Q: 64 years old male post-double lung transplant is found to have bilateral vocal cord paralysis after extubation. In exclusive bilateral vocal cord paralysis, which of the following is most likely?
A) Compromised voice quality
B) Respiratory symptoms
Answer: B
The voice quality is usually not compromised in local exclusive bilateral vocal fold paralysis. On exam, bilaterally denervated vocal folds appear midline, with a narrow glottic aperture. Voice is generally good with this glottic configuration. The primary symptoms are respiratory, including minimal dyspnea, inspiratory stridor, or severe respiratory distress. Phrenic nerve injury is a frequent side effect post-double lung transplant, though any clinical suspicion needs to be ruled out. The dysphonia due to respiratory symptoms is called 'breathy dysphonia'. Local edema and irritation caused by intubation may result in some hoarseness, which typically resolves.
This question again emphasizes the importance of close clinical observations and the skills of history taking and physical examination.
Post-tracheal intubation is the leading cause of bilateral vocal fold paralysis in intensive care units (ICUs).
Other causes are:
- Neck surgery, like Recurrent laryngeal nerve palsy post carotid endarterectomy (CEA)}
- ALS
- Diabetic neuropathy
- Myasthenia gravis
- Organophosphate poisoning
- Administration of vinca alkaloids
- Stroke
- Head injury
- hydrocephalus
- Brainstem compression
- Arnold-Chiari malformation
- Bilateral cricoarytenoid joint fixation (rheumatoid arthritis)
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References:
1. Jean M Bruch, Dipti V Kamani, Daniel G Deschler, Zehra Hussain : Hoarseness in adults :: Source: https://www.uptodate.com/contents/hoarseness-in-adults (accessed on April 26, 2025)
2. Hillel AD, Benninger M, Blitzer A, Crumley R, Flint P, Kashima HK, Sanders I, Schaefer S. Evaluation and management of bilateral vocal cord immobility. Otolaryngol Head Neck Surg. 1999 Dec;121(6):760-5. doi: 10.1053/hn.1999.v121.a98733. PMID: 10580234.
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