An 18-year-old female with a history of vocal cord nodules, chronic laryngitis, gastroesophageal reflux disease (GERD), and muscle tension dysphonia presented with a two-month history of acute dysphonia. Two months prior to arrival, the patient became infected with the SARS-CoV-2 virus verified by a positive rapid antigen test. The patient experienced symptoms of headache, fatigue, muscle aches, cough, and acute dysphonia during her infection. All symptoms resolved after 10 days except for the acute dysphonia. The infection was treated at home with over-the-counter acetaminophen and ibuprofen. On presentation, her voice was slowly returning; however, she was having trouble projecting and continued to have dysphonia. The patient was experiencing daily aspiration episodes if she was not cautious while drinking liquids. Videostroboscopy revealed findings consistent with right true vocal fold paralysis (Figure 1), and a CT scan of the neck found no evidence of occult malignancies or the mass effect that could have caused the paralysis.
The patient's voice history is significant for prior vocal cord dysfunction. At 13 years of age, the patient was seen for persistent hoarseness accompanied by nasal congestion and GERD. Laryngoscopy revealed bilateral erythema of the vocal cords and a small nodule on the right vocal cord. The patient was diagnosed with chronic laryngitis caused by overuse and reflux disease and was prescribed reflux medications, speech therapy, and steroids. At 16 years of age, the patient returned to be seen for hoarseness. The patient described her voice as low-pitched, scratchy, strained, and effortful. Nasal congestion and heartburn were also noted in the patient's review of systems. The patient was prescribed reflux medications and vocal rest and was referred to a laryngologist for speech evaluation. Upon referral to the voice clinic, the laryngologist noted that the patient complained of a raspy voice since childhood due to her being a "loud talker" and frequently overusing her voice. The laryngologist described her voice as rough, breathy, and strained. The patient's voice received a 20/40 on the Voice Handicap Index (VHI). Laryngeal function studies were performed, and the patient was noted to have decreased breath support and a significantly strained voice consistent with muscle tension dysphonia. Videostroboscopy revealed nodules on the left and right vocal cords, an hourglass glottic closure, and anteroposterior compression. The patient was diagnosed with normal vocal mobility, muscle tension dysphonia, and vocal cord nodules, and the patient was referred to speech therapy. Over the following two years, the patient improved steadily with speech therapy until she became infected with SARS-CoV-2, at that point she lost her voice completely. Interestingly, the patient's vocal cord nodules seemed to have resolved during the VCP. This finding could be a result of her inability to use her voice while her vocal cords were paralyzed, effectively forcing her to observe vocal rest, or the nodules persisted but were masked by edema due to the infection. The patient recovered without any medical or surgical treatment for VCP. Since her recovery, the patient has had complete return of vocal cord mobility and vocal cord nodules.