Takotsubo syndrome (TTS) is a transient stress-induced cardiomyopathy that typically presents with apical ballooning; focal variants are rare and may closely mimic acute coronary syndromes. We present the case of a 74-year-old woman who developed acute hypoxemic respiratory failure secondary to vocal cord and phrenic nerve paralysis following an interscalene block. During hospitalization, she exhibited isolated troponin elevation without chest pain or electrocardiographic changes. Coronary angiography demonstrated nonobstructive coronary arteries, while ventriculography revealed focal lateral wall hypokinesis consistent with focal TTS. Initial management included full acute coronary syndrome therapy, which was subsequently de-escalated after the diagnosis was established. Acute airway obstruction is an uncommon trigger, underscoring the role of catecholamine-mediated myocardial stunning and the importance of early recognition to avoid unnecessary interventions and guide appropriate management.

Recurrent laryngeal nerve (RLN) injury is a significant morbidity following transhiatal esophagectomy (THE). While surgical platforms have evolved, the clinical burden and longitudinal management of these injuries remain under-characterized. This study evaluates RLN injury incidence and the effectiveness of a multidisciplinary management pathway in a contemporary cohort. A retrospective review of 135 patients undergoing THE with cervical anastomosis between 2017 and 2024 was conducted. The primary outcome was confirmed RLN injury via laryngoscopy and postoperative hoarseness. Predictors of injury and specialty follow-through with Otolaryngology (ENT) and Speech-Language Pathology (SLP) were analyzed. Postoperative hoarseness occurred in 43.7% (n = 59) of patients, while RLN injury was confirmed in 11.9% (n = 16), which falls within the reported national average. Surgical approach was not an independent predictor of injury (MIS vs. Open, P = 0.309). Notably, only 44.1% of symptomatic patients completed an ENT referral. However, 100% of those with confirmed paralysis required surgical intervention (eg, injection laryngoplasty and thyroplasty) to restore laryngeal function. Mean specialty follow-up for the intervention group was 20.8 months. RLN injury is a persistent complication of THE that is likely underdiagnosed by reactive, symptom-triggered screening. The 100% requirement for surgical correction among confirmed cases underscores that these injuries are rarely self-limiting. To bridge the significant gap in specialty follow-through and mitigate complications like aspiration, a standardized, proactive multidisciplinary referral protocol is necessary.

Vagal schwannoma is a rare benign tumor of the head and neck, originating from Schwann cells of peripheral nerves. These tumors are typically slow-growing and often present with nonspecific clinical features. The most common manifestation is a gradually enlarging neck mass; therefore, preoperative diagnosis is quite challenging, and such lesions are frequently misdiagnosed as parotid tumors, paragangliomas, or metastatic lymph nodes. We report the case of a 55-year-old male who presented with a right infra-auricular mass. The initial clinical evaluation suggested a parotid tumor; however, preoperative computed tomography revealed that the tumor was located posterior to the carotid space. After thorough discussion with the patient regarding surgical risks, including the possibility of postoperative vocal cord paralysis, the patient elected to proceed with surgical treatment. Intraoperatively, the tumor was identified as originating from the vagus nerve, and the diagnosis of schwannoma was confirmed by postoperative histopathological examination. The patient developed right vocal cord paralysis after surgery, and the symptoms gradually improved after voice rehabilitation therapy. This case demonstrates that for neck masses located in the infra-auricular or parotid region, vagal schwannoma should be included in the differential diagnosis. In addition, detailed preoperative counseling regarding potential complications, such as vocal cord paralysis, is essential for informed decision-making and optimal treatment planning.

We present the case of a man in his 40s with Miller Fisher/Guillain-Barré overlap syndrome complicated by bilateral vocal cord (BVC) paralysis and respiratory failure. MRI, nerve conduction studies confirming motor-predominant axonal loss, and positive anti-GD1b and GM1 antibodies supported the diagnosis. Emergency intubation and tracheostomy for ventilatory weaning was required. Persistent BVC immobility despite peripheral neurological recovery prevented decannulation and prompted further evaluation. Laryngeal electromyography (LEMG) revealed BVC denervation and reinnervation suggesting neurological recovery and mechanical fixation as the likely cause of persistent BVC immobility. Intraoperative findings confirmed a type 1 Bogdasarian posterior glottic stenosis. Voice-preserving microlaryngoscopic surgery with CO2 laser scar excision, balloon dilation and steroid injection improved airway patency and led to successful tracheostomy decannulation. This case highlights the importance of recognising both neuropathic and mechanical causes of persistent BVC immobility following neurological injury and intubation, the value of multidisciplinary management and LEMG in guiding diagnosis and treatment.

Video-assisted thoracoscopic surgery (VATS) thymectomy may cause phrenic nerve injury (PNI) or recurrent laryngeal nerve (RLN) injury. Combined PNI and RLN injury is rare but can cause fatal respiratory failure. This study reported a case of VATS thymectomy in a 50-year-old man. The patient received a VATS thymectomy at an external hospital and presented to our hospital 10 days later with severe dyspnea and abdominal distention. Pre-surgery radiologic examination identified a 1.6-cm anterior mediastinal mass, and thymoma was considered. The pathology report confirmed benign reactive lymph node hyperplasia. The patient was hypoxemic with a PaO2 of 54 mmHg in room air. Pulmonary CT angiography ruled out pulmonary embolism. Laryngoscopy and fluoroscopic sniff test showed paradoxical left hemidiaphragm movement, leading to a diagnosis of left vocal cord paralysis. Chest CT revealed left lower lobe atelectasis with severe gastric distension that compressed the left hemithorax. Removal of the mucus plugs by bronchoscopy gave short-term relief. Bilevel positive airway pressure (BiPAP) caused a counterintuitive increase in gastric distension, which is expected after air enters an incompetent glottis. We proposed that combined PNI and RLN injury leads to ineffective cough, aerophagia, and a self-reinforcing pathophysiological cycle. Conservative treatment failed. Single-incision VATS left diaphragmatic plication was performed on hospital day 7 at our hospital. Oxygen saturation returned to normal, the lung re-expanded, and the abdominal girth reduced by 14 cm in less than 48 h. This report demonstrated the effect of combined PNI and RLN injury after VATS thymectomy and suggested early diaphragmatic plication as a potential therapeutic option in cases failing to respond to conservative treatment.

Vocal cord palsy may reveal underlying sinister pathology. Unilateral vocal cord palsy can be detected incidentally on FDG PET-CT scan performed for oncologic evaluation. There may be asymmetrically increased FDG uptake in the contralateral vocal cord due to compensatory hyperactivity and hypertrophy, along with dilatation of the affected laryngeal ventricle, consistent with vocal cord paralysis. PET-CT also aid in identifying the underlying etiological lesion along the course of the recurrent laryngeal nerve. Awareness of these characteristic imaging features is essential to prevent misinterpretation as primary laryngeal malignancy. This case highlight the integral role of FDG PET-CT in assessing the causes of vocal cord palsy.

We present a case of a male in his fifties who attended with wheezing, dysphonia and shortness of breath. He was under investigation for asymmetrical muscle weakness in the absence of a sensory deficit for the preceding 1 year. Spirometry (flow volume loop) suggested extra-thoracic restriction and bronchoscopy confirmed bilateral vocal cord palsy. Due to clinical presentation and a positive anti-GM1, a diagnosis of multifocal motor neuropathy (MMN) with bilateral vocal cord palsy was made. The patient was initiated on intravenous immunoglobulin therapy with good effect on his general muscle weakness and respiratory symptoms, lung function and vocal cord abductor function. MMN with conduction block is a rare autoimmune condition, and vocal cord paresis from bilateral Xth cranial nerve involvement (recurrent laryngeal) is a very rare presentation of an MMN. Early diagnosis led to good patient outcomes.