Granulomatous inflammation and nerve necrosis in a case of apparent idiopathic vocal fold paralysis: report of a case.

Abstract

We will present clinical and pathologic findings of the recurrent laryngeal nerve of a 54-year-old man with apparent idiopathic vocal fold paralysis and discuss clinical and scientific implications of these findings. Our design is in the format of a case report with emphasis on the clinical, intraoperative, histologic, and neuropathologic findings, followed by a discussion of contemporary theories of idiopathic unilateral vocal fold immobility and the implications of our findings. A 54-year-old man presented with a 2-year history of unilateral vocal fold motion impairment (VFMI) after an upper respiratory infection. Radiographic and laboratory data revealed no organic cause. The patient clinically appeared to have a classical unilateral vocal fold paralysis and had previously undergone collagen injection and medialization thyroplasty, each with only temporary improvement of voice. We performed ansa cervicalis-recurrent laryngeal nerve anastomosis. Intraoperative dissection revealed an indurated and thickened section of nerve approximately 15 mm in length, located at the beginning of the intralaryngeal segment, near the cricothyroid joint. Segments of this nerve were submitted for histologic evaluation, revealing necrosis with granulomatous inflammation. Postoperative electromyography and videostrobolaryngoscopy were consistent with successful reinnervation from the ansa procedure. The diagnosis of "idiopathic VFMI" likely represents a number of distinct pathologic entities. This case highlights our lack of understanding of idiopathic VFMI and raises many important questions regarding our current theories of this diagnosis. The clinical and pathologic implications are discussed, and continued investigation is recommended.