Covid-19 causes first-of-its-kind vocal cord paralysis in US girl

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In a first-of-its-kind case a 15-year-old girl has experienced bilateral vocal cord paralysis after suffering a bout of Covid-19 infection.

The patient, an otherwise healthy girl, was presented at the emergency department at Massachusetts General Hospital with symptoms of respiratory distress nine days after diagnosis with SARS-CoV-2 infection.

Examination with an endoscope revealed bilateral vocal cord paralysis, which is an immobility of both vocal cords found in the larynx or voice box.

According to physician-researchers at Mass Eye and Ear, a member of Mass General Brigham, it is "The first paediatric case of bilateral vocal cord paralysis after Covid and was likely a downstream effect of the Covid."

The case, detailed in the journal Pediatrics, suggests that vocal cord paralysis may be a nervous system-related (neuropathic) complication of the virus, in addition to already well-established neurologic complications in children and adults.

"Given how common this virus is among children, this newly-recognised potential complication should be considered in any child presenting with breathing, talking or swallowing complaint after a recent Covid-19 diagnosis," said first author Danielle Reny Larrow, a resident in the Department of Otolaryngology-Head and Neck Surgery at Mass Eye and Ear.

"This is especially important as such complaints could be easily attributed to more common diagnoses such as asthma."

While at the hospital, the patient underwent a detailed battery of diagnostic tests including blood work, imaging, cerebrospinal fluid analysis and consultations with otolaryngology, neurology, psychiatry, speech language pathology and neurosurgery. When speech therapy failed to relieve the patient's symptoms, the physicians performed a tracheostomy -- a surgically created opening in the windpipe -- to relieve the patient's breathing difficulties.

She remained tracheostomy-dependent for more than 13 months after initial treatment, suggesting that this type of nerve complication may not be temporary. Following the submission of this case report, the physicians were able to remove the tracheostomy -- 15 months after it was inserted and just in time for the patient's high school graduation and prom.

"She was having her senior prom a year and a quarter to the date of when she lost her function, and she told me she was not going to go to the prom with her tracheostomy in place," Hartnick said.

"We decided to intervene so that she could graduate high school and go to her prom tracheostomy-free, which she did."

Post-viral neuropathy is a known cause of vocal cord paralysis, and there have been several reports of paralysis in one or both vocal cords of adults as a complication of SARS-CoV-2 infection, but this is the first report of the complication in an adolescent.

This is important, the team said, because these types of complications are not usually expected in young, healthy individuals and there have been more than 15 million reported cases of paediatric SARS-CoV-2 infection.

"To have a young, healthy, vibrant high schooler all of a sudden lose one of their important cranial nerves such that they can't breathe is highly unusual and took some parsing," said senior author Christopher Hartnick, director of the Division of Pediatric Otolaryngology at Mass Eye and Ear.

"The fact that kids can actually have long-term neurotrophic effects from Covid-19 is something that is important for the broader paediatric community to be aware of in order to be able to treat our kids well."

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