FINAL DIAGNOSIS Metastatic Esophageal Carcinoma with Primary Neoplasm resulting in circumferential infiltration of the distal esophagus and resulting metastatic right paratracheal conglomerate lymphadenopathy extending superiorly encompassing and resulting in mass effect on the right recurrent laryngeal nerve. DISCUSSION Vocal cord paralysis (VCP) can cause both personal and social distress. An afflicted patient may experience dyspnea and labored breathing. VCP can cause hoarseness and affect a person’s ability to communicate with others. Often time the vocal cords are temporarily affected resulting in paresis, rather than paralysis. Our case presents VCP resulting from right paratracheal lymphadenopathy affecting the right recurrent laryngeal nerve. VCP results from damage to a recurrent laryngeal nerve (RLN), which are branches off the vagus nerves. The RLNs innervate all the intrinsic laryngeal muscles, excluding the cricothyroid and control movement of the vocal cords. 1 Damage to the vagal nerves proximal to the branch point of the RLNs as well as damage to the either RLNs themselves can result in VCP. VCP is a well-known complication of surgical procedures involving the neck to include thyroidectomy and carotid endarterectomy. After surgical procedures of the neck, patients are closely monitored for common presenting symptoms of VCP: dyspnea, hoarseness, and dysphonia. Other less common etiologies of VCP include trauma, infection, inflammation, other idiopathic causes, and external mass effect or impingement from a subjacent space occupying lesion. 2,3 Imaging offers confirmation of clinically suspected VCP and the opportunity to locate any underlying lesions and evaluate underlying etiologies. It has been noted that VCP may be a sign of a more serious pathology such as underlying malignancy. Without a doubt, imaging can be valuable in determining the cause and directing treatment. 1 Laryngoscopy provides direct observation of vocal cord mobility. Ultrasound is another modality by which the neck can be evaluated. 1 Laryngeal electromyography can confirmnerve injury. 2 For our casediscussion,we focusedon computed tomography (CT) and PET/CT imaging findings. The American College of Radiology (ACR) offers imaging modality recommendations for VCP evaluation based on the location of the lesion along the vagus nerve or RLN pathway. CT is recommended to evaluate the lower course of the vagus nerve. CT and magnetic resonance (MR) is recommended to evaluate the mid-neck and larynx. MR is
recommended to evaluate the upper course of the vagus nerve including the skull base. 3 Our patient underwent a pre and post contrasted CT examination of the neck. Dankbaar and Pemijer described the imaging findings of VCP which include ipsilateral laryngeal ventricle dilatation, ipsilateral aryepiglottic fold thickening and medial deviation of the aryepiglottic fold, ipsilateral piriform sinus dilatation, and ipsilateral paramedian position of the paralyzed vocal cord. 3 Imaging findings may be unilateral or bilateral depending on the location of underlying nerve injury or compromise. Our patient exhibited right- sided VCP secondary to conglomerate right paratracheal lymphadenopathy compromising the right RLN function. REFERENCES 1. Kwong Y, Boddu S, Shah J. Radiology of Vocal Cord Palsy. Clinical Radiology 2012 Nov;67(11):1108-14. 2. Stager S. Vocal Fold Paresis: Etiology, Clinical Diagnosis and Clinical Management. Current Opinion in Otolaryngology & Head & Neck Surgery: December 2014 - Volume 22 - Issue 6 – p 444–449. 3. Dankbaar JW, Pameijer FA. Vocal Cord Paralysis: Anatomy, Imaging and Pathology. Insights in Imaging. 2014 Dec;5(6):743-51. 4. Wippold, FJ, Cornelius RS, Aiken AH et al. ACR Appropriateness Criteria® Cranial Neuropathy: Vocal Cord Paralysis. Available athttps://acsearch. acr.org/docs/69509/Narrative/. American College of Radiology. Accessed 14 September 2016. ACKNOWLEDGMENTS Jane Ball is a 4th year radiology resident at Louisiana State University School of Medicine in New Orleans, LA. Jagan DewanGuptaMDisaclinical andacademicneuroradiologist in New Orleans and serves as adjunct clinical assistant professor within the Department of Radiology at the Tulane University Medical Center. Neel Dewan Gupta MD is a clinical and academic musculoskeletal radiologist in New Orleans and serves as a clinical assistant professor within the Department of Radiology at the Tulane University Medical Center. Jeremy Nguyen MD, FACR is clinical radiology professor within the Department of Radiology at the Tulane University Medical Center. Donald Olivares, Digital Imaging Specialist and Graphic Designer. ■
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