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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 90-92

Vocal cord palsy secondary to parathyroid cyst in the young: Rare case report with review of the literature


1 Department of ENT and Head Neck Surgery, Paras HMRI Hospital, Patna, Bihar, India
2 Department of Pathology, Paras HMRI Hospital, Patna, Bihar, India
3 Department of Radiology, Paras HMRI Hospital, Patna, Bihar, India

Date of Web Publication22-Jan-2018

Correspondence Address:
Dr. Mitali Dandekar
Department of ENT and Head Neck Surgery, Paras HMRI Hospital, Patna - 800 012, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_24_17

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  Abstract 


Parathyroid cyst causing vocal cord palsy is extremely rare. The youngest case of parathyroid cyst causing compressive recurrent laryngeal nerve palsy is reported. The timely surgical intervention resulted in complete recovery of vocal function. Difficulty in diagnosis is highlighted and early reported cases are discussed.

Keywords: Cyst in neck, parathyroid cyst, vocal cord paralysis


How to cite this article:
Lall A, Haque I, Kumar R, Sinha N, Sinha B, Dandekar M. Vocal cord palsy secondary to parathyroid cyst in the young: Rare case report with review of the literature. J Head Neck Physicians Surg 2017;5:90-2

How to cite this URL:
Lall A, Haque I, Kumar R, Sinha N, Sinha B, Dandekar M. Vocal cord palsy secondary to parathyroid cyst in the young: Rare case report with review of the literature. J Head Neck Physicians Surg [serial online] 2017 [cited 2019 Sep 15];5:90-2. Available from: http://www.jhnps.org/text.asp?2017/5/2/90/223761




  Introduction Top


The parathyroid cyst is a rare occurrence and generally encountered in the fourth to fifth decade.[1] Parathyroid cysts causing vocal cord palsy are exceptionally rare with only 13 cases reported to date.

When vocal cord paralysis occurs in the young, it generally results in spontaneous recovery in up to 50% of cases.[2] However, timely intervention can help resolve compressive unilateral recurrent nerve palsy.

We report the youngest case of hoarseness secondary to a parathyroid cyst with complete recovery after the active intervention. Comprehensive literature review of early reported cases is highlighted and diagnostic hurdles are discussed.


  Case Report Top


A 16-year-old female presented to the Outpatients Department with progressive change in the voice of 3 months duration. She had no other associated significant history. Clinical examination revealed a left-sided neck bulge of approximately four centimeters, diffuse, soft, with movement on deglutition. The thyroid gland was not separately palpable. On laryngoscopic examination, there was left-sided vocal paralysis. The patient was subjected to a computed tomography (CT) with contrast from the base skull to the mediastinum. CT picture revealed a smooth fluid filled, noncontrast enhancing cystic lesion corresponding to the left-sided tracheoesophageal groove causing mass effect on the trachea. Anatomical planes with the adjacent structures, namely, thyroid gland and esophagus were intact [Figure 1]. Serum calcium level was tested in view of the location of the lesion and was normal. A cytological examination was asked for which revealed clear, watery aspirate with no cellularity. The decision was taken for complete surgical excision. The lesion was approached through a horizontal skin crease incision. The cyst was encountered after retraction of the strap muscles lateral to the edge of the thyroid gland. The recurrent laryngeal nerve was compressed but intact and was traced until the point of entry [Figure 2]. Cyst was excised in toto after careful dissection. Histopathological examination of the specimen confirmed the diagnosis of the parathyroid cyst with a fibrocollagenous cyst wall lined by cuboidal to low columnar epithelial cells, many with clear cytoplasm and round nuclei. The patient was discharged on the 3rd postoperative day. Laryngoscopic examination 4 weeks after surgery demonstrated normal vocal cord function with symptomatic improvement in voice quality.
Figure 1: Axial (A) and coronal (B) images showing noncontrast enhancing solitary cyst along left-sided inferior pole of thyroid gland (C)

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Figure 2: Thin-walled cyst in relation to the recurrent laryngeal nerve

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  Discussion Top


We performed a literature search through PubMed. The search strategy included “parathyroid cyst,” “vocal paralysis,” “hoarseness,” and “recurrent laryngeal nerve paralysis” in various combinations along with cross references of articles. Each article was reviewed for case description of parathyroid cyst causing recurrent laryngeal nerve palsy. Our search revealed 13 cases of the parathyroid cyst with vocal cord palsy of which 9 were located in the mediastinum.[3] Of the four cases with cervical parathyroid cyst, three cases had documented recovery of the vocal function postoperatively. Details of the 13 patients are tabulated [Table 1].
Table 1: Previous reports of parathyroid cysts associated with vocal cord paralysis

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Mallette [15] theorized three types of parathyroid cysts based on their origin:

  1. Ontogenous parathyroid cyst (congenital)
  2. Coalescence parathyroid cyst (coalescence of microcysts) and
  3. Parathyroid pseudocyst (infarction with a parathyroid adenoma). Notwithstanding the congenital theory of the origin of the parathyroid cysts, they have been rarely reported in children.[16],[17] However, our case presenting at 16 years of age supports the congenital theory of origin.


Woo et al.[7] have reported a parathyroid cyst mandating intraoperative sacrifice of the recurrent laryngeal nerve probably due to engulfment of the nerve thus emphasising the need for timely intervention; prolonged compression of the cord further complicating the recovery. Parathyroid cyst can be functional but predominantly is known to be nonfunctioning as was in our case. In fact, the performance of parathormone levels in the cystic fluid aspirate can aid in the diagnosis irrespective of the functional status.[18],[19] A high degree of clinical suspicion is required in case of a clear, acellular aspirate prompting confirmatory parathormone assay.

While the patient responded to aspiration with some symptomatic relief, therapeutic aspiration is not routinely recommended in view of reaccumulation and potential infection.[20]


  Conclusion Top


Compressive vocal paralysis secondary to a parathyroid cyst is a rare phenomenon Timely diagnosis and intervention is the key to regain vocal function diagnosis is predominantly clinicoradiological with histological confirmation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ihm PS, Dray T, Sofferman RA, Nathan M, Hardin NJ. Parathyroid cysts: Diagnosis and management. Laryngoscope 2001;111:1576-8.  Back to cited text no. 1
    
2.
Grover N, Bhattacharyya A. Unilateral pediatric vocal cord paralysis: Evolving trends. J Laryngol Voice 2012;2:5-9.  Back to cited text no. 2
  [Full text]  
3.
Shields TW, Immerman SC. Mediastinal parathyroid cysts revisited. Ann Thorac Surg 1999;67:581-90.  Back to cited text no. 3
    
4.
Grey AB, Shaw JH, Anderson NE, Holdaway IM. Parathyroid cyst with recurrent vocal cord paresis. Aust N Z J Surg 1993;63:561-2.  Back to cited text no. 4
    
5.
Sen P, Flower N, Papesch M, Davis A, Spedding AV. A benign parathyroid cyst presenting with hoarse voice. J Laryngol Otol 2000;114:147-8.  Back to cited text no. 5
    
6.
Coelho DH, Boey HP. Benign parathyroid cyst causing vocal fold paralysis: A case report and review of the literature. Head Neck 2006;28:564-6.  Back to cited text no. 6
    
7.
Woo EK, Simo R, Conn B, Connor SE. Vocal cord paralysis secondary to a benign parathyroid cyst: A case report with clinical, imaging and pathological findings (2008:6b). Eur Radiol 2008;18:2015-8.  Back to cited text no. 7
    
8.
Crile G Jr., Perryman RG. Parathyroid cysts; report of five cases. Surgery 1953;34:151-4.  Back to cited text no. 8
    
9.
Beahrs OH, Devine KD. Unusual diagnostic problems in the neck. Surg Clin North Am 1961;41:1069-75.  Back to cited text no. 9
    
10.
Marco V, Carrasco MA, Marco C, Bauza A. Cytomorphology of a mediastinal parathyroid cyst. Report of a case mimicking malignancy. Acta Cytol 1983;27:688-92.  Back to cited text no. 10
    
11.
Takahashi E, Kohno A, Narimatsu A, Miyake H, Kimura F, Shigeta A, et al. A case of mediastinal parathyroid cyst. Rinsho Hoshasen 1988;33:393-6.  Back to cited text no. 11
    
12.
Delaunay T, Peillon C, Manouvrier JL, Deotto JF, Doucet J, Nicaise JM, et al. Cysts of the parathyroid glands. Apropos of 6 cases. Ann Chir 1990;44:231-5.  Back to cited text no. 12
    
13.
Coates G, Pearman K, Holl-Allen RT. Recurrent nerve palsy due to parathyroid cyst. Int Surg 1991;76:192-3.  Back to cited text no. 13
    
14.
Landau O, Chamberlain DW, Kennedy RS, Pearson FG, Keshavjee S. Mediastinal parathyroid cysts. Ann Thorac Surg 1997;63:951-3.  Back to cited text no. 14
    
15.
Mallette LE. The functional and pathologic spectrum of parathyroid abnormalities in hyperparathyroidism. In: Bilezikian JP, Levine MA, Marcus R, eds. The parathyroids. New York: Raven Press; 1994. p. 423.  Back to cited text no. 15
    
16.
Clark OH. Parathyroid cysts. Am J Surg 1978;135:395-402.  Back to cited text no. 16
    
17.
Petri N, Holten I. Parathyroid cyst: Report of case in the mediastinum. J Laryngol Otol 1990;104:56-7.  Back to cited text no. 17
    
18.
Absher KJ, Truong LD, Khurana KK, Ramzy I. Parathyroid cytology: Avoiding diagnostic pitfalls. Head Neck 2002;24:157-64.  Back to cited text no. 18
    
19.
Makino T, Sugimoto T, Kaji H, Yamaguchi T, Kitazawa R, Yamauchi M, et al. Functional giant parathyroid cyst with high concentration of CA19-9 in cystic fluid. Endocr J 2003;50:215-9.  Back to cited text no. 19
    
20.
Ferrara BE, Hazell S, Parker TH, Rutland ED. Parathyroid cyst. South Med J 1985;78:528-32.  Back to cited text no. 20
    


    Figures

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    Tables

  [Table 1]



 

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