Should Lyme disease be added to the causes of vocal cord paralysis?

In a recent case series published in Voice entitled Laboratory Evaluation of Vocal Fold Paralysis and Paresis investigators identify Lyme disease (LD) as one of several causes of vocal cord paralysis, a condition that can dramatically impact patients' lives, effecting voice, swallowing and airway function. Authors of the new paper point out the importance in determining the cause of vocal cord paralysis to effectively manage the condition. [1]

 

by Daniel J. Cameron, MD MPH

The most common causes of the disorder, according to White and colleagues, include non-laryngeal malignancies, iatrogenic injuries, and idiopathic causes. Post-operative dysfunction after retraction, dissection along the recurrent laryngeal nerve and  thoracic malignancy have also been identified as contributing triggers. [1]

White reports on infectious, neurologic and inflammatory causes, as well. “Infectious causes include Lyme disease, West Nile virus, varicella, herpes, Epstein-Barr, syphilis, and others.”

“Neurologic causes include myasthenia gravis, severe degenerative spine disease, multiple sclerosis, amyotrophic lateral sclerosis, and Parkinson disease, as well as other disorders.”

“Inflammatory causes include, among other entities, sarcoidosis, systemic lupus erythematosus, amyloidosis, and polyarteritis nodosa.”

“Additionally, diabetes, thyroid disease, malnutrition, and vinca alkaloids have been found to cause vocal fold (cord) paralysis or paresis.”

White and colleagues point out the importance of testing patients with vocal cord paralysis for Lyme disease, particularly in endemic regions.

Records for 231 patients with vocal cord paralysis or paresis were reviewed to determine whether testing resulted in a clinically important diagnosis. [1] The authors found the prevalence of syphilis, myasthenia gravis, and Lyme disease were higher in these subjects than the national prevalence. Other medically important conditions identified included diabetes and thyroid dysfunction.

Lyme disease as the cause of vocal cord paralysis was found in the Pennsylvania patients. “A positive Lyme titer with confirmatory Western blot was found in five patients (2.2%). When compared with the 2013 incidence of Lyme disease in Pennsylvania (0.039%), these results were statistically significant (P < 0.0001).” [1] The authors did not address whether there could be cases of Lyme disease not confirmed with positive serologies.

There have been past reports of Lyme disease as the cause of vocal cord paralysis. “One case was reported in 1988, in which a singer was diagnosed with Lyme disease and appropriately treated with doxycycline for 3 weeks resulting in improvement in voice quality, return to normal speaking and singing, and normal findings via laryngoscopic examination,” states White and colleagues. In 2010, Martzolff reported two cases of vocal fold paresis secondary to neuroborreliosis. “Both cases resulted in favorable outcomes after antibiotic treatment.” [3]

The authors point out the importance of testing vocal cord paralysis patients for Lyme disease, particularly in those living in endemic regions. “Because vocal fold paresis secondary to Lyme disease can be treated easily with antibiotics, testing patients with idiopathic vocal fold paresis should be routine, especially in endemic areas or in patients who have traveled to areas in which Lyme disease is endemic.” [1]

White and colleagues did not design their case series to test casualty. “Although their causal relationship to vocal fold paralysis or paresis has not been investigated or established by this study, the medical importance of having established these diagnoses and instituted treatment is self-evident, and their possible causal association awaits further study.”

Nevertheless, the authors recommended implementing a comprehensive evaluation to identify serious and treatable causal or associated disorders underlying vocal fold paralysis and paresis.

“It is important for clinicians, especially tertiary and quaternary providers, to be familiar with the numerous diseases that may present in association with vocal fold paralysis or paresis,” states White and colleagues “and to consider comprehensive diagnostic evaluation to identify serious and treatable causal or associated disorders.”

References:

  1. White, M., et al., Laboratory Evaluation of Vocal Fold Paralysis and Paresis. J Voice, 2016.
  2. Schroeter, V., G.G. Belz, and H. Blenk, Paralysis of recurrent laryngeal nerve in Lyme disease. Lancet, 1988. 2(8622): p. 1245.
  3. Martzolff, L., et al., [Recurrent nerve palsy due to Lyme disease: report of two cases]. Rev Med Interne, 2010. 31(3): p. 229-31.

 


5 Replies to "Should Lyme disease be added to the causes of vocal cord paralysis?"

  • Shelly Scheyder
    11/05/2016 (7:43 pm)
    Reply

    Eight years ago I fell ill with bilateral vocal cord paralysis and all of the major symptoms of Lyme disease. I tested 4 bands positive. I had many diagnoses including Bulbar ALS. I am just this year getting treatment after 50 doctors including Mayo Clinic. Was told it was in my head. Thankful to finally be with an excellent LLMD. My vocal cords and one diaphragm are paralyzed.

  • Lori Geurin
    11/09/2016 (7:04 pm)
    Reply

    Interesting that they’ve found a tie between Lyme disease and issues with the vocal cords.

    Ever since I’ve been infected with Lyme disease, my vocal quality has deteriorated at times. I used to love to sing, but lately have been frustrated with a scratchy voice which I’m sometimes unable to control like I could before Lyme.

    I’ve read of other Lyme patients having chronic strep and throat pain but this hasn’t been my issue. It has been more about the vocal quality and control, which I’m assuming could be related to the vocal cords.

    • Dr. Daniel Cameron
      11/09/2016 (11:48 pm)
      Reply

      I also found the article helpful. You may want to contact the authors or share the blog with your ENT.

  • Colleen
    12/31/2016 (6:58 am)
    Reply

    I’ve been searching for an overall review of my medical issues and found several with all the cysts in or on brain and other organs also with swollowing gag reflex issues. This will be added to my list of papers to take to my Drs. But Geisinger has also just denied one of my scripts which is for Lyme and many tests have been ignored with ” we don’t think insurance will cover” and they don’t even try to submit. Geisinger insurance too.
    Suggestions?

    • Dr. Daniel Cameron
      01/03/2017 (1:37 am)
      Reply

      The medical community is beginning to publish a wider range of papers covering new areas e.g. vocal cords. The issues are complex. Hopefully, other ENT specialists will look further.


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