Graves’ Disease Manifested as Vocal Cord Dysfunction
Captain Tabatha H. Matthias, MC (Associate); Colonel Thomas B. Francis, MC;
Major Pedro F. Lucero, MC
Tripler Army Medical Center, Honolulu, Hawaii
Discussion and Literature Review
- Vocal cord dysfunction (VCD) is a respiratory disorder where the larynx exhibits paradoxical vocal cord adduction.
- An airflow obstruction occurs at the level of the larynx presenting as stridor or wheezing most often mistaken for asthma.
- Usually occurs in young adult females age 20-40 with psychiatric conditions such as anxiety or OCD, and health care workers.
- Clinical Manifestations of VCD:
- Acuity of symptoms can range from subclinical to feeling of impending suffocation
- Usually mimics mild persistent asthma most often with stridor, dyspnea, sense of chest constriction, and wheezing.
- Present in 40% of patients diagnosed with asthma refractory to treatment.
- Attacks usually during the day and are self limiting.
- VCD can occur alone or coexistence with asthma.
- Commonly occurs in exercised induced asthma refractory to treatment.
- Mistaken for angioedema or anaphylaxis.
- Dysphonia, voice fatigue, or sensation of choking
- Three case studies illustrate hypoxemia occurring with VCD.
- Heighten index of suspicion in asthmatic refractory to treatment
- Direct visualization via laryngoscopy
- Can be provoked with methacholine challenge
- Cardiopulmonary exercise testing-after “stressfull” situation for patient
- Speech and psychological therapy.
- Patient education.
- Acute attacks use a mixture of helium and oxygen.
- Botulinum toxin injection.
- Increased medical utilization with ambulatory patients with undiagnosed VCD versus asthma.
- Multiple ER visits and unnecessary treatments for asthma
- Unwarranted adverse effects from asthma medications (i.e exposure to steroids).
Figure 1. Laryngoscopy showing posterior glottic chink.
Figure 2.Oxygen pulse versus heart rate during exercise.
- Initial Presentation:
- 41 y/o active duty U.S. Marine presents to the ER for dyspnea after a company run
- Other complaints included: voice strain along with dyspnea that had been ongoing for four months.
- Symptoms began toward end of second Iraq deployment
- Physical exam: tachycardia, stridor over larynx, normal neck, cardiovascular, and lung exam.
- CXR- normal
- ENT was consulted, laryngoscopy showed paradoxical vocal cord motion with posterior glottic chink, and he was diagnosed with vocal cord dysfuction.
- Started on proton pump inhibitor, speech therapy, and behavioral health.
- Further Investigation:
- Continued dyspnea with exertion despite compliance with therapy
- Initial spirometry normal and negative methacholine challenge testing for bronchial hyperreactivity, but variable extrathoracic obstruction on spirmetry.
- Exercise testing: rapid heart rate increase with unexpected oxygen pulse plateau concerning for cardiomyopathy
- Transthoracic echo: mild left atrial enlargement with mild pulmonary hypertension PASP at 42-47mmHg, normal ejection fraction.
- CT of chest: bilateral thyroid lobar enlargement and anterior mediastinal smooth triagular mass.
- Labs: TSH- undetectable, FT4- 5.7 ng/dL
- Diagnosed with Grave’s disease and thymic hyperplasia.
- Patient’s Progress and Outcome:
- I-131 ablation then placed on thyroid replacement.
- VCD, dyspnea, and other symptoms improved.
- Patient went on third deployed to Iraq at his request.
Figure 3.A. Normal spirometry. B & C methacholine challenge showing blunting of the inspiratory portion of flow loop.
- Patient’s VCD resolved approximately two months after treatment of hyperthyroidism.
- The literature describes cases of vocal cord paralysis from compression or inflammation of the thyroid.
- To our knowledge there are no described cases of hyperthyroidism causing VCD.
Figure 4.CT scan showing large goiter and markings indicate presence of thymoma.
Figure 5.RAIU Scan 78% radioiodine uptake at 18 hours consistent with Graves’ disease.