Pharyngolaryngeal reflux simulating vocal fold paralysis hoarsenessfollowing total thyroidectomy

Sara Ramalho, Eugénia Castro, Leandro Ribeiro, Nuno Barros Lima, Artur CondéCentro Hospitalar Vila Nova de Gaia/Espinho

OBJECTIVE

Recognize potential “rare” cause of horseness following thyroid surgery

• 69 year old man• History of Systemic Multifocal Firosclerosis (with Riedel

thyroiditis) total thyroidectomy in February 2011

• Presented to ENT with hoarseness and aspiration episodes few days after total thyroidectomy

• Reflux Symptom Index (Koufman): 30

CASE REPORT

• Endoscopic laryngoscopy: exuberant pharyngolaryngeal reflux with consequent oedema and redundancy of arytenoid mucosa. Simetric mobility of the vocal folds.

• Reflux findig score (Koufman): 15

• Upper GI endoscopy: Inflammation of the esophagus suggesting gastroesophageal reflux and gastritis

Treatment:• Reflux diet• PPI 2id

Six month after treatment:

•Reduction of hoarseness and aspiration episodes

•Endoscopic laryngoloscopy: reduction of pharyngolaryngeal oedema and redundancy of arytenoids

•Reflux findig score (Koufman): 8

• The worsening dysphonia after total thyroidectomy leads to suspicion of iatrogenic vocal fold paresis

• The vocal fold preserved mobility, associated with signs of exuberant pharyngolaryngeal reflux with extensive mucosal damage reveals an insuspected cause of hoarseness

• The authors postulate that post-operatory changes in esophagic sphincter pressure may have triggered reflux

Figure 1 and 2 – laryngoscopy before treatment

Figure 3 and 4 – laryngoscopy six month after treatment

REFERENCES:

•Ozgen A, Cila A, Riedel’s thyroiditis in multifocal fibrosclerosis: CT and MR imaging findings, AJNR Am Neuroradiol 2000 Feb; 21(2):320-1; •Hennessey JV, Clinical review: Riedel’s thyroiditis: a clinical review. J Clin Endocrinol Metab 2011 Oct; 96(10):3031-41; •Cho MH, Kim CS, Park JS et al, Riedel’s thyroiditis in a patient with recurrent subacute thyroiditis: a case report and review of the literature, Endocr J 2007 Aug; 54(4):559-62; •Jamie A. Koufman, Silent Laryngopharyngeal Reflux (LPR): an overview, Voice Institute of New York