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I read with interest the piece by Morgan and coauthors regarding hoarseness of unclear origin in adults.[1] The authors, from a division of otolaryngology, are rightly concerned about clinicians overlooking hoarseness as an early feature of laryngeal cancer, and they are to be commended for highlighting this subtle, but sometimes ominous, sign.
Though laryngeal cancer is indeed one worrisome cause of hoarseness, a newly hoarse voice can be ominous for other reasons too – one of which is brainstem ischemia. One very common brainstem stroke syndrome, the lateral medullary (Wallenberg) syndrome, consists of the sudden-onset of a constellation of neurological deficits, including: hoarseness, ataxia, vertigo, dysphagia, ipsilateral Horner syndrome (miosis, partial ptosis, anhidrosis), hiccups, vomiting, and ipsilateral facial numbness with crossed (contralateral) body numbness. Hoarseness occurs in fully 55% of patients with lateral medullary syndrome.[2]
When the infarct in the lateral medulla is small, however, the clinical syndrome is often incomplete. It may therefore be difficult for clinicians who are assessing hoarseness to spot the syndrome in its partial form.[3] First, hoarse voice is the predominant presenting symptom of lateral medullary ischemia in some cases, with other more subtle signs evident only upon neurological examination;[4,5] furthermore, hoarseness can persist chronically even after other symptoms have resolved.[4] Second, when lateral medullary ischemia also causes dysphagia or vomiting,[5,6] it can be easy to overlook hoarseness as the independent neurological sign it sometimes is, and to inappropriately ascribe it to gastroesophageal reflux disease or aspiration.
The lateral medullary syndrome – like laryngeal cancer – is crucial to recognize early, because any delay in diagnosis put patients at risk for potentially fatal recurrent brainstem ischemia related to vertebral artery dissection or atheroembolism. For this reason, any patient presenting to their family physician with new hoarseness, whether chronic or sudden and acute, should undergo a neurological examination with, at minimum, a search for pupillary asymmetry, nystagmus, finger-to-nose dysmetria, or gait ataxia. While a referral to otolaryngology for laryngeal examination is certainly an important step in the diagnosis of isolated hoarseness of unclear origin in adults, one must first be certain the hoarseness is truly isolated to avoid introducing a dangerous delay in the management of what may be a neurological emergency instead.
REFERENCES
1. Morgan AP, Rigby MH. Hoarseness of unclear origin in adults. CMAJ. 2018; 190:E80. doi: 10.1503/cmaj.170660
2. Kim JS, Lee JH, Suh DC, Lee MC. Spectrum of lateral medullary syndrome. Correlation between clinical findings and magnetic resonance imaging in 33 subjects. Stroke. 1994; 25:1405-10.
3. Ogawa K, Suzuki Y, Oishi M, Kamei S. Clinical study of 46 patients with lateral medullary infarction. J Stroke Cerebrovasc Dis. 2015; 24:1065-74.
4. Baugh CW, Brown DF, Nadel ES. Horner’s syndrome, hoarseness, and unsteady gait. J Emerg Med. 2009; 36:176-80.
5. Roldan-Valadez E, Juarez-Jiminez H, Corona-Cedillo R, Martinez-Lopez M. Gac Med Mex. 2007; 143:429-32.
6. Castillo AL, Barahona-Garrido J, Criales S, Chang-Menendez S, Torre A. Wallenberg’s syndrome: an unusual cause of dysphagia. Case Rep Gastroenterol. 2007;1:135-43.