Reversible Recurrent Left Laryngeal Nerve Palsy in Pediatric Graves' Disease

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 449-497-Thyroid Neoplasia & Case Reports
Clinical
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-483
Harvey K. Chiu*1, Daniel Ledbetter2, Monica Richter3, Ramesh S. Iyer2 and Albert L. Merati4
1David Geffen School of Medicine at UCLA, Los Angeles, CA, 2Seattle Children's Hospital, Seattle, WA, 3General Pediatrics, Renton, WA, 4University of Washington Medical Center, Seattle, WA
Vocal cord paralysis in the context of goiter is usually ominous for the presence of a malignancy.  Pediatric patients retain significant thymic tissue that regresses only later in life. This thymic tissue can develop significant hyperplasia consequent to stimulation during an acute autoimmune process. We describe a case of a 17 year-old female who presented with a goiter secondary to severe Graves’ disease and a two-month history of hoarseness, choking of liquid intake, and small-volume vomiting especially after eating. She demonstrated a left vocal cord paralysis likely secondary to a unilateral left recurrent laryngeal nerve palsy. A marked enlargement of the thymus was discovered on thoracic imaging.  Treatment was initiated with methimazole, with near complete remission of her laryngeal nerve palsy within three months. Given the immunomodulatory effects of methimazole, a potential mechanism of the left recurrent laryngeal nerve palsy was autoimmune hyperstimulation of the thymus and consequent hyperplasia, resulting in distension of the nerve.  Attenuation of the hyperactive immune process with methimazole may have resulted in regression of the mass effect of the thymus and associated reduction of the nerve distension.  This case illustrates the unique risk of left recurrent laryngeal nerve palsy in pediatric patients with an acute immune stimulation and hyperplasia of the thymus and the reversibility in the context of mitigation of the immune hyperactivity.  Methimazole may be an optimal initial treatment choice in pediatric patients with Graves’ disease and left recurrent laryngeal nerve palsy.

Nothing to Disclose: HKC, DL, MR, RSI, ALM

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