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

1. 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.