EpistemisDull bitonal cough
Specialty: Respiratory.
Why it occurs
- Paralysis of the recurrent laryngeal nerve due to a dull central mediastinal tumor (for example, a large invasive thymoma, intrathoracic goiter or undifferentiated bronchogenic carcinoma of the anterior mediastinum that slowly compresses and destroys the recurrent laryngeal nerve, producing a cough where the paralyzed vocal cord vibrates weakly with a dull timbre, asynchronous with the contralateral cord)
- Post-histoplasmosis or idiopathic progressive mediastinal fibrosis (entrapment of mediastinal and tracheal nerves in a sheath of dense collagen tissue)
- Sequelae of mediastinal radiotherapy for lymphoma (leads to vocal cord stiffness due to chronic tissue damage).
Initial workup
Computed tomography (CT) of the neck and chest with multidetector intravenous contrast; Mediastinal magnetic resonance imaging (MRI); flexible nasofibrolaryngoscopy; Barium esophagram; Flexible bronchoscopy to evaluate dynamic tracheal compressibility.
red flags
Progressive dyspnea at rest with audible dull inspiratory stridor, severe dysphagia for liquids and solids due to esophageal compression, associated superior vena cava syndrome (clavine facial edema, jugular engorgement without collapse and thoracic collateral circulation), or severe weight loss.
Standard management
- There are no specific pharmacological treatments that recover the function of the chronically destroyed nerve
- Prednisone — 20-40 mg orally daily if there is an acute inflammatory component or active mediastinitis that secondarily compresses the nerve
- Decompressive surgical treatment of the mediastinum or local palliative chemotherapy/radiotherapy depending on the tumor origin.
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Respiratory
- Listed causes
- 3
- Treatment options
- 3