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Case report
Bilateral vocal fold paresis: the only presenting sign of anti-MUSK antibody myasthenia gravis
  1. Sam Arman1,
  2. Norman Kock2,
  3. George Mochloulis1 and
  4. Gorande Kanabar3
  1. 1ENT, Lister Hospital, Stevenage, UK
  2. 2Neurology, Lister Hospital, Stevenage, UK
  3. 3Neurophysiology, Hertford County Hospital, Hertford, UK
  1. Correspondence to Sam Arman; sam.arman{at}


A previously fit and well 53-year-old man was referred to the otolaryngology clinic with intermittent stridor and was found to have bilateral vocal fold paresis. Subsequent airway compromise necessitated emergency surgical tracheostomy. The man was discharged home with tracheostomy in situ and a diagnosis of idiopathic bilateral vocal cord palsy, as all primary investigations were negative. Neurological disease was suspected following readmission to hospital several weeks later with diplopia. Electromyography and serum antibody testing confirmed a diagnosis of anti-muscle-specific tyrosine kinase antibody positive myasthenia gravis (MuSK-MG); a subset of MG where autoantibodies are directed against MuSK. Resolution of bilateral vocal fold paresis was found 8 months after a short course of immunoglobulin (intravenous immunoglobulin (IVIg)) and daily mycophenolate therapy was commenced. Multidisciplinary teamwork between ear, nose and throat surgeons, neurologists and speech therapists enabled successful decannulation of tracheostomy. The patient has recovered well and remains minimally symptomatic.

  • ear, nose and throat/otolaryngology
  • neurology

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  • Contributors All authors have approved the manuscript and this submission. All authors were involved in the diagnosis and management of the patient within the report. All additional authors have been involved with writing the paper. SA was lead author and was in charge of data collection, analysis, literature review and final editing of the paper. NK was the lead neurologist caring for the patient and was responsible for initial investigations and the long-term management of the patient. He has gained consent from the patient for publication in BMJ. He is also taken a large role in proof-reading and editing the paper. GM was consultant in-charge of care for patient during surgery and further ongoing tracheostomy care. He was involved in writing and editing the paper. GK was the neurophysiologist who diagnosed the patient via electromyography and was involved in proof-reading and editing the case section of the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.