A 63-year-old soprano who was incapacitated for work presented for a phoniatric consultation due to an 11-year history of gradually progressive loss of head voice. Laryngeal videostroboscopy revealed flaccid vocal folds with glottic insufficiency in the chest voice register and bilateral inability to elongate when transition to the head voice was attempted (left Figure). The patient’s voice range profile was significantly reduced, given that notes above the central passaggio (from D#4) could no longer be formed. Ultrasound of the neck showed hypoechoic, atrophic cricothyroid muscles on both sides together with hypoechoic, inhomogeneous parenchyma of the two atrophic lobes of the thyroid in the setting of Hashimoto’s thyroiditis that had been known for decades and was under L-thyroxine replacement therapy (right Figure). Transcutaneous laryngeal electromyography of the cricothyroid muscles confirmed the diagnosis of bilateral paralysis of the external branch of the superior laryngeal nerve (EBSLN) with classic signs of denervation. The case described here suggests that, in addition to cervical trauma, chronic inflammatory processes in this immediate anatomical vicinity may also be a cause of EBSLN lesions. Due to the lack of restorative treatment options for EBSLN paralysis, we recommend regular phoniatric monitoring for professional singers with Hashimoto’s thyroiditis. Timely (“prophylactic”) neuromonitoring-guided thyroidectomy for head voice preservation is open to critical discussion, taking into account the risk of intraoperative damage to the recurrent laryngeal nerve.

Figure

a) laryngeal videostroboscopy image showing incomplete glottic closure in the chest voice register and unsuccessful vocal fold elongation during attempted phonation in the head voice in bilateral paralysis of the external branch of the superior laryngeal nerve (EBSLN). b) ultrasound overview image of the left lobe of the thyroid in the transverse plane with evidence of atrophic, hypoechoic and inhomogeneous parenchyma (arrow) in chronic Hashimoto’s thyroiditis.

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Dr. med. M. Sc. Martin J. P. Kampmann, Prof. Dr. med. Philipp P. Caffier, Klinik für Audiologie und Phoniatrie, Charité – Universitätsmedizin Berlin, Germany

Dr. med. M. Sc. Martin J. P. Kampmann, Prof. Dr. med. Philipp P. Caffier, Klinik für Audiologie und Phoniatrie, Charité – Universitätsmedizin Berlin, martin.kampmann@charite.de

Prof. Dr. med. Thomas Steinmüller, Zentrum für endokrine Chirurgie Westend, Klinik für Allgemein-, Viszeral- und Minimalinvasive Chirurgie, DRK Kliniken Berlin

Conflict of interest statement: The authors state that no conflict of interest exists.

Translated from the original German by Christine Rye.

Cite this as: Kampmann MJP, Steinmüller T, Caffier PP: Loss of head voice function in long-standing Hashimoto’s thyroiditis. Dtsch Arztebl Int 2024; 121: 881. DOI: 10.3238/arztebl.m2024.0202