Suicide is a worldwide phenomenon which is a second leading cause of mortality in adolescents¹. Hanging is one of the most common methods of suicide, as it is a relatively easy method of achieving the goal of suicide¹.

Survival from hanging is often associated with various complications including cerebral hypoxia, airway obstruction, bony fracture, pulmonary complications and other neurologic sequelae². However, development of dysphagia after non-lethal suicidal hanging has not been described widely in the literature and most reports are of single cases^3,4.

We report a case of a 17-year-old man who presented with dysphagia after non-lethal suicidal hanging.

A 17-year-old male had an argument with his mother at home and he then attempted suicide by hanging himself with a power cord tied around his neck. He was soon discovered and transferred to our hospital’s emergency department. During transportation, he developed cardiac arrest, but normal rhythm was successfully restored after 4 minutes of cardiopulmonary resuscitation.

As he was in a semi-comatose state upon arrival, the emergency medicine physician applied endotracheal intubation. He was then admitted to our intensive care unit for further management. The endotra-cheal tube was extubated on day 5 after admission after he became medically stable, and his mental status improved. He showed intact cognitive function (Mini-Mental Status Examination score: 30). Brain magnetic resonance imaging (MRI) showed no significant lesion, which implied hypoxic brain injury in the cerebral hemisphere, cerebellum, brainstem, ventricle, and extra-axial space.

However, when he was allowed to drink 3 ml (half a teaspoon) of water, he complained of dysphagia with aspiration. Examination of the major cranial nerves showed no abnormalities including movement of the tongue and soft palate. Apart from swallowing, there were no abnormalities of motor function and activities of daily living, except for hoarseness of voice. To evaluate dysphagia, a computed tomography (CT) scan was performed, which showed a patent airway and no abnormalities on cervical spine and soft tissue. Impaired bilateral vocal cord movement was seen by an otolaryngologist using a laryngeal fiberscope.(Fig. 1A, B)

Figure 1. Laryngeal fiberscope findings showing impaired bilateral vocal cord movement. (A, B) Vocal cord paralysis with incomplete glottic closure (arrow) and pooling of saliva in piriform sinus were observed 6 weeks after onset. (C, D) Improvement in vocal cord paralysis was observed 14 weeks after onset. (E, F) Improvement in vocal cord paralysis showing complete glottic closure (arrow) without saliva pooling was observed 20 weeks after onset.

The patient was referred to the department of rehabilitation for Videofluoroscopic. Swallowing Study (VFSS). A compression scar caused by a cord line was still seen on his neck at that time. As all nutrition and hydration was received via levin tube, the American Speech Language Hearing Association National Outcomes Measurements System Swallowing Scale (ASHA- NOMS) was 1. Initial VFSS and motor nerve conduction study were performed 4 weeks after onset.

During VFSS, the patient was allowed to ingest yogurt and liquid with barium. Normal findings were seen in the oral phase: spontaneous posterior falling of bolus due to delayed swallowing reflex. Vallecular remnant even after repeated swallowing and incomplete laryngeal elevation was seen in the pharyngeal phase.(Fig. 2A, Supplementary Video 1) Aspiration with liquid of penetration aspiration scale (PAS) 7 was seen during the swallowing phase.(Fig. 2B, Supplementary Video 2)

Figure 2. Findings of the initial and subsequent video fluoroscopic study of swallowing. The examination was performed after ingestion of barium containing yogurt and liquid. Initial VFSS finding presented (A) vallecular remnant with yogurt after repeated swallowing and (B) aspiration with liquid. Subsequent VFSS which was performed 12 weeks after initial evaluation, presented (C) near cleared vallecular remnant with yogurt after repeated swallowing and (D) penetration (PAS 5) with liquid.

Brain lesion and cervical abnormality were ruled out by imaging studies. To evaluate the etiology of incomplete bilateral vocal cord palsy and impaired laryngeal elevation, recurrent laryngeal nerve conduction studies were done according to the protocols of a previous study⁵. The recording electrode was attached on the thyroarytenoid muscle, and electrical stimulation was applied 3 cm below the lower margin of cricoid cartilage. The peripheral motor nerve conduction study showed prolonged latency (6.3 ms) and low amplitude (0.1 mV) of compound muscle action potential (CMAP) at the right recurrent laryngeal nerve and no response of CMAP at the left recurrent laryngeal nerve. (Fig. 3A, B) These findings are suggestive of bilateral recurrent laryngeal nerve injuries at or around the wound site. Conventional laryngeal electromyography was refused by the patient due to fear.

Figure 3. Waveforms of evoked potentials in the initial recurrent laryngeal nerve conduction study showing (A) prolonged latency (6.3 ms) and low amplitude (0.1 mV) of CMAP at the RIGHT recurrent laryngeal nerve; (B) no response of CMAP at LEFT recurrent laryngeal nerve. These findings are suggestive of bilateral recurrent laryngeal nerve injury, especially showing conduction block at LEFT side. Subsequent recurrent laryngeal nerve conduction study was performed 14 weeks after initial evaluation, showing (C) prolonged latency (5.0 ms) and low amplitude (0.1 mV) of CMAP at the RIGHT recurrent laryngeal nerve and (D) prolonged latency (8.1 ms) and low amplitude (0.1 mV) of CMAP at the LEFT recurrent laryngeal nerve; CMAP at LEFT recurrent laryngeal nerve, which was not observed in the previous study, was observed, which was consistent with clinical improvement.

Referring to previous studies, we applied dysphagia rehabilitation approaches⁶. The following rehabilitation exercises were taught to the patient and his parent, performed 20 times per day, including supraglottic swallowing, neck strap muscle strengthening exercise (such as shaker exercise), and Mendelsohn’s maneuver. Thick semisolid was edible by the supraglottic swallowing method. However, in the beginning, he could not perform shaker exercise due to severe neck flexor and hyoid elevator muscle weakness, and aspiration continued despite the Mendelsohn’s maneuver being done.

After discharge, the patient was regularly checked at the outpatient clinic for recovery of the recurrent laryngeal nerve and improvement of symptoms of dysphagia. Subsequent VFSS was performed 12 weeks after initial evaluation, presenting near cleared vallecular remnant with yogurt (PAS 1) and penetration (PAS 5) with liquid.(Fig. 2C, D) Subsequent recurrent laryngeal nerve conduction study was also performed 14 weeks after initial evaluation, showing prolonged latency (8.1 ms) and low amplitude (0.1 mV) of CMAP at the left recurrent laryngeal nerve, which was not observed in the previous study.(Fig. 3C, D) Subsequent laryngeal fiberscope evaluation was performed 14 and 20 weeks after onset, presenting improvement in vocal cord paralysis.(Fig. 1C-F) After 16 weeks of onset, the symptoms of dysphagia have improved (ASHA-NOMS 5) and then, Levin tube was removed. Improvement of subsequent VFSS, fiberscopic finding and motor nerve conduction study were consistent with clinical improvement.

Dysphagia have been reported in some cases of survival after hanging². Various underlying etiologies can cause dysphagia, including hypoxic brain damage and cord injury. Although hypoxic brain damage and tissue damage of larynx were initially considered, CT, MRI, and endoscopic examination confirmed no evidence of central lesions and injury to the vocal cord or larynx. A motor nerve conduction study was suggestive of bilateral recurrent laryngeal nerve injuries. In this case, vocal cord paralysis and dysphagia due to incomplete laryngeal elevation were considered attributable to compression of the recurrent laryngeal nerves by a cord wrapped around the neck.

Laryngeal electromyography including cricothyroid muscle was attempted to differentiate vagus and superior laryngeal nerve injury, but there was limitation due to patient’s fear. However, clinically, symptoms of the patient correlated better with the injury of the recurrent laryngeal nerve; such as sensory impairment below the vocal cord level, location of the scar, and hoarseness. Therefore, motor nerve conduction study to recurrent laryngeal nerve was performed to confirm the injury of the nerve.

The recurrent laryngeal nerve can be affected in various situations which can cause compression to the recurrent laryngeal nerve, commonly to the left recurrent laryngeal nerve⁷. Injury to the recurrent laryngeal nerve would cause paralysis of all intrinsic muscles of the larynx except the cricothyroid muscle, which result in vocal cord paralysis⁷.

Injury to the recurrent laryngeal nerve can cause life threatening complications, including pulmonary aspiration, obstruction of the airway, and can also result in hoarseness of voice, which affects quality of life⁸. Symptoms may vary depending on the site and severity of compression to the neck.

We presented a case of dysphagia due to failure of laryngeal elevation and vocal cord adduction by recurrent laryngeal nerve injury after suicidal hanging. Improvement of subsequent VFSS, fiberscopic finding and motor nerve conduction study were observed, which were consistent with clinical symptom. These findings suggested neuropraxia recovery after transient recurrent laryngeal nerve injury.  

Supplementary data including two videos can be found with this article online at https://doi.org/10.34160/jkds.2022.12.2.008.

Supplementary Video 1. Fluoroscopic barium swallow examination (yogurt).

Supplementary Video 2. Fluoroscopic barium swallow examination (liquid).

The authors have no potential conflicts of interest to disclose.

Woo In Choi initiated the case report after reviewing the literature and wrote the first draft of the manuscript, Hyoung Seop Kim reviewed and revised the manuscript critically and was a major contributor to the discussion of the case report. All authors read and approved the final manuscript.