Covid-19 Era Post Viral Vagal Neuropathy Presenting as Persistent Shortness of Breath with Normal Pulmonary Imaging

Authored by

Jonathan E Aviv

Clinical Professor of Otolaryngology,
Icahn School of Medicine at Mount Sinai, USA

Published Date
October 06, 2020

Published in the Journal of

International Journal of Pulmonary & Respiratory Sciences

Juniper Publishers INC.
3700 Park View Ln #12B Irvine,

CA 92612, USA

Opinion Int J Pul & Res Sci
Copyright © All rights are reserved by Jonathan E Aviv
Volume 4 Issue 4 - October 2020

DOI: 10.19080/IJOPRS.2020.04.555641

Covid-19 Era Post Viral Vagal
Neuropathy Presenting as Persistent

Shortness of Breath with Normal
Pulmonary Imaging

Jonathan E Aviv1*, Sujana Chandrasekhar2 and Byron Thomashow3

1Clinical Professor of Otolaryngology, Icahn School of Medicine at Mount Sinai, USA
2Clinical Professor of Otolaryngology, Zucker School of Medicine at Hofstra/Northwell, USA
3Clinical Professor of Medicine, Columbia University Medical Center, USA
Submission: September 24, 2020; Published: October 06, 2020
*Corresponding author: Jonathan E Aviv, Clinical Professor of Otolaryngology, Icahn School of Medicine at Mount
Sinai, Clinical Director of the Voice and Swallowing Center at ENT and Allergy Associates, New York, USA

Keywords: Pulmonary; Covid-19; Laryngoscopy; Viral vagal neuropathy; Otolaryngology

Opinion investigation, the flow volume loop showed
flattening of the inspiratory curve in all 4.
All that is shortness of breath is not
pulmonary.  We have identified a cohort of History revealed that the SOB was generally
18 outpatients in a general otolaryngology not waking these patients up at night nor
practice in New York City who presented was it affecting their exercise tolerance.
with persistent shortness of breath (SOB) Indeed, they often reported feeling breathing
despite normal pulmonary imaging. All difficulties  after  their activity.  Talking,
patients had cough, fever and SOB between shouting, singing, and odors typically brought
March 15 - May 15, 2020 during the height on the SOB.
of the COVID-19 pandemic in New York City,
with the SOB persisting for 4 - 12 weeks at On physical exam of the larynx with awake
the time of their presentation. 3/12 were video transnasal flexible laryngoscopy, all
positive for COVID-19 IgG antibodies, one of patients demonstrated that their vocal folds
whom also tested positive with a nasal swab were not moving in normal synch with their
polymerase chain reaction (PCR) assay. Due breathing, that is, they were closing more
to limited access, only 12 patients were able than 50% of their glottic airway during quiet
to obtain an antibody test and only 7 were respiration when they should be opening.
able to get the PCR test. Of the 4 patients who This abnormal vocal fold adduction could
had spirometry as part of their pulmonary also be elicited by having the patient say the

Int J Pul & Res Sci 4(4): IJOPRS.MS.ID.555641 (2020) 0075

International Journal of Pulmonary & Respiratory Sciences

5-word sentence “we see three green trees” retraining - and diet modification techniques.
and observing the vocal folds slowly closing The handful of foods and beverages less than
afterwards for as long as 9 seconds. We believe pH4 (Table 1) tend to aggravate the breathing
that the persistent vocal fold adduction gave issues so we recommended that they be
the patients their SOB. The flattening of the avoided.
inspiratory curve on spirometry corroborated
the laryngeal exam findings. This is different We feel that in a time of understandably
than laryngospasm where the vocal folds great emphasis on serial CT scans of the
suddenly slam shut for prolonged periods of chest to evaluate patients with persistent
time and gives a different symptom profile.   shortness of breath, offering this other,
emerging diagnostic possibility to account
This vocal fold dysfunction, or paradoxical for such symptoms may be helpful to the
vocal fold movement disorder [1], is a vagal clinician. In patients with persistent SOB,
neuropathy, often occurring after a viral with or without cough, where the pulmonary
illness. One of the reasons it has traditionally imaging is unremarkable whether or not
been difficult to make the diagnosis of post they tested positive for, or have antibodies to,
viral vagal neuropathy is that most people are Covid-19, but certainly with positive testing,
unable to recall that they had a viral illness, one should consider both a spirometry and
especially if the inciting event happened years an otolaryngology evaluation. This symptom
ago. In the time of coronavirus, patients seem complex may be due to a virus-related cranial
to be paying much more attention to when neuropathy which can be readily identified
they began to feel ill. with office laryngoscopic evaluation and
then treated, with restoration of premorbid
Our cohort was treated successfully with a functionality.
combination of physical therapy - respiratory

Table 1: Foods with less than pH4.

Flavored sodas
Bottled iced tea

Citrus
Tomato sauce (raw tomatoes okay)

Vinegar
Wine

References

1. Murry T, Branski RC, Yu K, Sabrina CB, Suzy D, et al. (2010)
Laryngeal sensory deficits in patients with chronic cough
and paradoxical vocal fold movement disorder. Laryngoscope
120(8): 1576-1581.

0076 How to cite this article: Aviv JE, Chandrasekhar S, Thomashow B. Covid-19 Era Post Viral Vagal Neuropathy Presenting as Persistent Shortness of
Breath with Normal Pulmonary Imaging . Int J Pul & Res Sci. 2020; 4(4): 555641. DOI: 10.19080/IJOPRS.2020.04.555641

International Journal of Pulmonary & Respiratory Sciences

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0077 How to cite this article: Aviv JE, Chandrasekhar S, Thomashow B. Covid-19 Era Post Viral Vagal Neuropathy Presenting as Persistent Shortness of
Breath with Normal Pulmonary Imaging . Int J Pul & Res Sci. 2020; 4(4): 555641. DOI: 10.19080/IJOPRS.2020.04.555641