Days after infection with SARS-CoV-2, an otherwise healthy teenage girl suddenly developed breathing problems. It appears that COVID-19 has paralyzed her vocal cords.
The girl needed a surgical tracheostomy – an opening in the trachea below her voice box – to keep her breathing for more than a year. According to a new case report, the effects of COVID on the nervous system can cause paralysis of the vocal cords in rare cases.
The authors say this is the first case of vocal cord paralysis in a teenager following a COVID-19 diagnosis, although there have been reports of the condition in adults.
“The virus has known neurological complications, including headache, seizures, and peripheral neuropathy,” wrote otolaryngologists Daniel Larrow and Christopher Hartnick of Mass Eye and Ear at Harvard Medical School.
“The present case reveals that vocal cord paralysis may be an additional neuropathic consequence of the virus.”
Thirteen days after testing positive for SARS-CoV-2, the 15-year-old girl was admitted to the hospital’s emergency department. Her initial symptoms, including congestion, fever and fatigue, improved after five days. But she reported suddenly having trouble breathing nine days after the positive test, especially when active.
The emergency room doctors noted that her breathing was rapid and noisy on inspiration, indicating airflow obstruction, even though her oxygen levels were normal. Tests for SARS-CoV-2 and other respiratory infections were negative.
The patient, who had a history of asthma and anxiety, was given steroids and bronchodilators for a suspected asthma attack, but this did not help.
Otolaryngologists examined her vocal cords and diagnosed paradoxical vocal fold movement (PVFM), in which the vocal cords close instead of open when a person breathes. She began speech therapy to treat this involuntary closure, but her symptoms did not improve and became clear that they did not match the typical signs of PVFM.
She continued to have trouble breathing and developed new problems such as difficulty swallowing, weakness on one side, numbness and tingling, and an unsteady gait, so the girl was admitted to a pediatric hospital for further evaluation.
The otolaryngologists examined her vocal cords again and this time diagnosed bilateral vocal cord paralysis, which basically means that both of her vocal cords cannot move. But they still couldn’t find the cause of the paralysis.
The results of a battery of tests ruled out infections and neurological disorders. Her brain and spine scans showed no obvious problems that could be related to her symptoms, nor did tests on her swallowing.
Based on their findings, doctors concluded that the teenager’s previous infection with COVID-19 appeared to have weakened her vocal cords and may also be responsible for her numbness and weakness on one side.
Botulinum toxin injections into her throat muscles—a method that has shown efficacy in treating some throat conditions in children—failed to relieve her breathing problems.
Eventually, the girl was operated on for a tracheostomy, where a small opening is made in the trachea (trachea) to assist breathing. And finally her breathing improved.
Her weakness, numbness, and tingling improved over time, raising the possibility that they were related to her past infection with COVID-19.
The medical team tried several times to see if she could breathe without the tracheostomy, but it wasn’t until 15 months after placement that they were able to safely remove it.
“She had a prom a year and a quarter before the date she lost her function, and she told me she wasn’t going to the prom with a tracheostomy in place,” Hartnick says.
“We decided to step in so she could graduate high school and go to her prom without a tracheostomy, which she did.”
The case report was published in Pediatrics.