key: cord-0970058-x3euweym
authors: An, YouYoung; Park, KiNam; Lee, SeungWon
title: The First Case Report of Bilateral Vagal Neuropathy Presenting With Dysphonia Following COVID-19 Infection
date: 2022-02-14
journal: Ear Nose Throat J
DOI: 10.1177/01455613221075222
sha: 93e8fb27697fb168e0ea3eef8e282a8d8f06de73
doc_id: 970058
cord_uid: x3euweym

Coronavirus disease 2019 (COVID-19) is a pandemic with a variety of symptoms and complications. Impairments of taste and smell caused by COVID-19 are well known as otolaryngological sequelae. However, dysphonia due to bilateral vagal neuropathy has not been well described as a presenting symptom or complication of COVID-19 infection. In this paper, we report a case of a 47-year-old patient who experienced dysphonia after remission of COVID-19 infection and diagnosed bilateral vagal neuropathy.

COVID-19 disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is the first pandemic of the twenty-first century. SARS-CoV-2 uses the angiotensin-converting enzyme 2 (ACE2) receptor to infect cells, after which it injures many organs and triggers complications. 1 Neurological symptoms are evident in 36% of patients with COVID-19 infections 2 but, to the best of our knowledge, the report of vagal neuropathy presenting with dysphonia has not been well reported after COVID-19 infection.

We present here a case who experienced dysphonia after remission of COVID-19 infection. Bilateral vagal neuropathy was evident on laryngeal electromyography (L-EMG). The symptoms were successfully controlled via bilateral vocal fold injections.

A 47-year-old female had been diagnosed with COVID-19

After two sessions of voice therapy, there was no improvement. To improve the VF tension and close the glottic gap, we injected .5 mL of calcium hydroxyapatite (Radiesse Voice ® , Bioform Medical Inc., San Mateo, CA, USA) into both vocalis muscles using a 23-G needle via the transthyrohyoid membrane approach with the patient under local anesthesia ( Figure 1 ). One month later, the glottic insufficiency and VF tension improved ( Figure 1 ). Table 1 presents the voice data obtained after injection laryngoplasty. All objective and subjective voice parameters were significantly improved 1 month postoperatively (see Table 1 ). Three months after the procedure, the improved glottic gap and VF tension remained stable and no obstruction caused by the injected material was apparent.

The neurological manifestations of COVID-19 include central nervous system (CNS), peripheral nervous system (PNS), and skeletal muscular manifestations. Mao et al. reported that taste and smell impairments as CNS manifestations were the most common neurological problems; these are well known to trigger otolaryngological complications. 2 The pathophysiology of neurological symptoms reflects penetration by the SARS-CoV-2 virus of the cribriform lamina of the ethmoid bone; the virus thus enters the nervous system. 3 Recently, Sarah K. Rapoport et al. reported a case series of vocal fold paresis and paralysis after COVID-19 infection, which was thus suggested to have caused by post viral vagal neuropathy. 4 The distinct mechanism is not yet known.

In our case, L-EMG revealed decreased interference patterns in the bilateral thyroarytenoid and cricothyroid muscles, reflecting viral invasion of the superior and recurrent laryngeal nerves, 5 triggering bilateral vagal neuropathy. Vagus nerve injury may be caused by operation, intubation, a malignancy, systemic, and autoimmune diseases and viral infections. 6 Her only relevant history was COVID-19 infection. This made it reasonable for us to presume her symptoms as neurological sequelae from a COVID-19 infection. We injected calcium hydroxyapatite into both vocalis muscles to improve glottal contact and VF tension; the dysphonia symptoms resolved.

Impairments of taste and smell caused by COVID-19 are well known as otolaryngological sequelae, but dysphonia by vagal neuropathy is relatively unknown. To the best of our knowledge, this is the first case report of bilateral vagal neuropathy accompanied by dysphonia after recovery from COVID-19 infection. Therefore, since there is a possibility of vagal neuropathy as neurological sequelae from a COVID-19 infection, we suggest that otolaryngologists should carefully examine and treat patients with dysphonia after recovery from COVID-19 infection. It is also recommended to consider appropriate treatment depending on the severity of symptoms.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 

COVID-19 infection: origin, transmission, and characteristics of human coronaviruses

Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China

Neurological manifestations and complications of COVID-19: a literature review

Acute vocal fold paresis and paralysis after COVID-19 infection: a case series

Electromyography of intrinsic laryngeal muscles

Vocal fold paresis: etiology, clinical diagnosis and clinical management

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Soonchunhyang University Research Fund.

YouYoung An  https://orcid.org/0000-0001-6695-7655 KiNam Park  https://orcid.org/0000-0001-6641-3981 SeungWon Lee  https://orcid.org/0000-0002-0468-8143