sternoclavicular joint septic arthritis ( ssa ) and its clinical presentation are infrequently seen and often difficult to manage .
presenting symptoms of ssa can vary , with chest and shoulder pain being the most common clinical features .
after thorough literature search , no cases have yet been reported on ssa leading to vocal cord palsy .
vocal cord palsy is an important sign of thoracic and head and neck pathology that is caused by an extremely wide set of pathology .
a 67-year - old gentleman presented to the emergency department with a 3-week history of worsening dysphagia and hoarse voice .
routine examination of the patient in the emergency department revealed that he was haemodynamically stable and apyrexial and exhibited tenderness in the left anterior neck .
examination by the otolaryngology team demonstrated no evidence of cervical lymphadenopathy but tenderness of the lower left anterior triangle , as well as evident swelling , erythema and mild bruising of the anterior chest wall . on questioning the patient regarding this , he revealed that he burnt his chest using a hot water bottle 3 weeks previously and he also admitted to having stiffness and pain in the left shoulder over this same period .
indirect laryngoscopy with flexible nasendoscopy revealed non - discrete swelling / oedema of the left pharayngeal wall and reduced mobility of the left vocal cord .
routine haematological investigation revealed a white cell count of 18.6  10/l , c - reactive protein of 288 mg / l and platelets of 499  10/l .
no other haematological abnormality was noted on admission . with a working differential of parapharyngeal space infection and possible malignancy ,
the patient was referred for a computed tomography ( ct ) scan of the neck and thorax with contrast .
the patient was also started empirically on intravenous co - amoxiclav as treatment for neck space collection .
ct imaging , performed 24 h after admission , revealed no evidence of malignancy or indeed any paraphayrngeal space collection .
few small lymph nodes were noted on the left side of the neck , but were deemed to be reactive in nature , and left vocal cord palsy was evident ( fig .  1 ) .
the key finding was that of a left sternoclavicular joint collection and closely associated superficial anterior chest wall , soft tissue swelling and oedema ( fig .  2 ) .
this inflammatory process was also noted deep to the manubrium and sternum and extending somewhat into the mediastinum with evident enlarged mediastinal lymph nodes ( fig . 
the ct findings were in keeping with ssa with associated superficial and deep tissue inflammation and oedema . with no other
cause found , the vocal cord palsy was attributed to the inflammation within the mediastinum , which in turn was caused by superficial burn from hot water bottle use . 

findings : left vocal cord palsy indicated by the para - median position of the left vocal cord in comparison with the right .
findings : left sternoclavicular joint collection and closely associated superficial anterior chest wall , soft tissue swelling and oedema .
findings : soft tissue oedema of the chest seen retrosternally ( marker a ) and superficially on the left anterior chest ( marker b ) as well as evidence of mediastinal lymph node enlargement .
computed tomography . a 67-year - old male with ssa . findings : left vocal cord palsy indicated by the para - median position of the left vocal cord in comparison with the right .
findings : left sternoclavicular joint collection and closely associated superficial anterior chest wall , soft tissue swelling and oedema .
computed tomography . a 67-year - old male with ssa . findings : soft tissue oedema of the chest seen retrosternally ( marker a ) and superficially on the left anterior chest ( marker b ) as well as evidence of mediastinal lymph node enlargement .
the antibiotic regimen for the patient was converted to intravenous benzylpenicillin ( 1.2 g four times per day ) and flucloxacillin ( 1 g four times per day ) .
response to antibiotic therapy was limited in the first few days of admission with little change in haematological inflammatory markers .
after discussion with the microbiologist , the flucloxacillin was increased to 2 g four times a day on the fourth day of admission .
the patient made slow but positive improvements over the course of the next 8 days while on intravenous antibiotics , after which he was successfully discharged .
he continued on oral antibiotics and on outpatient review 3 weeks after his admission , his external swelling , erythema and voice had returned to normal .
repeat ct performed 3 months following discharge demonstrated complete resolution of the deep and superficial inflammatory process as well as the mediastinal lymph nodes .
vocal cord palsy can be due to weakness in one or both vocal cords , and diagnosis is made when reduced mobility is evident by laryngoscope examination . in a review of 117 cases ,
benninger et al .   attributed the following as the most common causes of vocal cord palsy : surgical trauma ( 44% ) , malignancies ( 17% ) , endotracheal intubation ( 15% ) , neurological disease ( 12% ) and idiopathic causes ( 12% ) .
furthermore , a review of 389 vocal cord palsy cases by holinger et al .   makes no reference to the cause being related to a septic sternoclavicular joint .
explanations for this unusual presentation of ssa seen in this case include tracking infection from the septic sternoclavicular joint , resulting in a vocal cord palsy due to reactive mediastinal lymphadenopathy . spreading infectious sequeale of ssa
significant contributing factors to these outcomes are the methicillin - resistant staphylococcus aureus ( mrsa ) strains , which are becoming increasingly prevalent .
a literature review of 180 cases shows mediastinitis as a clinical feature in up to 13% of patients with ssa .
reports of fibrosing mediastinitis and descending necrotizing mediastinitis leading to vocal cord palsy have been documented .
the mild reactive mediastinal inflammation seen in the presented case has not been presented in the literature as a cause of vocal cord palsy .
therefore , as mentioned previously , it is most likely explained by mediastinal lymphadenopathy , which is a known cause of left vocal cord palsy in malignancy and atypical infections such as tuberculosis .
it has been shown that if radiological findings indicate a limited extent of disease , then medical therapy alone should be sufficient .
this empirical antibiotic coverage should be active against s. aureus , the most common infective agent in ssa .
joint resection would only be indicated if extensive bony destruction , chest wall phlegmon or abscess , retrosternal abscess , mediastinitis or pleural extension is evident on ct / mri imaging .
it is clear from the haematological and radiological findings , as well as the response to treatment , that all the presenting features of this patient were as a result of the septic focus in the sternoclavicular joint .
 sternoclavicular joint septic arthritis ( ssa ) is rare and often difficult to manage condition . 
 the sternoclavicular joint is an unusual site of septic arthritis in healthy persons , but may be commonly involved in intravenous drug users , primary or secondary immunosuppressive disorders , infections or the presence of infected central lines . after thorough literature search , no cases have yet been reported on ssa leading to vocal cord palsy . 
 the following case describes a male patient who presented to hospital with left vocal cord palsy and symptoms consistent with aero - digestive tract malignancy . 
 radiological examination and subsequent response to treatment demonstrated the only causative pathology to be an ipsilateral septic sternoclavicular joint . 