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The Egyptian Journal of Otolaryngology
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Impact of COVID-19 on vocal cord mobility: a case series study

The Egyptian Journal of Otolaryngology volume 37, Article number: 93 (2021) Cite this article

A Correction to this article was published on 12 November 2021

This article has been updated

Abstract

Background

The World Health Organization (WHO) has declared the pandemic of COVID-19 infection in March 2020, most of cases presented with mild symptoms, and a significant number of cases showed variable neurological pictures. Vocal cord paralysis with no clear cause is termed as idiopathic vocal cord paralysis and supposed to be caused by viral infection. This is a case series study; data were collected prospectively from patients presented to the ENT clinic of Kasr Alainy (Cairo university) and Railway hospitals. Patients presented with defective vocal cord movement with concurrently or recently passed COVID-19 infection were reported from March 2020 to April 2021.

Results

Authors have reported 6 cases of vocal cord paralysis mainly unilateral due to COVID-19 infection as an only clear cause within 14 months. Age ranges from 39 to 69 years, 2 males and 4 females. Patients presented with different clinical scenarios. Follow-up of the cases showed spontaneous recovery in 5 cases and one case underwent cord medialization.

Conclusion

Viral infection could be an underlying cause of idiopathic laryngeal cord paralysis; in the new era of the COVID-19 pandemic, physicians all over the world noticed variable neurological pictures; in this study, we presented 6 cases of vocal cord paralysis mainly unilateral supposed to be due to COVID-19 infection; all cases showed spontaneous recovery apart from one case that needed medialization of the cord.

Background

The World Health Organization (WHO) has declared the pandemic of COVID-19 infection in March 2020. The disease has been arisen in Wuhan, China, and caused by respiratory droplets that carry SARS-CoV-2 [1]. The new disease is challenging due to different clinical scenarios, and most of the cases presented mild symptoms like fever, myalgia, and dry cough [2]. Serious progress of the disease may result in complications such as respiratory failure, disseminated intravascular coagulopathies, and other system failures [3], and a significant number of cases showed different neurological pictures [4] like hyposmia, ageusia, Bell’s palsy, Guillain-Barré syndrome, and encephalopathy [5,6,7,8].

Paralysis of the vocal cords is a serious problem; most of the causes are well known apart from some cases that presented with cord paralysis with no clear cause [9, 10]. Authors termed this condition as idiopathic vocal cord paralysis and supposed to be occurred due to viral infection [11, 12].

In this study, authors have spotted the light on a number of cases of laryngeal cord paralysis mainly unilateral as a result of COVID-19 infection.

Methods

A case series study, data were collected prospectively from patients presented to the ENT clinic of Kasr Alainy (Cairo university) and Railway hospitals. Patients who presented with defective vocal cord movement with concurrently or recently passed COVID-19 infection were reported from March 2020 to April 2021.

Results

Authors have reported 6 cases of vocal cord paralysis mainly unilateral due to COVID-19 infection as an only clear cause (Table 1).

Table 1 Data of study cases
Full size table

Case 1

A lady, 48 years old, presented with hoarseness of voice as a chief complaint and chocking of 3-week duration; by using a flexible fiber optic laryngoscope, we detected right vocal cord paralysis and no laryngeal or neck masses. She gave a history of recent COVID-19 infection manifested by fever, myalgia, bone aches, and fever and no anosmia or ageusia. The onset of these symptoms was at the same day of onset of the laryngeal symptoms. She also gave a negative history of hospitalization or endotracheal intubation. Included diagnostic tools revealed bilateral ground glass opacities in the CT scan on the chest and lymphopenia, elevated C reactive protein (CRP), D-dimer, serum ferritin, and lactate dehydrogenase (LDH). A new CT scan carried out on the skull, neck, and upper half chest was clearly free from any masses (Fig. 1).

Fig. 1
figure 1

Right vocal cord paralysis by fibro-optic laryngoscopy (case 1)

Full size image

Case 2

Another lady, 39 years old, coming with a history of a 5-day duration of fever, bony aches, anosmia, hypogeusia, dry cough, and change of voice. Nasopharyngeal swab and PCR for COVID-19 and CT scan on the chest were carried out and the results were confirmatory. She was isolated and hospitalized for treatment. Flexible fibro-optic laryngoscopic examination was performed after 3 weeks when the swab turned negative and it was diagnostic for right cord paralysis. A new CT carried out on the skull, neck, and upper half chest was clearly free from any masses (Fig. 2).

Fig. 2
figure 2

Right vocal cord paralysis (case 2)

Full size image

Case 3

A gentleman, 41 years old, past history of COVID-19 infection 5 weeks ago and hoarseness of voice 2 weeks ago. Left vocal cord paralysis was diagnosed by a fibro-optic laryngoscope (Fig. 3).

Fig. 3
figure 3

Left vocal cord paralysis (case 3)

Full size image

Case 4

A 51-year-old lady presented with just a mild degree of noisy difficult breathing of 5 days with no other symptoms; examination showed left vocal cord paralysis and right cord paresis. No history of neck surgery was found; a CT scan on the chest, neck, and skull base was carried out as a routine in cord paralysis cases but it showed COVID-19 opacities by accident. Then, she referred for nasopharyngeal swab and PCR that gave a positive result for COVID-19 (Fig. 4).

Fig. 4
figure 4

Left vocal cord paralysis and right cord paresis (case 4)

Full size image

Case 5

A lady, 44-year-old patient, coming to the clinic with fever, anosmia, mild abdominal dyspepsia, nausea, cough, and change of voice 3 days ago. Diagnosis confirmed as COVID-19; after treatment in an isolation hospital and being negative by PCR, the larynx was examined and left vocal cord paralysis was diagnosed (Fig. 5).

Fig. 5
figure 5

Left vocal cord paralysis (case 5)

Full size image

Case 6

A 69-year-old man already referred from an isolation hospital after finishing his treatment from COVID-19. The cause of referral was the persistent cough and change of voice despite a clear recent CT scan on the chest and negative post-treatment PCR. Laryngeal examination showed right vocal cord paralysis (Fig. 6).

Fig. 6
figure 6

Right vocal cord paralysis (case 6)

Full size image

All cases started speech therapy and were monitored by regular visits every 2 weeks. Five cases showed variable degrees of spontaneous recovery within 2–5 months; vocal cord medialization by hyaluronic acid was carried out in one case who showed no spontaneous improvement.

Discussion

This study suggests an association between the COVID-19 infection and the laryngeal vocal cord paralysis as there is no other clear cause of vocal cord paralysis in this study’s cases; none of the study cases was diabetic; also, all cases showed nearly the same onset of COVID-19 symptoms and laryngeal paralysis. Bhatt et al. have suggested the same theory of association between cord paralysis and viral upper respiratory tract infection [13].

Some authors have noticed that the incidence of idiopathic vocal cord paralysis is higher in winter due to the higher spread of droplet infections of viral origin [14,15,16].

Previous publications have diagnosed specific virus infections like herpes simplex, Epstein-Barr, West Nile, and varicella-zoster viruses clinically and laboratory in cases with idiopathic cord paralysis [12, 17,18,19,20,21].

There are many examples of viral-induced neuropathy in the field of otolaryngology other than the larynx. Anosmia and ageusia became very popular with COVID-19 infection [6, 8], also Bell’s palsy although its etiology is unknown but herpes simplex virus is highly accused as a cause in patients of Bell’s palsy, the same with the varicella-zoster virus which is assumed to be responsible for Ramsay Hunt syndrome [22,23,24,25].

The incidence of post-COVID-19 vocal fold paralysis is relatively low; however, mild paresis may be discovered accidentally. Furthermore, laryngeal examination has been limited by the pandemic. Thus, the prevalence, severity, and consequence of vocal cord insult during the COVID-19 pandemic remain to be determined [26]. In a study on 20 patients with post-COVID-19 dysphonia, 40% of cases were diagnosed as unilateral vocal cord paralysis [27]. Another study has reported 2 cases of bilateral vocal cord paralysis due to viral infection by COVID-19 [28].

Finally, literature has focused on anosmia and ageusia as a recently common picture of COVID-19 infection and it lacks studies that entail the issue of COVID-19 impact on vocal cord innervation and mobility.

Conclusions

Viral infection could be an underlying cause of idiopathic laryngeal cord paralysis; in the new era of the COVID-19 pandemic, physicians all over the world noticed variable neurological pictures; in this study, we presented 6 cases of vocal cord paralysis mainly unilateral supposed to be due to COVID-19 infection; all cases showed spontaneous recovery apart from one case that needed medialization of the cord.

Availability of data and materials

Data are available from the corresponding author on reasonable request.

Change history

Abbreviations

COVID-19:

Coronavirus disease 2019

References

  1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DS, Du B (2020) Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 382(18):1708–1720. https://doi.org/10.1056/NEJMoa2002032

    CAS  Article  PubMed  Google Scholar 

  2. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B (2020) Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 395(10223):497–506

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  3. Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, Greninger AL, Pipavath S, Wurfel MM, Evans L, Kritek PA (2020) Covid-19 in critically ill patients in the Seattle region - case series. N Engl J Med. 382(21):2012–2022. https://doi.org/10.1056/NEJMoa2004500

    CAS  Article  PubMed  Google Scholar 

  4. Nath A (2020) Neurologic complications of coronavirus infections. Neurology 94(19):809–810. https://doi.org/10.1212/WNL.0000000000009455

    CAS  Article  PubMed  Google Scholar 

  5. Toscano G, Palmerini F, Ravaglia S, Ruiz L, Invernizzi P, Cuzzoni MG, Franciotta D, Baldanti F, Daturi R, Postorino P, Cavallini A, Micieli G (2020) Guillain-Barré syndrome associated with SARS-CoV-2. N Engl J Med. 382(26):2574–2576. https://doi.org/10.1056/NEJMc2009191

    Article  PubMed  Google Scholar 

  6. Chen T, Di Wu HC, Yan W, Yang D, Chen G, Ma K, Xu D, Yu H, Wang H, Wang T, Guo W (2020) Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ. 368:m1091

    Article  PubMed  PubMed Central  Google Scholar 

  7. -Wan Y, Cao S, Fang Q, Wang M, Huang Y (2020) Coronavirus disease 2019 complicated with Bell’s palsy: a case report. doi.org/10.21203/rs.3.rs-23216/v1.

  8. Lechien JR, Estomba CM, De Siati DR, Horoi M, Le Bon SD, Rodriguez A, Dequanter D, Blecic S, El Afia F, Distinguin L, Idrissi CY, Hans S, Delgado IL, Henriquez CC, Lavigne P, Falanga C, Barillari MR, Cammaroto G, Khalife M, Leich P, Souchay C, Rossi C, Journe F, Hsieh J, Edjlali M, Carlier R, Ris L, Lovato A, De Filippis C, Coppee F, Fakhry N, Ayad T, Saussez S (2020) Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study. Eur Arch Otorhinolaryngol. 277(8):2251–2261. https://doi.org/10.1007/s00405-020-05965-1

    Article  PubMed  PubMed Central  Google Scholar 

  9. Spataro EA, Grindler DJ, Paniello RC (2014) Etiology and time to presentation of unilateral vocal fold paralysis. Otolaryngol Head Neck Surg 151(2):286–293. https://doi.org/10.1177/0194599814531733

    Article  PubMed  Google Scholar 

  10. Rosenthal LHS, Benninger MS, Deeb RH (2007) Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope 117(10):1864–1870. https://doi.org/10.1097/MLG.0b013e3180de4d49

    Article  PubMed  Google Scholar 

  11. Schindler A, Bottero A, Capaccio P, Ginocchio D, Adorni F, Ottaviani F (2008) Vocal improvement after voice therapy in unilateral vocal fold paralysis. J Voice 22(1):113–118. https://doi.org/10.1016/j.jvoice.2006.08.004

    Article  PubMed  Google Scholar 

  12. Chitose SI, Umeno H, Hamakawa S, Nakashima T, Shoji H (2008) Unilateral associated laryngeal paralysis due to varicella-zoster virus: virus antibody testing and videofluoroscopic findings. J Laryngol Otol. 122(2):170–176. https://doi.org/10.1017/S0022215107000898

    Article  PubMed  Google Scholar 

  13. -Bhatt NK, Pipkorn P, Paniello RC (2018) Association between upper respiratory infection and idiopathic unilateral vocal fold paralysis. Ann. Otol. Rhinol. Laryngol. 1-5

  14. Mourtzoukou EG, Falagas ME (2007) Exposure to cold and respiratory tract infections. Int J Tuberc Lung Dis. 11(9):938–943

    CAS  PubMed  Google Scholar 

  15. -Lowen AC, Mubareka S, Steel J, Palese P (2007) Influenza virus transmission is dependent on relative humidity and temperature. PLoS Pathog. 3:e151, 10, 1470, 1476, DOI: https://doi.org/10.1371/journal.ppat.0030151.

  16. Eccles R (2009) An explanation for the seasonality of acute upper respiratory tract viral infections. Acta Otolaryngol. 122(2):183–191. https://doi.org/10.1080/00016480252814207

    Article  Google Scholar 

  17. Parano E, Pavone L, Musumeci S, Giambusso F, Trifiletti RR (1996) Acute palsy of the recurrent laryngeal nerve complicating Epstein-Barr virus infection. Neuropediatrics. 27(03):164–166. https://doi.org/10.1055/s-2007-973769

    CAS  Article  PubMed  Google Scholar 

  18. Steele NP, Myssiorek D (2009) West Nile virus induced vocal fold paralysis. Laryngoscope 116:494–496

    Article  Google Scholar 

  19. Rothschild MA, Drake W, Scherl M (1994) Cephalic zoster with laryngeal paralysis. Ear Nose Throat J. 73(11):850–852. https://doi.org/10.1177/014556139407301111

    CAS  Article  PubMed  Google Scholar 

  20. Nishizaki K, Onoda K, Akagi H, Yuen K, Ogawa T, Masuda Y (1997) Laryngeal zoster with unilateral laryngeal paralysis. ORL J Otorhinolaryngol Relat Spec. 59(4):235–237. https://doi.org/10.1159/000276944

    CAS  Article  PubMed  Google Scholar 

  21. Hosseini S, Zawawi F, Young J (2015) Atypical presentation of a common disease: shingles of the larynx. J Voice 29(5):600–602. https://doi.org/10.1016/j.jvoice.2014.10.010

    Article  PubMed  Google Scholar 

  22. Furuta Y, Fukuda S, Chida E, Takasu T, Ohtani F, Lnuyama Y, Nagashima K (1998) Reactivation of herpes simplex virus type 1 in patients with Bell’s palsy. J Med Virol. 54(3):162–166. https://doi.org/10.1002/(SICI)1096-9071(199803)54:3<162::AID-JMV3>3.0.CO;2-3

    CAS  Article  PubMed  Google Scholar 

  23. Linder T, Bossart W, Bodmer D (2005) Bell’s palsy and herpes simplex virus: fact or mystery? Otol Neurotol. 26(1):109–113. https://doi.org/10.1097/00129492-200501000-00020

    Article  PubMed  Google Scholar 

  24. Zandian A, Osiro S, Hudson R, Ali IM, Matuzs P, Tubbs SR, Loukas M (2014) The neurologist’s dilemma: a comprehensive clinical review of Bell’s palsy, with emphasis on current management trends. Med Sci Monit. 20:83–90. https://doi.org/10.12659/MSM.889876

    Article  PubMed  PubMed Central  Google Scholar 

  25. Numthavaj P, Thakkinstian A, Dejthevaporn C, Attia J (2011) Corticosteroid and antiviral therapy for Bell’s palsy: a network meta-analysis. BMC Neurol. 11(1). https://doi.org/10.1186/1471-2377-11-1

  26. Helding L, Carroll TL, Nix J, Johns MM, LeBorgne WD, Meyer D (2020) COVID-19 after effects: concerns for singers. J Voice. https://doi.org/10.1016/j.jvoice.2020.07.032

  27. Naunheim MR, Zhou AS, Puka E, Franco RA, Carroll TL, Teng SE, Mallur PS, Song PC (2020) Laryngeal complications of COVID-19. Laryngoscope 5(6):1117–1124

    Google Scholar 

  28. -Barrera JJ, Vázquez B, Vinasco A, Zamora P, Solano S, Gisbert N, Castro R, Vinasco D, Álvarez M, Rueda A (2021) Bilateral vocal fold paralysis after COVID-19 infection. Another neuro-invasive manifestation? Case series. Colomb. J. Anesthesiol. https://www.revcolanest.com.co/index.php/rca/article/view/978

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Authors and Affiliations

  1. ENT Department, Faculty of Medicine, Cairo University, Cairo, Egypt

    Sameh M. Zamzam

  2. ENT Department, Kasr Alainy Hospital, Garden City, Cairo, Egypt

    Sameh M. Zamzam

  3. ENT Department, Railway Hospital, Ramsis, Cairo, Egypt

    Rania Gamal Hanafy

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  1. Sameh M. Zamzam
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  2. Rania Gamal Hanafy
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Contributions

SM contributes with putting the methods, data collection, writing the paper, and submitting the paper. RG contributes with the data collection and general revision. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Sameh M. Zamzam.

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Ethics approval and consent to participate

This study has been approved by the Ethical committee of ENT Department, Cairo University and Ethical Committee of Railway Hospital Committee for researches. Reference number: not applicable/or not available. Written informed consents were obtained from the patients.

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Written informed consents were obtained from the patients.

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The authors have no conflict of interest to declare.

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Zamzam, S.M., Hanafy, R.G. Impact of COVID-19 on vocal cord mobility: a case series study. Egypt J Otolaryngol 37, 93 (2021). https://doi.org/10.1186/s43163-021-00157-y

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Keywords

  • COVID-19
  • Vocal cord
  • Paralysis
  • China
  • WHO
  • Otolaryngology