Paradoxical vocal cord motion: an often misdiagnosed cause of postoperative stridor

This conference reports a case of acute functional airway obstruction occurring in the postoperative anesthesia care unit, which was diagnosed by fiberoptic laryngoscopy and successfully treated with intravenous midazolam after other more common causes of stridor were ruled out. The presentation, etiology, diagnosis, and treatment of paradoxical vocal cord motion as it relates to the care of the postoperative patient are discussed.     

Paradoxical vocal cord motion: an alarming stridor for a benign condition--case reports

Paradoxical vocal cord motion presents a challenge to medical practitioners in various specialties. Physicians in general and anesthesiologists should suspect this condition in a patient presenting with stridor or a history of choking or asthma not responding to medical treatment. Women are usually more affected than men and more often there is history of anxiety and/or a precipitating factor such as cough or hyperventilation. Accurate diagnosis relies on visualizing adduction of the vocal cords during inspiration or throughout the respiratory cycle using fiberoptic nasopharyngeal laryngoscopy or telescopic examination. The etiology varies from organic causes such as brainstem compression or lower motor neuron injury to non-organic causes such as malingering or conversion disorders. The pathophysiology is believed to be accentuation of the glottic closure reflex. Many modalities of treatment are available ranging from sedation, voice therapy and breathing exercises to Heliox administration, Botulinum toxin type A injection, intubation and at times tracheostomy.     

Improvement of vocal cord paresis after thyroidectomy

Iatrogenic vocal cord paralysis is a well-publicized complication of thyroid and parathyroid operations. Less appreciated is the improvement of vocal cord function after resection of a thyroid or parathyroid tumor. Over the last 22 years, 14 patients presented with vocal cord paresis in the presence of thyroid or parathyroid tumors. Of these 14 patients, nine had complete resolution of paresis following resection of the thyroid or parathyroid tumors: three had a thyroid carcinoma impinging upon the nerve, three had large colloid goiters, two had a follicular adenoma and one had a parathyroid adenoma displacing the nerve. In five of the 14 patients the vocal cord paralysis persisted after operation. In three, the pathology accounted for the vocal cord paralysis and was not amenable to operative improvement: one patient had an unresectable anaplastic thyroid carcinoma, one patient had long-standing idiopathic unilateral vocal cord paralysis, and one patient had laryngeal adenoid cystic carcinoma with thyroid invasion. The fourth patient had an extensive thyroid hemangioma. The paralysis persisted after resection. The fifth patient had long-standing idiopathic vocal cord palsy. A preoperative vocal cord paresis in a patient with thyroid or parathyroid disease does not indicate permanent loss of recurrent nerve function, even in the presence of carcinoma. In this series, vocal cord function was restored in 9 of 10 patients with resectable thyroid or parathyroid tumors.     

Paradoxical vocal cord motion: a postoperative dilemma--a case report

Paradoxical vocal cord motion (PVCM) is a dysfunction more often seen by otolaryngologists, but of which the anesthesiologist must also be aware of in order to prevent inappropriate invasive airway interventions. For the anesthesiologist, PVCM is most often seen as inspiratory stridor during the postoperative recovery period. Unfortunately, inspiratory stridor can also be a sentinel of impending respiratory failure, and so it is crucial that the serious etiologies be efficiently ruled out. Presented is a case of postoperative PVCM, diagnosed by direct fiberoptic examination, in which timely recognition of this benign, psychogenic postoperative complication resulted in effective and appropriate noninvasive management.     

An unusual cause of stridor after thyroidectomy

Two patients with nasopharyngeal carcinoma, radiotherapy treatment and 'difficult' airways were anaesthetised for oral surgery. A triple lumen central venous catheter was inserted through the cricoid membrane and transtracheal jet ventilation with an AMS 1000 jet ventilator was performed via the distal lumen. The middle and proximal lumens were connected to an airway pressure monitor and a capnograph, enabling breath-by-breath monitoring of ventilation.     

An unusual case of stridor after thyroidectomy

Twelve days after subtotal thyroidectomy, an air pocket developed in a patient's neck. The pressure in this pocket had gradually increased as small amounts of air, probably associated with coughing, came out of a tiny hole in the trachea to form a pneumocoele. This produced limited surgical emphysema, causing venous congestion and oedema of the soft tissues of the larynx, which in turn led to increasing airway obstruction. We believe that this is the first reported case of a pneumocoele that gradually increased in size, causing airway obstruction that was almost certainly due to secondary laryngeal oedema.     

Paradoxical vocal cord motion in the recovery room: a masquerader of pulmonary dysfunction

Purpose

We report a case of paradoxical vocal cord motion as an unusual cause of postoperative stridor and wheezing. A means of diagnosis and management is discussed.

Clinical findings

A 71-yr-old man developed paradoxical vocal cord motion following uncomplicated hip replacement. He was treated with standard therapy for postoperative stridor and wheezing. After extensive evaluation, a flexible fibreoptic laryngoscope was used and the vocal cords noted to move paradoxically. This was the cause of his postoperative stridor and wheezing. Paradoxical vocal cord motion should be suspected as a cause of postoperative stridor and wheezing when the airway is easily maintained by a hag and mask, there is previous history of psychological problems, and there exists an unexplained history of previous postoperative airway distress. The definitive diagnosis may be made using a fibreoptic laryngoscope. In this patient, intubation was deferred and a plan of conservative therapy pursued.

Conclusion

Paradoxical vocal cord motion is an unusual cause of postoperative respiratory distress. A definitive diagnosis may be made by the use of a flexible fibreoptic laryngoscope using topical anaesthesia.     

Voice and vocal self-assessment after thyroidectomy

BACKGROUND: Voice alterations after thyroidectomy can be found even with preserved function of laryngeal nerves. The purpose of this study was to evaluate voice before and after thyroid surgery and the role of orotracheal intubation on voice changes. METHODS: We conducted a prospective nonrandomized study of patients who underwent thyroid surgery and compared the results with a control group of patients who underwent breast surgery. Subjects underwent a videolaryngoscopic exam, a subjective and an objective voice analysis and a Voice Handicap Index (VHI) questionnaire before and after surgery. RESULTS: A total of 100 patients who underwent thyroidectomy and 30 who underwent breast surgery were studied. Both groups were similar in demographic, clinical, and surgical variables. Postoperative videolaryngoscopy showed larynx alterations in 28% of the thyroidectomized patients, without significant alterations in the control group. There were subjective voice changes in 29.7% of the patients without vocal fold immobility after thyroid surgery and no statistically significant changes after breast surgery. Acoustic analysis showed significant increased values in the voice turbulence index (VTI) parameter in both groups, although higher in the thyroid one. In the VHI assessment, voice complaints were more frequently registered in the thyroid group rather than in the control group. CONCLUSIONS: Voice alterations are frequent after thyroidectomy even with preserved vocal fold mobility. Such alterations were more frequently detected in that group than in patients who underwent breast surgery. Orotracheal intubation is just one of the multiple factors involved.     

Paradoxical vocal cord motion--a dangerous imitator of airway emergencies

We report a case of stridor in a 32 year old woman. Initial laryngoscopy demonstrated adduction of the vocal cords on inspiration, which reverted to abduction on induction of general anaesthesia. The airway was structurally normal. The most likely diagnosis was paradoxical vocal cord motion, a condition in which psychological stress can precipitate respiratory symptoms and signs due to involuntary adduction of the vocal cords during inspiration. Its importance to the anaesthetist lies in its ability to masquerade as a serious airway or respiratory condition.     

Acute stridor as a presentation of bilateral abductor vocal cord paralysis

We report the case of a 48-year-old woman, referred to the Intensive Care Unit with community-acquired pneumonia, who was noted to have stridor of acute onset. Subsequent indirect laryngoscopy revealed bilateral abductor vocal cord paralysis, secondary to unsuspected carcinoma of the oesophagus, requiring immediate tracheostomy. We highlight the importance of visualisation of the vocal cords in cases of stridor of uncertain aetiology.     

Bilateral vocal cord palsy causing stridor as the only symptom of syringomyelia and Chiari I malformation,a case report

IntroductionBilateral vocal cord palsy is a condition which has many causes (Gupta et al., 2012) [1]. Syringomyelia is an uncommon condition which describes the formation of fluid filled cavity, occupying the spinal cord (Chang, 2003) [2]. It rarely manifests itself as subacute onset of stridor.Presentation of caseWe present the case of a three year old female who presented for evaluation of her speech and language delay, when incidentally it was made note of her loud breathing which had previously been managed as bronchiolitis by her general practitioner. In hospital she was found to have a bilateral vocal cord palsy. Further investigation revealed a large syrinx as well as an associated Arnold Chiari 1 malformation, for which she required neurosurgical decompression.ConclusionAlthough uncommon, formation of a syrinx should be considered for patients who present with stridor and reiterates the importance of MRI as an important investigative tool of bilateral vocal cord palsy.     

Paradoxical vocal cord adduction in an adolescent with cystic fibrosis.

Many patients with cystic fibrosis have symptoms of dyspnoea and wheeze which are responsive to treatment with bronchodilators. An adolescent woman with cystic fibrosis is described who presented with inspiratory stridor and in whom the classical features of paradoxical vocal cord adduction were found.     

Tuberculous lymphadenopathy of superior mediastinum causing vocal cord paralysis

Vocal cord paralysis because of involvement of recurrent laryngeal nerve by benign and acute inflammatory lymphadenopathy is a rare condition. Presented here is a case of tuberculous lymphadenopathy of superior mediastinum causing left recurrent laryngeal nerve paralysis, which was successfully treated by antituberculosis treatment, with complete recovery of vocal cord function.     

Treating stridor with opioids: a challenging case of paradoxical vocal cord movement

A 61 year-old patient with a history of anxiety disorder presented with stridor after an uneventful laparotomy with a general anesthetic. Postoperative analgesia was withheld secondary to intermittent oxygen desaturation. She was unresponsive to standard therapies, including racemic epinephrine and albuterol nebulizers. An otolaryngology consultant performed fiberoptic laryngoscopy and paradoxical vocal cord movement was diagnosed. When fentanyl was subsequently administered to treat her pain, the stridor resolved.