidneys are usual. We present a case with an isolated rare involvement, which progressed to severe disease. This atypical case warns about laryngeal symptoms as initial manifestation of an anti-myeloperoxidase positive systemic vasculitides, and emphasizes the relevance of close observation when unexplained isolated conditions with accompanying evidence of autoimmunity, in this case high levels of specific autoantibodies, are present.

Resumen Descripción del caso: Una mujer de 16 años se presentó inicialmente con manifestaciones otorrinolaringológicas y posteriormente progresó hacia enfermedad renal grave, requiriendo hemodiálisis después de 11 meses de tener exclusivamente afección laríngea. Hallazgos clínicos: parálisis de cuerda vocal unilateral sin otros síntomas ni signos, pero con autoanticuerpos anticitoplasma de neutrófilo (ANCA) con patrón perinuclear y especificidad contra mieloperoxidasa, siguiendo un curso desfavorable meses después con desarrollo de glomerulonefritis rápidamente progresiva. La biopsia renal confirmó una vasculitis asociada con ANCA (VAA). Se diagnosticó entonces como poliangitis microscópica. Tratamiento y desenlace: Glucocorticoides a dosis altas, ciclofosfamida endovenosa, recambio plasmático y finalmente, hemodiálisis y transplante renal. Relevancia clínica: en contraste con la granulomatosis con poliangitis (Wegener), las manifestaciones otorrinolaringológicas en poliangitis microscópica son poco comunes, mientras que la afección pulmonar y renal es común. Presentamos un caso con afección inusual aislaea, que progresó a enfermedad grave. Este caso atípico enfatiza sobre los síntomas laríngeos como manifestación inicial de una vasculitis antimieloperoxidasa positiva, y subraya la relevancia de una estrecha observación cuando condiciones aisladas inexplicables, que como en este caso se acompañan de evidencia de autoinmunidad manifestado por presencia de niveles altos de autoanticuerpos, se presentan para su atención.

Tratamiento de la inmovilidad cordal bilateral / Bilateral vocal fold immobility treatment

La inmovilidad bilateral de las cuerdas vocales en aducción puede ser provocada por diversas etiologías y pone en riesgo la vida de los pacientes por la disnea grave que puede ocasionar. Existen diversas técnicas quirúrgicas para aumentar el espacio glótico, entre las que prevalecen las cirugías transorales que resecan tejido. El objetivo del presente trabajo es determinar la tasa de resolución de la disnea inspiratoria o decanulación, en pacientes con inmovilidad cordal bilateral en aducción, tratados mediante cordotomía posterior y aritenoidectomía parcial. Fueron tratados en este estudio 17 enfermos por inmovilidad bilateral de las cuerdas vocales en aducción, mediante cordotomía posterior y aritenoidectomía parcial medial por vía transoral con láser de CO2 , cauterio y radiofrecuencia. Ocho pacientes tuvieron traqueostomía. El 75% fueron decanulados. El 100% de los pacientes sin traqueostomía mejoraron la disnea inspiratoria y no tuvieron limitación para las actividades de su vida cotidiana. Como conclusión del trabajo, se determinó que la cordotomía posterior y la aritenoidectomía parcial por vía transoral fueron muy eficaces para mejorar el calibre de la vía aérea superior, con baja morbilidad y sin complicaciones. (AU)

Bilateral medial vocal fold immobility, can be caused by various etiologies and can lead to severe dyspnea that may risk patients life. There are several surgical techniques for increasing the glottic space, prevailing transoral surgeries that remove tissue. The objective of this study is to determine the rate of resolution of inspiratory dyspnea and decanulation in patients with bilateral vocal cord immobility in adduction. In this study 17 patients diagnosed with bilateral vocal fold immobility in adduction were treated with posterior cordotomy and partial medial arytenoidectomy with transoral approach, using CO2 laser, radiofrequency or electrocautery. Eight of our patients were tracheostomized. Six of the tracheostomized patients had their tracheostomies removed (6 out of 8, 75%). Nine without tracheostomy showed improvement of inspiratory dyspnea and had no limitation on their daily lives activities. (9 out of 9, 100%). As a conclussion, we can say that transoral cordotomy and partial arytenoidectomy were very effective in improving the caliber of the upper airway, with low morbidity and no complications. (AU)

Manejo de disfonía post cirugía tiroidea con laringoplastía por inyección con ácido hialurónico / Hyaluronic acid in the management of post-thyroidectomy vocal cord paralysis

Introduction: Thyroid surgery rates have tripled over the past 3 decades. Currently, the main postoperative complications of this surgery are vocal fold paralysis because of recurrent laryngeal nerve dysfunction and hypocalcemia. Case report: We report the case of a 58 years old woman who presented with persistent dysphonia post total thyroidectomy. Laryngeal videostroboscopy evidenced unilateral vocal fold paralysis. We performed a percutaneous injection laryngoplasty with hyaluronic acid achieving significant improvement in voice. Conclusions: Percutaneous injection laryngoplasty with hyaluronic acid is a safe and effective procedure in the management of post thyroidectomy vocal cord paralysis.

Introducción: La tasa de cirugía tiroidea se ha triplicado en las últimas 3 décadas. Dentro de sus complicaciones se encuentra la parálisis de cuerda vocal unilateral secundaria a lesión transitoria o permanente del nervio laríngeo recurrente, lo que se presenta clínicamente como disfonía. Caso clínico: Paciente de 58 años, post tiroidectomía total evoluciona con disfonía persistente. Videoestroboscopia evidencia parálisis cuerda vocal izquierda en posición paramediana, con hiato fonatorio longitudinal amplio. Se maneja con laringoplastía por inyección con ácido hialurónico a cuerda vocal paralítica, logrando mejora significativa de voz. En videoestroboscopia de control al 7º día se evidencia cuerda vocal izquierda en línea media, con borde libre recto, sin presencia de hiato al fonar. Conclusiones: La laringoplastía por inyección percutánea con ácido hialurónico es un procedimiento seguro y eficaz para el tratamiento de la disfonía secundaria a parálisis cordal unilateral post cirugía tiroidea.

Characteristics of voice and personality of patients with vocal fold immobility / Características vocais e de personalidade de pacientes com imobilidade de prega vocal

Purpose: To examine the voice and personality characteristics of patients diagnosed with organic dysphonia secondary to vocal fold immobility. Methods: The study comprised patients of both genders, attending the Clinic School of Speech Therapy of the Federal University of Paraíba, with otorhinolaryngological diagnosis of vocal fold immobility and speech therapy diagnosis of dysphonia. The self-assessment of voice was measured through a Vocal Screening Protocol and Voice Symptoms Scale (VoiSS), the voice was collected for auditory-perceptive evaluation, and the Factorial Personality Battery (FPB) was used. Descriptive statistical analysis was performed to determine the frequency, mean, and standard deviation of the studied variables. Results: Eight patients participated in the study, of both genders, with average age of 40.4±16.9 years. The more frequent risk factors were the personal ones (4.7±2.1). In the VoiSS, the patients presented a higher average in the limitation score (34.1±15.7). From the auditory-perceptive evaluation, moderate intensity of vocal deviation was obtained, with predominant vocal roughness (57.7±25.2). In the FPB, the patients had an average higher than the cutoff scores in neuroticism (3.8±1.4) and accomplishment (5.2±1.0). Conclusion: The predominant vocal parameter was roughness. The patients referred to a few risk factors that compromise the vocal behavior and presented the neuroticism and realization factors as a highlight in their personality. Thus, individuals with vocal fold immobility show personality characteristics that may be a reflection of their voice disorder, not a factor that determines their dysphonia. .

Objetivo: Averiguar as características vocais e de personalidade de pacientes com diagnóstico de disfonia orgânica secundária à imobilidade de prega vocal. Métodos : O estudo foi composto por pacientes de ambos os gêneros, atendidos na Clínica Escola de Fonoaudiologia da Universidade Federal da Paraíba, com diagnóstico otorrinolaringológico de imobilidade de prega vocal e fonoaudiológico de disfonia. Mensurou-se a autoavaliação da voz por meio de um Protocolo de Triagem Vocal e Escala de Sintomas Vocais (ESV), coletou-se a voz para a avaliação perceptivo-auditiva e aplicou-se a Bateria Fatorial de Personalidade (BPF). Realizou-se análise estatística descritiva para averiguar a frequência, média e desvio padrão das variáveis estudadas. Resultados: Participaram 8 pacientes, de ambos os gêneros, com a idade média de 40,4 ±16,9 anos. Os fatores de risco mais presentes foram os pessoais (4,7±2,1). Na ESV, os pacientes apresentaram maior média no escore de limitação (34,1±15,7). A partir da avaliação perceptivo-auditiva, obteve-se intensidade do desvio vocal moderada com qualidade vocal predominantemente rugosa (57,7±25,2). Na BFP, os pacientes tiveram médias maiores que o ponto de corte nos fatores neuroticismo (3,8±1,4) e realização (5,2±1,0). Conclusão: O parâmetro vocal predominante foi rugosidade. Os pacientes citaram poucos fatores de risco que comprometem o comportamento vocal e apresentaram os fatores neuroticismo e realização como destaque em sua personalidade. Assim, indivíduos com imobilidade de prega vocal demonstram características de personalidade que podem ser reflexo do seu distúrbio de voz, e não um fator que determine a sua disfonia. .

Extended Neuralgic Amyotrophy Syndrome: voice therapy in one case of vocal fold paralysis / Amiotrofia Nevrálgica Estendida: fonoterapia em um caso de paralisia de prega vocal

Neuralgic Amyotrophy (NA) is a rare disturb of the peripheral nervous system that can include extreme pain, multifocal paresis and atrophy of the muscles of the upper limbs. When the nerves located outside of the brachial plexus are involved, the term Neuralgic Amyotrophy Extended (ANE) is used. Diagnosis of NA is clinical and has a series of inclusion and compatibility criteria established by the European CMT Consortium. On this study the clinical history, multidimensional vocal assessment data and the vocal techniques used in five-weeks voice therapy for one patient, professional voice, with ANE are presented. In this case, sudden and recurrent paralysis of his right vocal fold was the only manifestation of the disease. At the end of the fifth week the patient's voice was normal, the spoken and sung vocal ranges were same as before the current episode of ANE and scores of his vocal self-assessment were appropriate.

A Amiotrofia Nevrálgica (AN) é um distúrbio raro do sistema nervoso periférico que pode incluir dor extrema, paresia multifocal e atrofia dos músculos dos membros superiores. Quando há o envolvimento de nervos localizados fora do plexo braquial, o termo Amiotrofia Nevrálgica Estendida (ANE) é utilizado. O diagnóstico da AN é clínico e possui uma série de critérios de inclusão, bem como critérios de compatibilidade estabelecidos pelo European CMT Consortium. Neste estudo são apresentados a história clínica, os dados da avaliação vocal multidimensional e as técnicas vocais utilizadas na terapia vocal de cinco semanas de um paciente, profissional da voz, com ANE. A paralisia súbita e recorrente da prega vocal direita foi a única manifestação da doença. Ao término da quinta semana, a voz do paciente estava adaptada, as extensões de voz falada e cantada eram as mesmas de antes da lesão e os escores de sua autoavaliação vocal estavam adequados.

Parálisis diafragmática y de cuerda vocal en un paciente cón Síndrome de Churg-Strauss: reporte de un caso / Diaphragmatic and vocal cord paralysis in Churg-Strauss syndrome: a case report

El Síndrome de Churg-Strauss es una vasculitis sistémica que afecta vasos de pequeño y mediano calibre y que suele presentarse con asma, fiebre, hipereosinofilia, insuficiencia cardiaca, daño renal y neuropatía periférica. esta última se observa en el 65 por ciento al 80 por ciento de los casos, siendo el compromiso de nervios craneales en una minoría, y aún más excepcional la parálisis de cuerdas vocales y el diafragma. Las neuropatías por vasculitis sistémicas pueden resultar en morbilidad grave e incluso la muerte, por esto la necesidad de instaurar un tratamiento temprano. Reportamos el caso de un paciente que padeció parálisis diafragmática y de cuerda vocal por síndrome de Churg-Strauss.

Churg-Strauss syndrome is a systemic vasculitis of the small and medium sized vessels that usually occurs with asthma, fever, hypereosinophilia, cardiac failure, renal damage and peripheral neuropathy. The latter affects 65 percent to 80 percent of patients, cranial nerves involvement is rare while vocal cord and diaphragmatic paralysis are exceptional. Neuropathies due to systemic vasculitis may result in significant disability and death, therefore the importance to institute an early treatment. We report here a patient who suffered diaphragmatic and vocal cord paralysis due to Churg-Strauss syndrome.

Ortner's syndrome: case series and literature review / Síndrome de Ortner: série de casos e revisão da literatura

More than a century ago, Ortner described a case of cardiovocal syndrome wherein he attributed a case of left vocal fold immobility to compression of the recurrent laryngeal nerve by a dilated left atrium in a patient with mitral valve stenosis. Since then, the term Ortner's syndrome has come to encompass any nonmalignant, cardiac, intrathoracic process that results in embarrassment of either recurrent laryngeal nerve-usually by stretching, pulling, or compression; and causes vocal fold paralysis. Not surprisingly, the left recurrent laryngeal nerve, with its longer course around the aortic arch, is more frequently involved than the right nerve, which passes around the subclavian artery. OBJECTIVES: To discuss the pathogenesis of hoarseness resulting from cardiovascular disorders involving the recurrent laryngeal nerve along with the findings of literature review. MATERIALS AND METHODS: This paper reports a series of four cases of Ortner's syndrome occurring due to different causes. DESIGN: Case study. RESULT: Ortner's syndrome could be a cause of hoarseness of voice in patients with cardiovascular diseases. CONCLUSION: Although hoarseness of voice is frequently encountered in the Otolaryngology outpatient department, cardiovascular- related hoarseness is an unusual presentation. Indirect laryngoscopy should be routinely performed in all cases of heart disease.

Há mais de um século, Ortner descreveu um caso de síndrome cardiovocal, no qual ele atribuiu um caso de imobilidade da prega vocal esquerda à compressão do nervo laríngeo recorrente causada por dilatação do átrio esquerdo em um paciente com estenose valvar mitral. Desde então, o termo Síndrome de Ortner tem sido usado para descrever qualquer condição cardíaca intratorácica não maligna que resulte no envolvimento do nervo laríngeo recorrente - geralmente por estiramento, contração ou compressão, causando paralisia vocal. Não é surpreendente que o nervo laríngeo recorrente esquerdo, com seu curso mais longo, contornando o arco aórtico, seja mais frequentemente afetado que o direito - que cursa ao redor da artéria subclávia. OBJETIVOS: Discutir a patogênese da rouquidão resultante de lesão cardiovascular que envolve o nervo laríngeo recorrente, juntamente com uma revisão da literatura. MATERIAIS E MÉTODOS: Este trabalho relata uma série de quatro casos de Síndrome de Ortner resultantes de diferentes causas. Tipo de estudo: Estudo de Casos. RESULTADO: A Síndrome de Ortner pode representar uma causa de rouquidão em pacientes com doenças cardiovasculares. CONCLUSÃO: Apesar de rouquidão ser frequentemente encontrada em ambulatórios de otorrinolaringologia, sua etiologia associada ao aparelho cardiovascular é pouco frequente. Laringoscopia indireta dever ser empregada rotineiramente em todos os casos de doenças cardíacas.

Bilateral vocal fold immobility: diagnosis and treatment / Imobilidade bilateral de pregas vocais: diagnóstico e tratamento

Vocal fold immobility may be due to bilateral neurogenic paralysis, cricoarytenoid joint fixation, laryngeal synechiae, or posterior glottic stenosis. Treatment aims to establish a patent airway and preserve the function of the glottic sphincter and voice quality. OBJETIVES: To analyze the diagnostic and therapeutic approaches in cases of bilateral vocal fold immobility seen at our unit. MATERIALS AND METHODS: A retrospective study of 35 patient registries at our unit with a diagnosis of bilateral vocal fold immobility; the etiology and treatment results were evaluated. RESULTS: Among the patients, 18 (51.4 percent) were cases of bilateral vocal fold palsy, and 17 (48,6 percent) were cases of posterior glottic stenosis. Patients with bilateral palsy underwent unilateral subtotal arytenoidectomy, and patients with stenosis were treated with the microtrapdoor flap technique, subtotal arytenoidectomy, and/or posterior cricoidotomy (Rethi). CONCLUSION: Bilateral vocal fold immobility is a potentially fatal condition; it is essential to differentiate vocal fold palsy from fixation to choose the appropriate treatment. Subtotal arytenoidectomy with microscopy is our surgery of choice for treating bilateral paralysis; the technique for treating stenosis depends on the amount of stenosis.

A Imobilidade Bilateral de Pregas Vocais pode ser decorrente de paralisia neurogênica bilateral, fixação de articulação cricoaritenoidea, sinequia laríngea ou estenose glótica posterior. O tratamento visa a restabelecer uma via aérea pérvia mantendo a função esfincteriana glótica e a qualidade vocal. OBJETIVOS: Analisar os métodos diagnósticos e terapêuticos dos casos de Imobilidade Bilateral de Prega Vocal atendidos em nosso serviço. MATERIAIS E MÉTODOS: Estudo retrospectivo de 35 prontuários de pacientes atendidos em nosso serviço com diagnóstico de Imobilidade Bilateral de Prega Vocal, sendo avaliados fatores etiológicos e resultados terapêuticos. RESULTADOS: Dentre os pacientes, 18 (51,4 por cento) eram casos de paralisia bilateral de pregas vocais e 17 (48,6 por cento), de estenose glótica posterior. Os pacientes com paralisia bilateral foram submetidos à aritenoidectomia subtotal unilateral e os com estenose, submetidos à "microtrapdoor flap", aritenoidectomia subtotal e/ou cricoidotomia posterior (Rethi). CONCLUSÃO: A imobilidade bilateral de prega vocal é um quadro potencialmente fatal e a diferenciação entre paralisia e fixação de pregas vocais é essencial para a escolha do método terapêutico. A aritenoidectomia subtotal, via microscópica, é nossa opção cirúrgica para o tratamento da paralisia bilateral e nas estenoses a escolha da técnica varia conforme o grau de estenose.

CT Evaluation of Vocal Cord Paralysis due to Thoracic Diseases: A 10-Year Retrospective Study

PURPOSE: To discuss computed tomography (CT) evaluation of the etiology of vocal cord paralysis (VCP) due to thoracic diseases. MATERIALS AND METHODS: From records from the past 10 years at our hospital, we retrospectively reviewed 115 cases of VCP that were evaluated with CT. Of these 115 cases, 36 patients (23 M, 13 F) had VCP due to a condition within the thoracic cavity. From these cases, we collected the following information: sex, age distribution, side of paralysis, symptom onset date, date of diagnosis, imaging, and primary disease. The etiology of VCP was determined using both historical information and diagnostic imaging. Imaging procedures included chest radiograph, CT of neck or chest, and esophagography or esophagoscopy. RESULTS: Thirty-three of the 36 patients with thoracic disease had unilateral VCP (21 left, 12 right). Of the primary thoracic diseases, malignancy was the most common (19, 52.8%), with 18 of the 19 malignancies presenting with unilateral VCP. The detected malignant tumors in the chest consisted of thirteen lung cancers, three esophageal cancers, two metastatic tumors, and one mediastinal tumor. We also found other underlying etiologies of VCP, including one aortic arch aneurysm, five iatrogenic, six tuberculosis, one neurofibromatosis, three benign nodes, and one lung collapse. A chest radiograph failed to detect eight of the 19 primary malignancies detected on the CT. Nine patients with lung cancer developed VCP between follow-ups and four of them were diagnosed with a progression of malignancy upon CT evaluation of VCP. CONCLUSION: CT is helpful for the early detection of primary malignancy or progression of malignancy between follow-ups. Moreover, it can reveal various non-malignant causes of VCP.

Recurrent laryngeal nerve injury in thyroid surgery

Vocal cord paresis or paralysis due to iatrogenic injury of the recurrent laryngeal nerve [RLNI] is one of the main problems in thyroid surgery. Although many procedures have been introduced to prevent the nerve injury, still the incidence of recurrent laryngeal nerve palsy varies between 1.5-14%. The aim of the present study is to assess the risk factors of recurrent laryngeal nerve injury during thyroid surgery. Patients who had thyroid surgery between 1990 and 2005 and were admitted to the surgical department of King Fahd hospital of the University, Al-Khobar, Saudi Arabia were enrolled for this retrospective review, Factors predisposing to recurrent laryngeal nerve injury were evaluated such as pathology of the lesions and the type of operations and identification of recurrent laryngeal nerve intra-operatively. Preoperative and postoperative indirect laryngoscopic examinations were performed for all patients. 340 patients were included in this study. Transient unilateral vocal cord problems occurred in 11 [3.2%] cases, and in 1 [0.3%] case, it became permanent [post Rt. Hemithyroidectomy]. Bilateral vocal cord problems occurred in 2 cases [0.58%], but none became permanent. There were significant increases in the incidence of recurrent laryngeal nerve injury in secondary operation [21.7% in secondary vs. 2.8% in primary, p=0.001], total/near total thyroidectomy [7.2% in total vs. 1.9% in subtotal, p=0.024], non-identification of RLN during surgery [7.6% in non-identification vs. 2.6% in identification, p=0.039] and in malignant disease [12.8% in malignant vs. 2.9% in benign, p=0.004]. However, there was no significant difference in the incidence of recurrent laryngeal nerve injury with regards to gender [4.1% in male vs 3.8% in female, p=0.849]. The present study showed that thyroid carcinoma, re-operation for recurrent goiter, non-identification of RLN and total thyroidectomy were associated with a significantly increased risk of operative recurrent laryngeal nerve injury

thyroidectomy safe after identification of recurrent laryngeal nerve - fact or fiction

Injury to recurrent laryngeal nerve remains a common complication of thyroid surgery. It is argued whether routine dissection leads to increase risk of palsy or otherwise. To assess recurrent laryngeal nerve injury risk during thyroidectomy with and without routine identification of the recurrent laryngeal nerve during surgery. Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro/Hyderabad over 3 years. The frequency of recurrent laryngeal nerve injury following surgery for benign, nontoxic thyroid disease was studied in consecutive patients undergoing hemithyroidectomy, subtotal thyroidectomy or near total thyroidectomy. Patients with benign and non toxic goitre were included in the study while those with toxic goitre and malignancy were excluded. A total of 88 patients were included in the study. They were divided into two groups, group A included patients in whom dissection of recurrent laryngeal nerve was done as standard procedure while in group B, the nerve was not exposed. There were 34 unilateral and 54 bilateral explorations. The mean age of patients in the two groups was almost same, with preponderance of females [M:F ratio 1:17]. The incidence of recurrent laryngeal nerve injury was not significant in both groups [p=0.502], but the incidence of nerve injury in patients who underwent near total thyroidectomy was 17.6% compared to 0.17% in patients who had hemithyroidectomy, indicating that it is not the exploration but the extent of thyroid resection that is a risk factor for recurrent laryngeal nerve injury. Dissection of nerve does not significantly reduce the risk of recurrent laryngeal nerve injury therefore, routine exploration of the nerve during thyroid surgery is not recommended in an expert hand

Protocolo de cooperação fonoaudiológica para avaliação nasofibrolaringoscópica da mobilidade laríngea em doenças da tireóide (PAN) / Speech-language cooperation protocol for the fiberoptic laryngoscopy evaluation of larynx mobility

TEMA: protocolo de avaliação da voz. OBJETIVO: proposição de um protocolo de cooperação fonoaudiológica para avaliação nasofibrolaringoscópica da mobilidade laríngea em doenças da tireóide (PAN), visando a composição de um instrumento objetivo, preciso e consensual para avaliação. MÉTODOS: a primeira versão do protocolo foi elaborada a partir de fundamentação bibliográfica; o PAN foi julgado em duas instâncias pelo método de triangulação por seis juízes em três etapas; foi constituída uma versão piloto do protocolo e aplicada em 11 pacientes; houve novo julgamento de médicos e fonoaudiólogos; a partir da concordância dos juízes, após a aplicação do piloto, foi construída a versão final do PAN. RESULTADOS: o PAN final foi composto por duas partes. A primeira parte considerada o procedimento padrão composta por 4 itens imprescindíveis e que devem necessariamente ser avaliados são: inspiração normal; inspiração forçada; vogal /é/ isolada e sustentada e vogal /i/ aguda isolada e sustentada. A segunda parte considerada de complementação fonoaudiológica é composta pelos itens que são entendidos pelos fonoaudiólogos como fatores informativos ou preditivos para a eficácia da terapia. Esses itens são: vogal /é/ sustentada e fraca; vogal /é/ sustentada e aguda; vogal /é/ sustentada e grave; vogal /é/ curta com ataque vocal brusco. CONCLUSÕES: o PAN, em sua versão final, contribui para a sistematização dos procedimentos de avaliação fundamentados em evidências e concordâncias profissionais. O PAN resulta na descrição de itens a serem solicitados durante a avaliação médica e fonoaudiológica no exame de nasofibrolaringoscopia da alteração da mobilidade laríngea em doenças da tireóide

BACKGROUND: voice protocol. AIM: to propose a protocol for the fiberoptic laryngoscopy evaluation of larynx mobility in thyroid illnesses (PAN), with the intention of having an objective, precise and consensual instrument for this assessment. METHOD: the first version of the protocol was elaborated based on data found in the literature; the protocol was judged twice, using the triangulation method; a pilot version was presented and applied in 11 patients; it was then judged again by doctors and speech-language pathologists; based on the analysis of the judges and after the application of the pilot version, the final version of the PAN was proposed. RESULTS: the final protocol was composed by two parts. The first part, considered a standard procedure, is composed by 4 essential items that necessarily should be evaluated: normal inspiration; forced inspiration; vowel /é/ isolated and sustained; and sharp vowel /i/, isolated and sustained. The second part, considered a speech-language complementation, is composed by items that should be understood as being important for speech-language pathologists as they are informative or predictive of the effectiveness of therapy: vowel /é/ sustained and weak; vowel /é/ sustained and sharp; vowel /é/ sustained and deep; vowel /é/ short with abrupt vocal onset. CONCLUSIONS: the PAN, in its final version, contributes for the systematization of the assessment procedures based on evidence and on the agreement of professionals. The PAN results in the description of items to be obtained during medical and speech-language assessment during the fiberopticlaryngoscopy evaluation of larynx mobility in thyroid illnesses

Recurrent laryngeal nerve injury; a risk in thyroid surgery

Aim of this study was to find out the frequency of recurrent laryngeal nerve injury in different types of thyroid surgery. An experimental study. The study was carried out at Combined Military Hospital, Rawalpindi from January 2001 to July 2002. Seventy two patients were included in this study. Case selection was done by non probability convenient sampling from surgical out patient department. Age of patients ranged between 15 years to 73 years. Mean age was 36.5 years with maximum prevalence in the range of 31-40 years [31.5%] Male to female ratio was 1:1.7. All patients were evaluated clinically and were advised preoperative routine investigation. All patients had voice analysis along with indirect laryngoscopic examination preoperatively. The commonest presenting complaint in 72 patients was lump front of neck in 69 [95.8%] patients, 48[66.7%] patients were having nontoxic goiter, 15 [20.8%] patients were having toxic goiter and 9 [12.5%] patients were having malignant goiter. Out of all thyroidectomies performed 48 [66.7%] were sub total, 18 [25%] lobectomy with Isthmusectomy, 5 [6.9%] were near total and 1 [1.4%] was total thyroidectomy. Temporary recurrent laryngeal nerve injury occurred in 2 [2.8%] cases. Permanent injuries to recurrent laryngeal nerve occurred in 2 [2.8%] cases, one patient had vocal cord paralysis and other developed vocal cord paresis which improved partially with time. Recurrent laryngeal nerve injury is a potentially dangerous and a serious complication of thyroid surgery. The overall percentage of injury to recurrent laryngeal nerve in thyroid surgery in this study was 4 [5.6%] cases