Right vocal cord paralysis and mediastinal lymphadenopathy

Abstract

A non-smoking 45-year-old white man presented with a globus sensation worsened by lying down, with no complaints of hoarseness or dysphonia. He denied fever, fatigue, cough, chest pain, sweats, weight loss, reflux, arthralgias, myalgias and rash. He also denied exposure to asbestosis, beryllium, silica, HIV or tuberculosis, but he reported a recent cat bite. Physical examination revealed normal vital signs, no cervical or supraclavicular lympadenopathy and a normal cardiorespiratory system. He was referred to the otolaryngology department. Laryngoscopy revealed right vocal cord paralysis. A CT scan of the neck/chest identified diffuse mediastinal lymphadenopathy without parenchymal changes (figures 1 and 2).A purified protein derivative test was negative. Endobronchial ultrasound (EBUS)-directed transbronchial needle aspirations (TBNA) were performed of the paratracheal and subcarinal lymph nodes (figure 3). Diagnostic bronchoscopy revealed no endobronchial lesions or mucosal abnormalities. Acid-fast bacilli studies were negative and flow cytometry detected no monoclonal lymphocytes. Bacterial and fungal cultures, cryptococcal/ histoplasma antigen, HIV and Bartonella serology were negative. ACE was 31 U/l (reference range 9e67 U/l). Pulmonary function testing revealed mild decreased diffusion capacity but was otherwise normal. Empirical steroid therapy failed to provide benefit and mediastinoscopic right paratracheal lymphadenectomy was subsequently conducted (figure 4). QUESTION What is the diagnosis?See page

Sarcoidosis Presenting as Bilateral Vocal Cord Paralysis due to Bilateral Vagal Nerve Involvement

“…Nonetheless, in approximately 75% of the patients with sarcoidosis, nodal enlargements in the right paratracheal or aortopulmonic window lesions have been identified (16), and case reports of vocal cord paralysis due to the compression of the enlarged mediastinal lymph nodes are rare (3)(4)(5)(6)(7)(8)(9)(10)17). Most cases of unilateral vocal cord paralysis in sarcoidosis tend to occur in the left vocal cord as a result of left recurrent laryngeal nerve palsy by the lymph nodes as they hook around the arch of the aorta (3)(4)(5)(6)(7)(8).…”

“…Most cases of unilateral vocal cord paralysis in sarcoidosis tend to occur in the left vocal cord as a result of left recurrent laryngeal nerve palsy by the lymph nodes as they hook around the arch of the aorta (3)(4)(5)(6)(7)(8). Only one case of right vocal cord paralysis due to mediastinal lymphadenopathy has been reported (17). It would therefore be quite rare for enlarged mediastinal lymph nodes to cause bilateral vocal cord paralysis by compressing the left and right laryngeal recurrent nerves around the aorta and the right subclavian artery, respectively (9, 10).…”

“…Corticosteroid therapy is performed in most cases of vocal cord paralysis with sarcoidosis (3,(5)(6)(7)(8)(9)(10)17). One case was caused by both compressive lymphadenopathy and cranial polyneuritis (10).…”

“…All of the other cases were caused only by compressive lymphadenopathy (3,(5)(6)(7)(8)(9)(10)17). Except for one case (4), oral prednisone therapy at a dose of 0.5-1 mg·kg -1 · day -1 could resolve almost all of the vocal cord paralyses within one to two weeks in the unilateral cases (3,(5)(6)(7)(8)(9)(10)17). High-dose intravenous methylprednisone therapy was administered in the bilateral cases (8, 9) (Table).…”

A rare manifestation of a multisystemic disease: a case of vocal cord palsy secondary to sarcoidosis

“…Vocal cord paralysis is a rare complication of the multisystemic inflammatory disease, sarcoidosis 1. Sarcoidosis initially presenting with hoarseness due to vocal cord paralysis has been rarely reported 2…”