Unilateral Vocal Cord Paresis Caused by Diffuse Idiopathic Skeletal Hyperostosis: Case Report and Literature Review
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsDear Author,
Many thanks for allowing to read this interesting case report. It is very interesting case reports. The DISH I have seen have large central osteophytes but lateral osteophytes causing vocal cord palsy is surely unusual and rarity .
The paper reads well and an interesting case report. I have no concerns regarding the content or presentation.
My main concerns are, both these patients have been referred to the spine surgeons , what was the outcome . Were they offered surgery, it seems this should be the case as the osteophyte has already caused a cranial nerve palsy. It will be good to have a conclusion to the problem . Were they not offered surgery because of age or patients choice, this needs to be mentioned .
Minor issues
- page 1 line 37, I am confused what do the authors mean by immobilisation and paresis. Do you infer that immobilisation is complete lack of movement and paresis partial movement ? Immobilisation is term also used for cricoarytenoid joint ankylosis causing fixed cords
- Was EMG considered, it may not have changed the management
- why was no medialisation performed in the younger patient , was it due to low VHI ? or patient preference
- why was carboxymethylcellulose gel used for medialisation, is this not a temporary method . Where as calcium hydroxy appatite is permanent
Author Response
Comments 1: My main concerns are, both these patients have been referred to the spine surgeons , what was the outcome Were they offered surgery, it seems this should be the case as the osteophyte has already caused a cranial nerve palsy. It will be good to have a conclusion to the problem . Were they not offered surgery because of age or patients choice, this needs to be mentioned .
Response 1: Thank you for your comment! For Patient A, he was sent to orthopedic surgeon but patient and surgeon are deferring osteophytectomy for now . Patient and orthopedic surgeon will follow up to consider further intervention. For Patient B, she has not been seen since summer 2024 and I do not see an orthopedics follow up visit. The patient did not wish to seek further management for her dysphonia and paresis due to the mild nature of her symptoms at this time. We have added the text in the manuscript on Page 2 Line 68-69 and Page 3 Line 99-100 to reflect this: The patient did not elect for further management of his osteophytes at this time.
Comments 2: page 1 line 37, I am confused what do the authors mean by immobilisation and paresis. Do you infer that immobilisation is complete lack of movement and paresis partial movement ? Immobilisation is term also used for cricoarytenoid joint ankylosis causing fixed cords
Response 2: Thank you for your comment! We agree that defining the terms is needed and have added the following text in the manuscript to reflect this at Page 1 Line 38-40: Vocal fold immobilization is defined as complete lack of movement (which can be due to complete paralysis or joint ankylosis) whereas vocal fold paresis is defined as partial movement.
Comments 3: Was EMG considered, it may not have changed the management
Response 3: Thank you for your question! EMG was not considered as our practice is to perform EMG for immobility cases ideally within 1 year of injury in order to predict chance of recovery from injury. Due to the nature of the patients' dysphonia we did not believe that EMG would significantly change management.
Comments 4: Why was no medialisation performed in the younger patient , was it due to low VHI ? or patient preference.
Response 4: Thank you for your question! No injection was performed due to low VHI and patient preference to defer care for her mild dysphonia.
Comments 5: Why was carboxymethylcellulose gel used for medialisation, is this not a temporary method . Where as calcium hydroxy appatite is permanent.
Response 5: Thank you for your question! Calcium hydroxylapatite was offered to the patient but he refused and instead elected for carboxymethylcellulose gel. The patient is educated regarding injectable choices and continues to elect for carboxymethylcellulose gel.
Reviewer 2 Report
Comments and Suggestions for AuthorsThis is a case report describing a very rare cause of unilateral vocal cord paresis in two patients: cervical spine osteophytes associated with Forestier’s disease.
The manuscript is clearly written, well documented with photographs, and not too long. I would suggest only one minor change in the text:
Row 130 – I don’t like the term “nerve mobility” at all. Do nerves in our body have the opportunity to move? Please, rephrase this sentence.
Author Response
Comments 1: Row 130 – I don’t like the term “nerve mobility” at all. Do nerves in our body have the opportunity to move? Please, rephrase this sentence.
Response 1: Thank you for your comment! We have adjusted the language in our text and rephrased. This can be found at page 5 line 134: Over time, this may compromise the nerve's blood supply and function, leading to neuropraxia or axonotmesis and manifesting as progressive paresis
