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• W2981284504 abstract "SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Respiratory difficulties in patients who suffer from stroke may rarely be attributed to upper airway disease. Below we present a case with spasmodic vocal cord and hemi-diaphragm dystonia leading to breathing difficulties and hypercarbia. CASE PRESENTATION: 81-year-old female, former 35 pack year smoker, with a history of facial and vocal cord dystonia since the time of an ischemic stroke treated with clonazepam; presented to the hospital with hypercarbic respiratory failure following stopping her clonazepam. She had an unsubstantiated diagnosis of COPD. She was tachypneic with a venous blood gas pCO2 of 77 and a pO2 of 59 mmHg. Lung examination showed poor air entry, intermittent upper airway “clicking” on inspiration and interrupted breathing cycles. Neurological examination revealed mild right sided weakness and intermittent eyebrow twitching. She was initially managed for a COPD exacerbation with initiation of BiPAP and glucocorticoids. Static imaging studies were unremarkable. ENT identified no vocal cord (VC) abnormalities. Pulmonary was consulted and dynamic chest imaging studies revealed vocal cord and diaphragm spasms. Spirometry demonstrated oscillations in her inspiratory flow volume loop (FVL). The hypoxic-hypercapnic respiratory failure was attributed to VC and diaphragm dystonia. She was restarted on her home clonazepam with resolution of the hypercarbia. Glucocorticoids and BiPAP were discontinued with normalization of air entry and no further upper airway “clicking” on exam. Repeat spirometry, while on clonazepam, showed a normalization of her FVL and no obstruction. She was discharged on daily low dose clonazepam and was arranged for outpatient follow-up. Neuro-ENT follow-up recommended continuation of clonazepam but advised against botulinum injections of the larynx, as it would lead to a significant risk for future aspiration. DISCUSSION: VC and diaphragm dystonia is a rare and often overlooked cause of dyspnea. It is a primary disorder presenting in middle-aged individuals, but, rarely, can also be a manifestation of stroke and may be associated with diaphragm dystonia. ENT examination rarely detects VC abnormalities in such cases, with botulinum toxin being well established for voice improvement in VC dystonia. In our case, concern was raised for excessive risk of aspiration with such treatment. Benzodiazepines are advised alternatives despite the lack of strong evidence. In our patient, her symptoms appeared after the cessation of clonazepam and resolved by re-instating it. VC with or without diaphragm dystonia should be considered in the differential diagnosis of patients with episodic dyspnea and voice changes after suffering a stroke. Unlike most causes of hypercarbia, clonazepam can have a beneficial effect in the setting of dystonia. CONCLUSIONS: VC and diaphragm dystonia should be considered as a differential diagnosis in patients with dyspnea post stroke. Reference #1: Greene P, Shale H, Fahn S. Experience with high dosages of anticholinergic and other drugs in the treatment of torsion dystonia. Adv Neurol. 1988;50:547-56. PubMed PMID: 3400509. DISCLOSURES: No relevant relationships by Mohammad Ghanbar, source=Web Response No relevant relationships by Mary O Sullivan, source=Web Response No relevant relationships by Janvi Paralkar, source=Web Response" @default.
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• W2981284504 date "2019-10-01" @default.
• W2981284504 modified "2023-09-25" @default.
• W2981284504 title "A RARE CAUSE OF HYPERCARBIA" @default.
• W2981284504 doi "https://doi.org/10.1016/j.chest.2019.08.2049" @default.
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