anaesthesianetvigator

HongKongMedJVol13No4#August2007#www.
hkmj.
org327IntroductionImprovedhygieneandpublicawarenesshaveledtoasteadydeclineintheincidenceofpulmonarytuberculosis(PTB)indevelopedcountries.
1Bettersocio-economicconditionsandamoreeffectivepublichealthpolicyinHongKongledtoaremarkabledropinthenotificationrateper100000population,from528.
9in1954to90.
5in2004.
2DespitesuchasharpdeclineinPTB,somelong-termsequelae,suchasunilateralvocalfoldparalyses,remainandshouldnotbeunderestimatedeveninamodernsociety.
Pulmonarytuberculosismayinvolvetherecurrentlaryngealnerve,eitherasaresultofinflammatorylymphadenopathyorchroniclungfibrosis.
3Thelatterisusuallyirreversible,evenwithanti-tuberculoustreatment,thusearlydiagnosisandsurgicalinterventionareoftheutmostimportance.
Wepresentthreepatients,whosufferedfromunilateralleftvocalfoldparalysiscausedbypost-PTBchroniclungfibrosis.
Theyallunderwentmedialisationthyroplastyandhadsatisfactoryspeechandswallowingoutcomes.
CasereportsCase1A58-year-oldmanwithchronicobstructivepulmonarydisease,bronchiectasis,andahistoryoftreatedPTB30yearsearlier,complainedofhoarsenessfor3months.
Hedescribedeasyaspirationwhenswallowing,followedbydifficultycoughingouttheaspiratedmaterials.
Therewasnoconcomitantmedicalillnessabletoaccountforhissymptoms.
ThepatientwasreferredtotheVoiceClinicatQueenMaryHospitalinFebruary2001andunderwentlaryngoscopicexamination.
Thisshowedaleftvocalfoldparalysiswithapersistentglotticgaponphonation(Fig1a).
Atransnasalupperendoscopy(includingpharyngoscopy,bronchoscopy,andoesophagoscopy)detectednoabnormalitiesandacomputedtomographic(CT)scanofthethoraxshowedgrossparenchymaldestructionatbothupperlobeswithformationoflargebullaeattheapices.
Cysticandfibroticchangeswerealsoobservedintherightmiddle,rightlower,andleftupperlobes.
TheoverallfindingswereconsistentwithpreviousPTBinfection.
Thediagnosisofpost-PTBlungfibrosisandtractionbronchiectasiswasconfirmedbyrepeatingthechestX-rayonseveraloccasions.
Asputumsmearandculturewasnegativeforacid-fastbacillusandsputumcytologywasnegativeformalignancy.
WeperformedamedialisationthyroplastyasproposedbyIsshikietal4underlocalanaesthesia.
Duringtheprocedure,a10-mmx5-mmwindowwasmade5mmposteriortothethyroidcartilagemidline.
Aself-fabricatedsilasticimplantwasthenusedtomedialisetheparalysedvocalfold(Fig1b).
Thepatient'spostoperativecoursewasuneventfulandbothhisspeechandswallowingwererectified.
Thispatientremainedwellfor3yearsaftersurgerybutdiedfromanexacerbationofbronchiectasisanddecompensatedtypeIIrespiratoryfailure.
Case2A79-year-oldwomanwithbronchiectasiswasreferredtoourdivisioninJune2001withaImprovedhygieneandpublicawarenesshaveledtoasteadydeclineintheincidenceofpulmonarytuberculosisindevelopedcountries.
Nonetheless,long-termsequelaelikeunilateralvocalfoldparalysisshouldnotbeunderestimatedinamodernsociety.
Wereportthreepatientswithchroniclungfibrosisfollowingpulmonarytuberculosisleadingtounilateralvocalfoldparalysis.
Allthreepatientshadhoarsenessandchronicaspirationonswallowing.
Earlydiagnosisandpromptsurgicalinterventionareessentialifthispotentiallyfatalcomplicationistobeprevented.
MedialisationthyroplastyforunilateralvocalfoldparalysisassociatedwithchronicpulmonarytuberculosisCASEREPORTKeywordsTuberculosis,pulmonary;VocalfoldparalysisHongKongMedJ2007;13:327-9DivisionofOtorhinolaryngology,HeadandNeckSurgery,DepartmentofSurgery,UniversityofHongKongMedicalCentre,QueenMaryHospital,PokfulamRoad,HongKongPKYLam,FRCS(Edin)WIWei,FRCS(Eng)Correspondenceto:DrPKYLamE-mail:lamkyip1@netvigator.
comPaulKYLamWilliamIWei#LamandWei#328HongKongMedJVol13No4#August2007#www.
hkmj.
orghistoryofhoarsenessfor1year.
Shealsocomplainedofaspirationifdrinkingfast.
ShehadbeentreatedforPTB51yearsearlierandhadnoothersignificantmedicalhistorythatmightexplainhersymptoms.
Onlaryngoscopicexamination,theleftvocalfoldwasparalysedandtherewasapersistentglotticgapandinadequatecompensationofthecontralateralvocalfold.
Athoroughheadandneckexaminationandtransnasalupperendoscopicexaminationwereallnormalexceptfortheleftvocalfoldparalysis.
Computedtomographicscanningofthethoraxrevealedacollapsedleftupperlobewithamediastinalshifttotheleft.
TherewassignificantlossofleftlungvolumeandtheoverallfeatureswereconsistentwitholdPTBchanges(Fig2).
Asputumsmearandcultureforacid-fastbacilluswasnegativeandsputumcytologywasnegativeformalignancy.
Sherefusedtohaveanysurgicalinterventionsowasreferredtoourspeechtherapistforconservativetreatment.
Bothherspeechandswallowingproblemspersistedforthenext6monthssosheeventuallyagreedtohavesurgery.
Amedialisationthyroplastywasperformedasdescribedincase1;andan8-mmx4-mmwindowwasmadeduetothesmallerfemalelarynx.
Thesurgerywasuneventfulandspeechandswallowingweresuccessfullyrehabilitated.
Shewaslastseen5yearsaftersurgeryandremainedwellwitharepeatedchestX-rayshowingchronicPTBchangesandnoothersignificantpathology.
Case3An82-year-oldmanpresentedtoourdivisioninOctober2003witha6-monthhistoryofhoarsenessandrecurrentaspirationonswallowing.
Hehadchronicobstructivepulmonarydisease,emphysema,PTBtreated5yearsearlier,andnoothersignificantmedicalillness.
Onlaryngoscopicexamination,theleftvocalfoldwasfoundtobeparalysedleavingalargeglotticgap.
Atransnasalupperendoscopyandaheadandneckexaminationwerenormal.
Computedtomographicscanningfromtheskullbasetothethoraxshowedextensivefibrosisandlungdestructioninbothupperlobes.
Pleuralthickeningwasnotedintheupperpartofthehemithoraxonbothsides.
TheoverallfeatureswerecompatiblewithlongstandingPTB.
Asputumsmearandcultureforacid-fastbacilliwasnegativeandsputumcytologywasnegativeformalignancy.
Amedialisation(a)(b)FIG1.
LaryngoscopicexaminationParalysedleftvocalfoldbefore(a)andafter(b)medialisationthyroplastyFIG2.
Post-contrastaxialcomputedtomographicthoraxTherewerecalcifiedlesionswithfibrosispresentintheleftupperlobe,associatedwithamediastinalshifttotheleftside.
Calcifiedlymphnodeswerealsoevidentintherightaxilla#Medialisationthyroplastyforvocalfoldparalysis#HongKongMedJVol13No4#August2007#www.
hkmj.
org329thyroplastywasperformedasincase1witha10-mmx5-mmwindowmadeforvocalfoldmedialisation.
Thepatientrecoveredwellpostoperatively,achievingsatisfactoryspeechandswallowing.
Hedid,however,needhomeoxygen7monthsaftersurgeryforhisend-stagelungdisease.
ChestX-raysdoneonseveraloccasionsconfirmedpost-PTBlungfibrosis.
Hedied9monthsaftersurgeryfromdecompensatedtypeIIrespiratoryfailure.
DiscussionWehavereportedthreecasesinvolvingpatientswithleftvocalfoldparalysis,allofwhomwerediagnosedwithchronicPTBbasedontheirhistories,thefindingsonCTimagingandrepeatedchestX-rays,andthelackofotheridentifiablemedicalorsurgicalcauses.
ChronicPTBpredominantlyinvolvingtheupperlobesisawell-documentedcauseofvocalfoldparalysis.
Intrathoracicdiseaseusuallyaffectsonlytheleftrecurrentlaryngealnerve,whilsttherightonemaybeaffectedinapicalpleuralfibrosisorbycervicallymphnodes.
Inallthreecases,extensivepulmonaryfibrosisintheupperlobessuggestedthattheleftrecurrentlaryngealnervecouldbeaffectedbyeitherentrapmentinthescarortractionneuropathy.
3Withwidespreaduseofeffectiveanti-tuberculoustreatment,vocalfoldparalysisrarelycomplicatesprimarytuberculousmediastinallymphadenopathy.
Withimprovedhygieneandnutrition,morepatientswithtreatedtuberculouslesionslivelongenoughtodevelopchroniclungfibrosis.
Thisimmobilityofthevocalfoldisusuallyirreversibleanddoesnotrespondtoanti-tuberculouschemotherapy.
Unilateralvocalfoldparalysiswithinadequatecompensationbythecontralateralvocalfoldusuallypresentswithhoarseness.
Somepatientsmaydevelopseveresymptomssuchasaspiration,poorcoughingeffort,orpneumonia.
Heitmilleretal5showedthatinpatientswithunilateralvocalfoldmotionimpairment,aspirationwasseenin38%andlaryngealpenetrationin12%.
Normalswallowinginvolvesrepeatedvocalfoldclosure,whichimpliesaperiodofapnoea.
Inpatientswithcompromisedpulmonarycapacitylikepost-PTBchroniclungfibrosis,theserepeatedinstancesofforcedapnoeaduringeveryswallowmayleadtoinsidiousfatigueoftheairwayprotectivemechanism.
Thus,astheyeatameal,patientsincreasetheirriskofaspiration.
6Indebilitatedpatientswithcompromisedpulmonaryfunction,aspirationcanbealife-threateningevent.
Thetimingofsurgicalinterventionforunilateralvocalfoldparalysisdependsontheseverityofsymptomsandtherecoverypotential.
SincethemajorityofchronicPTBpatientshaveirreversiblevocalfoldparalysis,surgicalmedialisationshouldbeundertakenearlyforpersistentaspiration.
VocalfoldaugmentationwithTeflonhasbeenlargelysuper-sededbytheuseoffat,collagen,orhyaluronicacidinjections.
7Nonetheless,spontaneousabsorptionoftheinjectedfat,collagen,orhyaluronicacidmakestheoutcomeunpredictable.
Medialisationthyroplastyisnowbeingselectedasamorereliabletreatmentalternative.
Paralysedvocalfoldsaremedialisedbyinsertingacarvedsilasticimplantorotheralloplasticmaterialsthroughawindowinthethyroidalarcartilagetocorrectglotticinsufficiency.
Ifthisprocedureisperformedunderlocalanaesthesiawithconcomitantflexiblelaryngoscopicassessmentandevaluationofthepatient'svoice,wecanoptimisethevocalfoldpositionintra-operatively.
Withsuccessfulglotticclosure,normalspeechcanberestoredandaspirationpneumonitiscanbeprevented.
ChronicPTBlungfibrosispresentingwithunilateralvocalfoldparalysisstillhappensindevelopedsocieties.
SincerespiratoryorfamilyphysiciansseemostcasesofunilateralvocalfoldparalysissecondarytochronicPTB,promptreferraltoanotorhinolaryngologistofpatientswithchroniclungfibrosispresentingwithbreathyvoicesandchokingisoftremendousimportance.
Chronicaspiration,recurrentpneumonitis,andthelowrateofspontaneousrecoveryallsupportearlysurgicalmedialisationoftheparalysedfoldtopreventapotentiallyfataloutcome.
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