A case of hoarseness and vocal cord immobility.

40-year-old woman presented to the oto-laryngology clinic with a 7-week history of hoarseness. The symptom had occurred suddenly, and no upper respiratory tract infections or history of vocal overuse immediately preceded the onset. Her voice had not improved during the intervening weeks. She reported symptoms of potential aspiration when drinking thin liquids, and she found herself short of breath when speaking. She had no odynopha-gia or throat pain, or systemic symptoms such as fever, chills or night sweats. She had not experienced substantial changes in her voice previously. Three weeks before the onset of hoarseness, the patient had undergone intubation for removal of a benign soft tissue nodule on her left foot. Her voice was normal after the surgery. Her medical history was otherwise unremarkable. She was not taking any medications and had no allergies. She did not smoke and had low alcohol consumption. On examination, the patient was found to have a breathy, hoarse voice with a self-reported lower pitch than normal. Evaluation of the oral cavity, oropharynx and nasal cavity was unremarkable. Examination of the neck showed no lymphad-enopathy. The thyroid examination was normal. Evaluation of cranial nerve function showed no abnormalities other than the hoarseness. Complete left vocal cord immobility was identified on laryn-goscopy using a flexible na so pharyngoscope. No laryngeal lesions were found. The patient had a substantial gap between her vocal folds on phona-tion as a result of the immobility (Figure 1). The cause of the patient's immobile left vocal cord was not readily apparent from her history and physical examination. The 3-week delay between intubation and development of hoarse-ness made it unlikely that an intubation injury had initially been masked by postoperative laryn-geal edema. Computed tomography (CT) from skull base to mediastinum, ordered to rule out malignant lesions along the course of the left vagus nerve and its recurrent laryngeal branch, was normal. Given the negative clinical and imaging work-up, the patient's vocal cord immo-bility was considered idiopathic. Because she had substantial symptoms of vocal insufficiency from the glottic air leak, the patient was offered a temporary medialization procedure with injectable hyaluronic acid under local anesthesia by the staff laryngologist. (See Appendix 1, available at www.cmaj.ca /lookup /suppl /doi:10.1503/cmaj.112112/-/DC1 for a diagram of this procedure.) The goal was to improve vocal strength, decrease vocal fatigue and decrease the risk of aspiration while we waited to see if the vocal fold would recover over …