A Lecture on some Points in Relation to the Diagnostic Significance and Therapeutic Indications of Laryngeal Symptoms Resulting from Pressure of Aneurysms upon the Vagus and Re-Current Laryngeal Nerves
Authors: D. Newman
Journal: BMJ (1887)

IT will be my endeavour to show by reference to cases of aortic and innominate aneurysm: First, that aneurysm of aorta and innominate artery may exist and give rise to laryngeal symptoms only, but in most instances, on critical physical examination, certain collateral signs may be made out sufficient to warrant one in forming a positive dia- gnosis, or to give rise to a very strong suspicion of an intra-thoracic tumour.Second, that in the early stage pressure may cause paroxysms of most urgent dyspncea, accompanied by laryngeal stridor and paroxysmal cough.Third, that at a later stage paralysis occurs usually, but not always, limited to one side, characterised by phonative waste of breath and imperfect cough, but without dyspucea, except when reflex spasm is indicated on the opposite side, or when pressure- stenosis is caused by the aneurysm.Fourth, that in certain cases tracheotomy should be performed not only to prevent impending death from asphyxia, but also as a remedial measure.In this paper it is not my intention to consider the various causes of paralysis of the vagus or recurrent laryngeal nerves, but it may be mentioned that paralysis results from a multitude of conditions, for example, enlargement of the thyroid body or of the bronchial glands, intra-thoracic tumours, growths in the cesophagus, pleuritic adhesions at or fibroid induration of the apices of the lngs, and certain diseases of the heart which lead to displacement, sucs as hypertrophy or great pericardial exudation.These and other rarer lesions have come to be recognised as Possible causes of unilateral or bilateral recurrent paralysis, and mustgtherefore be held in view in forming an opinion respecting the pathology of a case.On account of the relationship of the left recurrent laryngeal nerve to the arch of the aorta, it is especiaully exposed to pressure by aneurysms, enlarged bronchial glands, or tumour within the mediastinum, while, on the other hand, the nerve on the right side, because of its proximity to the apex of the right lunR and to the innominate artery, is more apt to be included in fibroid induration of the apex, pleuritic adhesions, or aneurysm of the innominate artery.The disturbances which may lead to paralysis cannot be considered in detail, but we must now endeavour to answer the first question proposed for discussion, namely, the fact that an aneurysm of the aorta may give rise to laryngeal symptoms only.The word " 8ymptoms " is used in contra-distinction to "physical signst," for this reason.It is because of some particular disturbance of function that a patient seeks medical advice, and it has been found at the Oat-door Department for Diseases of the Throat at the Glasgow Royal Infirmary, that patients have been sent by their medical attendants, or bave come of their own accord, seeking relief from what they re- garded to be a throat affection and nothing else, but which ultimately 11383] proved to be disturbance of the voice as a consequence of impairment of tho function of the muscles supplied by the rocurnt larygeal nerve.The purpose of this paper is to represent the general and important facts, and indicate the conclusions which may be arived at respecting what may be described as the gross characteristics of the lesion, the finer distinctions being left out of account, or only briefly alluded to, when they have a direct bearing upon the question under discussion.With these preliminary remarks the history of the cases from which deductions have been drawn may now be given.CASE I. AneUrysM of Innominate Artery and Descending Aorta: Paroxysmal Dyspnwa fom Unilateral Spasm of Right Vocal Cord, followed three months after by Bilcral Spasm of Adductors, and at a more remote date by Bilateral Paralysis of Addudtors: Dysphagia and Laryngeal Symptoms only early Evidences of Aneurtysm: Appropri.ate Treatment reco,nmended but not carried out: Increwe in Size of Aneurysm: Death from direct Pressure of Ancurysmt upon Trachea.-J.K., aged 45, is a particularly interesting case in many respect., ~I