Bitonal cough

Specialty: Respiratory.

• double tone cough
• cough due to vocal cord paralysis

Why it occurs

• Unilateral paralysis or paresis of the recurrent laryngeal nerve due to intrathoracic tumor compression (especially due to non-small cell lung cancer in the left upper lobe, which compresses the nerve at the level of the aortic arch)
• Aneurysm of the arch of the aorta (Cardarelli-Ortner syndrome, where aortic dilation stretches and compresses the left recurrent laryngeal nerve)
• Massive metastatic lymphadenopathy in the middle mediastinum or aortopulmonary window (of pulmonary, esophageal or lymphomatous origin)
• Previous thyroid, esophageal, or chest surgery (inadvertent iatrogenic damage to the recurrent laryngeal nerve)
• Apical pulmonary tuberculosis with pleuritis and fibrosis that pulls on the recurrent laryngeal nerve (Lian-Siguier syndrome)

Initial workup

Flexible nasofibrolaryngoscopy in phonation (to document the immobility of one of the vocal cords, typically in the paramedian position); Computed tomography (CT) from the skull base to the thoracic operculum/middle mediastinum with contrast; Magnetic resonance imaging (MRI) of the neck and chest; High resolution thyroid ultrasound.

Standard management

• There are no drugs that reverse the structural injury of the recurrent laryngeal nerve; The treatment is fundamentally etiological and rehabilitative
• Methylprednisolone — scheduled at decreasing doses if the cause is inflammatory or acute postsurgical due to nerve edema
• Phoniatric compensation therapy (speech therapy exercises to improve glottic closure).