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Graves ’ Disease Manifested as Vocal Cord Dysfunction Captain Tabatha H. Matthias, MC (Associate); Colonel Thomas B. Fr PowerPoint Presentation
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Graves ’ Disease Manifested as Vocal Cord Dysfunction Captain Tabatha H. Matthias, MC (Associate); Colonel Thomas B. Fr - PowerPoint PPT Presentation


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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. Introduction. Discussion and Literature Review .

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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

Introduction

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.
  • Diagnosis:
    • Heighten index of suspicion in asthmatic refractory to treatment
    • Direct visualization via laryngoscopy
    • Spirometry
    • Can be provoked with methacholine challenge
    • Cardiopulmonary exercise testing-after “stressfull” situation for patient
  • Management:
    • Speech and psychological therapy.
    • Patient education.
    • Acute attacks use a mixture of helium and oxygen.
    • Botulinum toxin injection.
  • Costs:
  • 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).

Case Presentation

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.

A

B

C

Figure 3.A. Normal spirometry. B & C methacholine challenge showing blunting of the inspiratory portion of flow loop.

Conclusion

  • 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.