A Mirror of
Hospital
Practice
A CASE OF BILATERAL ABDUCTOR PARALYSIS OF THE VOCAL CORDS WITH IRRITATION OF THE RIGHT PHRENIC NERVE By S. R. RAO, m.b., b-s. Karimnagar (Hyderabad State)
October, 1947, B. V., aged 21 years, was brought to the clinic with a hard indurated abscess, the size of a lemon, right in the middle line of the nape of the neck, about 2^ inches below the level of the occipital protuberance. He complained of pain in both On 5th
a
villager,
sides of the neck and was unable to turn his head in any direction. Temperature 101 ?F. The occipital and the mastoid groups of lymph glands along with the deep cervical glands were enlarged. The rest N.A.D. He xwas treated with sulphathiazole 4 tablets stat and 2 tablets every 4 hours with alkaline mixture for two
days. On 7th October, 1947, he complained of cough and dyspnoea which
resembled asthma clinically, but no adventitious sounds were heard. He was given asthma mixture along with an injection of adrenaline in oil, without any obvious relief of symptoms. Next day the resembling static
condition became very acute asthma without the typical adventitious sounds. The voice was very husky but loud enough to be audible. Inspiration was very difficult and expiration was slightly less so. Indirect laryngoscopy (after desensitization of the pharynx): Both the vocal cords were congested and drawn together, almost touching each other and in the middle line. No separation of the cords during inspiration and it looked as though there was a little separation during expiration. Bilateral incomplete abductor paralysis of the vocal cords.
(The patient's relatives were informed of the seriousness of the condition but they had their A few said own individual opinions about it. it was asthma but others maintained it is not yet the season. Quite a few suggested that an evil spirit was tormenting the poor chap. Every one of them vehemently declared that whatever may be the capabilities of the vocal cords they can never suffocate a sturdy young fellow, just like that, by pure and simple nonco-operation. It was then that some womenfolk came out with the idea that some enemy of this It was man took advantage of black magic. unanimously approved of and the patient was immediately taken away for necessary counteraction to neutralize the alleged black magic.) On 27th December, 1947, the walked into the clinic with a
same
patient
friend
who
392
THE INDIAN MEDICAL GAZETTE that ten
after the onset of the the acuteness subsided very gradually with the voice becoming an actual whisper. Hiccough also appeared and persisted. He developed pain in the right shoulder region and along the right costal margin. (The abscess" on the nape of the neck by this time had burstand healed with the pain in the neck disappear-
explained
attack of
dyspncea
days
ing completely.)
He complained of slight dyspncea, expiration being as difficult as inspiration. Persistent hiccough, pain in the right shoulder region and along the right costal margin. Had to make great efforts to produce an almost inaudible whisper. Complete absence of cough. Indirect laryngoscopy : both vocal cords pale and moderately abducted and lying motionless. Other systems N.A.D.?bilateral abductor paralysis of the vocal cords, complete. Total R.B.C. and W.B.C. and differential counts normal. Wassennann reaction and Kahn tests : repeatedly negative (even after a provocative* dose of arsenic). Urine.?No abnormality. Screening.?Revealed no abnormality except sudden contraction, i.e. pulling down?of the right side of the diaphragm. (Irritation of the right phrenic nerve.) Treatment.?First ten days : Iodides with Tr. nux vomica by mouth. Daily injections of 100 mg. of vitamin Bx. First month.?-Next 20 days : Iodides with Tr. nux vomica by mouth. 100 mg. of vitamin Bx on alternate days injection. By this time the hiccough disappeared and he could produce the same whisper without any effort. No dyspncea. Vocal cords lying still in the same abducted position motionless. Second month.?Iodides with Tr. nux vomica. 100 mg. vitamin Bx every seventh day. Able to talk with a very husky voice. Vocal cords still separated and equidistant from the middle line. No vibrations of the cords (position of the cords not cadaveric). Third month.?Iodides with Tr. nux vomica.100 mg. vitamin B1 every seventh day. Voice absolutely normal and as of old. The vocal cords do come very close to each other and make their normal excursions during both inspiration and expiration.
points to be considered : (1) Lymphatic drainage of the area of the abscess. (2) Causation of the paralysis of both the recurrent laryngeal nerves (the cause of the abductor paralysis of the vocal cords). (3) Causation of the irritation of the right phrenic nerve which produced the hiccough and pain in the right shoulder region. Discussion.?Three
* The provocative dose is being discarded in Europe nowadays. In India its utility was doubted some time ago. The reaction when provoked may not indicate
syphilis.?Editor,
I.M.G.
[Sept., i949
1. The lymphatic drainage of the area of the abscess is via the superficial occipital and mastoid groups of lymph glands, and upper and lower posterior deep cervical groups to lower anterior deep cervical glands. Some of the members of this group lie inside the carotid sheath along with some of the upper anterior deep cervical group. The inflammation of the above-mentioned three groups of the deep cervical glands produced structural changes in the nerves concerned. 2. (a) Paralysis of both the recurrent laryngeal nerves due to the close apposition of some of the inflamed members of lower anterior deep cervical glands to the nerves until they get under cover of the inferior constrictor muscles. (The' nerves are closely associated with the lymphatic vessels from the infraglottic area-^ these anastomose freely with those of the supraglottic area which go to the upper anterior deep cervical?as they run downwards in the grove between the trachea and the oesophagus into the lower anterior deep cervical glands. It is too far-fetched?unless it is a malignant case?to say that inflammation of the glands of the above deep group can produce inflammation?retrograde?of the above lymph vessels indirectly causing the paralysis.) {b) The condition is one of perineuritis (toxic). It consists pathologically in an increase of all the connective tissue of a nerve both around it and between the fasciculi with compression of the vessels and nerve fibres. 3. Irritation of the right phrenic nerve was due to the inflammation of the deep cervical glands which like the phrenic nerve itself are also under cover of the sterno-mastoid muscle. Posteriorly the carotid sheath extends laterally so as to overlap the phrenic nerve. The hiccough was the product of the irritation thus caused. The pain in the right shoulder region is due to the sensory stimuli referred via the phrenic nerve and the fourth cervical segment of the spinal cord along the supra-clavicular nerves to the shoulder region.
Hospital
Practice
A CASE OF BILATERAL ABDUCTOR PARALYSIS OF THE VOCAL CORDS WITH IRRITATION OF THE RIGHT PHRENIC NERVE By S. R. RAO, m.b., b-s. Karimnagar (Hyderabad State)
October, 1947, B. V., aged 21 years, was brought to the clinic with a hard indurated abscess, the size of a lemon, right in the middle line of the nape of the neck, about 2^ inches below the level of the occipital protuberance. He complained of pain in both On 5th
a
villager,
sides of the neck and was unable to turn his head in any direction. Temperature 101 ?F. The occipital and the mastoid groups of lymph glands along with the deep cervical glands were enlarged. The rest N.A.D. He xwas treated with sulphathiazole 4 tablets stat and 2 tablets every 4 hours with alkaline mixture for two
days. On 7th October, 1947, he complained of cough and dyspnoea which
resembled asthma clinically, but no adventitious sounds were heard. He was given asthma mixture along with an injection of adrenaline in oil, without any obvious relief of symptoms. Next day the resembling static
condition became very acute asthma without the typical adventitious sounds. The voice was very husky but loud enough to be audible. Inspiration was very difficult and expiration was slightly less so. Indirect laryngoscopy (after desensitization of the pharynx): Both the vocal cords were congested and drawn together, almost touching each other and in the middle line. No separation of the cords during inspiration and it looked as though there was a little separation during expiration. Bilateral incomplete abductor paralysis of the vocal cords.
(The patient's relatives were informed of the seriousness of the condition but they had their A few said own individual opinions about it. it was asthma but others maintained it is not yet the season. Quite a few suggested that an evil spirit was tormenting the poor chap. Every one of them vehemently declared that whatever may be the capabilities of the vocal cords they can never suffocate a sturdy young fellow, just like that, by pure and simple nonco-operation. It was then that some womenfolk came out with the idea that some enemy of this It was man took advantage of black magic. unanimously approved of and the patient was immediately taken away for necessary counteraction to neutralize the alleged black magic.) On 27th December, 1947, the walked into the clinic with a
same
patient
friend
who
392
THE INDIAN MEDICAL GAZETTE that ten
after the onset of the the acuteness subsided very gradually with the voice becoming an actual whisper. Hiccough also appeared and persisted. He developed pain in the right shoulder region and along the right costal margin. (The abscess" on the nape of the neck by this time had burstand healed with the pain in the neck disappear-
explained
attack of
dyspncea
days
ing completely.)
He complained of slight dyspncea, expiration being as difficult as inspiration. Persistent hiccough, pain in the right shoulder region and along the right costal margin. Had to make great efforts to produce an almost inaudible whisper. Complete absence of cough. Indirect laryngoscopy : both vocal cords pale and moderately abducted and lying motionless. Other systems N.A.D.?bilateral abductor paralysis of the vocal cords, complete. Total R.B.C. and W.B.C. and differential counts normal. Wassennann reaction and Kahn tests : repeatedly negative (even after a provocative* dose of arsenic). Urine.?No abnormality. Screening.?Revealed no abnormality except sudden contraction, i.e. pulling down?of the right side of the diaphragm. (Irritation of the right phrenic nerve.) Treatment.?First ten days : Iodides with Tr. nux vomica by mouth. Daily injections of 100 mg. of vitamin Bx. First month.?-Next 20 days : Iodides with Tr. nux vomica by mouth. 100 mg. of vitamin Bx on alternate days injection. By this time the hiccough disappeared and he could produce the same whisper without any effort. No dyspncea. Vocal cords lying still in the same abducted position motionless. Second month.?Iodides with Tr. nux vomica. 100 mg. vitamin Bx every seventh day. Able to talk with a very husky voice. Vocal cords still separated and equidistant from the middle line. No vibrations of the cords (position of the cords not cadaveric). Third month.?Iodides with Tr. nux vomica.100 mg. vitamin B1 every seventh day. Voice absolutely normal and as of old. The vocal cords do come very close to each other and make their normal excursions during both inspiration and expiration.
points to be considered : (1) Lymphatic drainage of the area of the abscess. (2) Causation of the paralysis of both the recurrent laryngeal nerves (the cause of the abductor paralysis of the vocal cords). (3) Causation of the irritation of the right phrenic nerve which produced the hiccough and pain in the right shoulder region. Discussion.?Three
* The provocative dose is being discarded in Europe nowadays. In India its utility was doubted some time ago. The reaction when provoked may not indicate
syphilis.?Editor,
I.M.G.
[Sept., i949
1. The lymphatic drainage of the area of the abscess is via the superficial occipital and mastoid groups of lymph glands, and upper and lower posterior deep cervical groups to lower anterior deep cervical glands. Some of the members of this group lie inside the carotid sheath along with some of the upper anterior deep cervical group. The inflammation of the above-mentioned three groups of the deep cervical glands produced structural changes in the nerves concerned. 2. (a) Paralysis of both the recurrent laryngeal nerves due to the close apposition of some of the inflamed members of lower anterior deep cervical glands to the nerves until they get under cover of the inferior constrictor muscles. (The' nerves are closely associated with the lymphatic vessels from the infraglottic area-^ these anastomose freely with those of the supraglottic area which go to the upper anterior deep cervical?as they run downwards in the grove between the trachea and the oesophagus into the lower anterior deep cervical glands. It is too far-fetched?unless it is a malignant case?to say that inflammation of the glands of the above deep group can produce inflammation?retrograde?of the above lymph vessels indirectly causing the paralysis.) {b) The condition is one of perineuritis (toxic). It consists pathologically in an increase of all the connective tissue of a nerve both around it and between the fasciculi with compression of the vessels and nerve fibres. 3. Irritation of the right phrenic nerve was due to the inflammation of the deep cervical glands which like the phrenic nerve itself are also under cover of the sterno-mastoid muscle. Posteriorly the carotid sheath extends laterally so as to overlap the phrenic nerve. The hiccough was the product of the irritation thus caused. The pain in the right shoulder region is due to the sensory stimuli referred via the phrenic nerve and the fourth cervical segment of the spinal cord along the supra-clavicular nerves to the shoulder region.
