Harsh bitonal cough

Specialty: Respiratory.

• harsh double tone cough
• dysfunctional tracheobronchial cough due to vocal paralysis

Why it occurs

• Tumoral compression of the right recurrent laryngeal nerve due to neoplasia of the superior sulcus or Pancoast tumor in the right lung apex (causing paralysis of the right vocal cord that generates a harsh blowing tone, combined with the normal tone generated by the contralateral mobile cord)
• Hodgkin or non-Hodgkin lymphoma with large mediastinal adenopathic masses trapping the left recurrent laryngeal nerve in its aortic loop
• Reconstructive surgery of the thoracic aorta or correction of aortic coarctation (direct post-surgical nerve damage)
• Locally advanced esophageal carcinoma with invasion of the sheath of the recurrent laryngeal nerve and the posterior tracheal wall.

Initial workup

High-resolution computed tomography (CT) from the neck to the upper abdomen with intravenous contrast; Magnetic resonance imaging (MRI) of the brachial plexus and thoracic operculum (if Pancoast tumor is suspected); Flexible nasofibrolaryngoscopy (evaluate the position and mobility of both vocal cords); Bronchoscopy and diagnostic esophagoscopy with biopsy.

Standard management

• There are no drugs to restore the function of the severed or infiltrated nerve
• Directed oncological treatment according to the anatomopathological diagnosis — local palliative chemotherapy or radiotherapy
• Codeine (15-30 mg orally every 6-8 hours if the cough is refractory and irritative in nature, controlling airway patency).