Vocal fold hemorrhage observed during laryngoscopy.

A 69-year-old woman presented with a history of coughing fits, dyspnea, and a feeling that her "throat was closing" upon exposure to strong perfumes and lotions. Episodes would last several minutes and resolve spontaneously. She had been treated for laryngopharyngeal reflux with twice-daily esomeprazole and nightly ranitidine, but her symptoms did not resolve. Her medical history was otherwise significant for deep vein thrombosis, for which she took warfarin.

A diagnosis of paradoxical vocal fold motion disorder (PVFM) with laryngospasm was suspected. (1,2) The patient was instructed to return to the office with provocative perfumes and lotions so that laryngoscopy could be performed during an acute attack to confirm the diagnosis. Immediately prior to the patient's inhalation challenge, flexible laryngoscopy showed mild vocal fold edema and inflammatory changes (figure, A). Inhalation of the provocative agents immediately induced frank laryngospasm and a bout of coughing, confirming the diagnosis of PVFM. (3) Laryngoscopy immediately after the coughing identified a new hemorrhage on the left vocal fold (figure, B). There were no acute voice changes, but mild odynophonia was present, which lasted 2 days. The patient was placed on voice rest. At follow-up 1 week later, the hemorrhage had resolved.

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This is a case of a witnessed vocal fold hemorrhage resulting from relatively minor vocal trauma in a patient with PVFM. Patients with PVFM frequently have sudden voice changes and throat symptoms following their episodes of cough and laryngospasm. This case emphasizes the need for careful evaluation of these patients' symptoms. Clinicians should maintain a low threshold for laryngeal endoscopy and should not assume that the patient's complaints are always related to laryngospasm and muscle tension that are commonly associated with PVFM.

References

(1.) Vertigan AE, Theodoros DG, Gibson PG, Winkworth AL. The relationship between chronic cough and paradoxical vocal fold movement: A review of the literature. J Voice 2005; Nov 3: [Epub ahead of print].

(2.) Sandage MJ, Zelazny SK. Paradoxical vocal fold motion in children and adolescents. Lang Speech Hear Serv Sch 2004;35:353-62.

(3.) Huggins JT, Kaplan A, Martin-Harris B, Sahn SA. Eucalyptus as a specific irritant causing vocal cord dysfunction. Ann Allergy Asthma Immunol 2004;93:299-303.

Justin S. Golub, BA; Edie Hapner, CCC-SLP; Michael M. Johns III, MD

From the Emory Voice Center, Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta.