Anesth Pain Med 2012; 7: 67～70 ￭Case Report￭
Transient unilateral vocal cord paralysis following endotracheal intubation in elderly patient with the abdominal surgery -A case report-
Department of Anesthesiology and Pain Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
Mee Young Chung, Ji-Young Lee, Eun-jeong Cho, Chang Jae Kim, Jong-tae Jeong, Jun Seuk Chea, and Byung Ho Lee
Vocal cord paralysis is one of the most serious complications, which, in most situations, is preventable, associated with tracheal intubation. Unilateral vocal cord paralysis following tracheal intuba- CASE REPORT tion usually causes hoarseness. Postoperative vocal cord paralysis may be due to mechanical or neurogenic factors. The patient A 71-year-old man, 74 kg in weight, and 168 cm in height, complained of hoarseness one day after operation and coughing entered the hospital via emergency room with a history of on swallowing water ten days after operation. The vocal cords were abdominal distension and vomiting. He was diagnosed with examined with a fiberoptic nasopharyngolaryngoscopy and the right vocal cord was fixed in the paramedian position. We present a descending colon carcinoma and left renal cell carcinoma and case of unilateral vocal cord paralysis following endotracheal admitted for left hemicolectomy and left nephrectomy. There intubation in a 71-year-old male patient with descending colon was no significant past medical history except for lumbar carcinoma and left renal cell carcinoma. (Anesth Pain Med 2012; discectomy thirteen years before. The preoperative physical 7: 67∼70) examination, blood tests, electrocardiogram, pulmonary function Key Words: Coughing, Hoarseness, Tracheal intubation, Vocal test, and echocardiography were normal and airway assessment cord paralysis. revealed no abnormalities. His chest X-ray revealed minimal pleural effusion on both side of the lung. He had a normal speaking voice without evidence of respiratory obstruction. The Complications of tracheal intubation are well known and patient was arrived conscious in the operating room without vocal cord paralysis is one of the most serious complications premedication. The patient was positioned with the supine among them, resulting in severe vocal disability and aspiration position for general anesthesia and operation. The preanesthetic [1]. Unilateral vocal cord paralysis following surgical vital signs were normal and peripheral oxygen saturation procedures unrelated to the neck has been reported rare [2,3]. (SpO2) was 97% before induction of general anesthesia. Patient Because of an increase in elderly patients and pre-existing received 0.2 mg glycopyrrolate and 100 μg fentanyl intra- morbidities in surgical patients, patients remain in danger of venously just before induction of general anesthesia. After vocal cord paralysis and vocal cord dysfunction despite preoxygenation, the general anesthesia was induced with advance in intubation techniques and devices [4]. We present a propofol 140 mg intravenously, rocuronium 50 mg was case of unilateral vocal cord paralysis ten days after abdominal administered and the trachea was intubated without difficulty surgery in a 71-year-old male patient with descending colon using an 8-mm cuffed endotracheal tube (Tracheal tube, carcinoma and left renal cell carcinoma. Mallinckrodt Medical, Athelone, Ireland) with a No. 3 Macin- Received: July 13, 2011. tosh style of fiber optic blade (fiber optic laryngoscope blades, Ⓡ Revised: July 27, 2011. Welch Allyn , NY, USA). With laryngoscopy, a laryngeal Accepted: August 4, 2011. Corresponding author: Byung Ho Lee, M.D., Department of Anesthesiology view score by Cormack and Lehane was grade one in this and Pain Medicine, The Catholic University of Korea, College of Medicine, patient. The tracheal cuff was inflated until gas failed to leak 620-56, Jeonnong-2 dong, Dongdaemun-gu, Seoul 130-709, Korea. Tel: around the cuff. It was confirmed that breathing sound was 82-2-958-2464, Fax: 82-2-967-0235, E-mail: [email protected] equal on both sides of the lung by stethoscope. The
67 68 Anesth Pain Med Vol. 7, No. 1, 2012 endotracheal tube was fixed at 22 cm from incisor and taped recovered. The patient was discharged after thirty-two days into place. General anesthesia was maintained with 2 vol% when movement of both vocal cords was adequate and his sevoflurane, 2 L/min O2 and 2 L/min N2O. Respirations were voice had recovered completely and he could tolerate liquids controlled by mechanical ventilator during general anesthesia. orally. The operation was terminated uneventfully, and during the eight hour surgical procedure neither the head nor the DISCUSSION endotracheal tube was moved. At the end of surgery, the lungs were ventilated with 100% oxygen and when spontaneous Injuries to the airway are well-recognized complications of ventilation appeared adequate, the cuff was deflated and anesthesia. The most frequent types of laryngeal injury are extubation was performed. The patient did not demonstrated vocal cord paralysis, which is one of the most serious evidence of airway obstruction and transported to the intensive anesthetic complications related to endotracheal intubation, and care unit with stable vital signs. hematoma or granuloma of the vocal cords [1]. Mun et al. [5] The patient complained of hoarseness one day after reported that unilateral vocal cord paralysis occurred after operation and coughing on swallowing water ten days after difficult endotracheal intubation using intubating laryngeal mask operation. His voice remained hoarse. The vocal cords were airway . examined with a fiberoptic nasopharyngolaryngoscopy by the Unilateral or bilateral vocal cord paralysis has been reported otolaryngologist, who found the right vocal cord paralysis. The frequently following neck surgery, whereas unilateral vocal left vocal cord was normal and the right vocal cord was fixed cord paralysis such as this case following surgical procedures in the paramedian position (Fig. 1). The vocal cords showed unrelated to the neck and recurrent laryngeal nerve has been no edema, hematoma, or ulceration, and no sign of chemical reported rare [2,3]. The clinical symptoms of unilateral vocal damage. The videofluoroscopic scoring by the physiatrist cord paralysis were hoarseness and aspiration but complete revealed the pattern of penetration and delayed aspiration on bilateral recurrent laryngeal nerve paralysis usually causes acute liquid during pharyngeal phase. Therefore, the patient was airway obstruction due to unopposed vocal cord adduction [6]. treated with rehabilitative dysphagia therapy and vital In this case, the clinical pictures of unilateral vocal cord Ⓡ stimulation therapy using vital stim (Vital Stim , PJO LCC, paralysis were hoarseness, coughing and aspiration on liquid USA) for dysphagia rehabilitation by rehabilitation therapist. postoperatively. The usual cause of unilateral or bilateral vocal After four weeks, the vocal cords were again examined by an cord paralysis is a direct injury to one or both recurrent otolaryngologist and movement of the right vocal cord was laryngeal nerves, either directly by severing the nerve or pressure during dissection following neck surgery or thoraco- tomies [2]. Therefore, we could rule out the cause of unilateral vocal cord paralysis was the surgery-related injury because of abdominal operation in this case. Yamashita et al. [7] reported nine cases of vocal cord paralysis after endotracheal anesthesia for abdominal operation like this case. In this case, we could suspect that laryngeal damage may not only occur during intubation but also be the result of some intraoperative factors. Postoperative vocal cord paralysis may be due to mechanical or neurogenic factors. Ellis and Pallister [8] reported that when an endotracheal tube with the inflated cuff was passed within the larynx, it compressed the anterior branch of the recurrent laryngeal nerve, which passed medial to the lamina of the thyroid cartilage to supply the lateral cricoarytenoid and thyroarytenoid muscles, between the cuff and the interior surface of the thyroid lamina. Mechanical injury such as dislocation or subluxation of the cricoarytenoid joints may Fig. 1. The white arrow demonstrates the right paralyzed vocal fold, which is characteristically foreshortened, lateralized, and flaccid. result from traumatic endotracheal intubation or extubation. Mee Young Chung, et al：Unilateral vocal cord paralysis 69
Unilateral vocal cord paralysis following tracheal intubation is tubes with cuffs that, on testing, inflated unevenly before associated with discernible damage to tracheal or laryngeal induction of general anesthesia in this case. Also, the cuff was mucosa, or visible evidence of trauma to the arytenoid inflated with air to the level just necessary to prevent gas cartilage or joint. Injuries of the arytenoid cartilage or joint leakage but measurements of the cuff pressure were not may be caused by excessive extension of the neck, driving the performed. Therefore, we could not definitely exclude the tube back against the arytenoids with or without dislocation of possibility of a misplaced endotracheal tube, possibly combined the cricoarytenoid joint [1]. This complication may occur if the with a hyperinflated cuff which caused the vocal cords cuff is placed at too high a level so that it lies at, or just paralysis. Kikura et al. [4] reported that the risk of vocal cord below, the level of the cords. The need to avoid intubation of paralysis was increased in patients with old age, hypertension, the right main bronchus or the use of too short a tube may or diabetes mellitus, and increased intubation time. They encourage this complication [8]. In this case, intubation and suggested that degenerated tissues in the laryngeal system in extubation were performed without difficulty and we confirmed patients with old age are more susceptible to acute the inflated cuff was passed within the larynx during inflammation and microcirculatory insufficiency due to cuff intubation and fixed the endotracheal tube at 22 cm from the pressure and mechanical damage by the tracheal tube. In case incisor. Then the correct placement of the endotracheal tube of unilateral vocal cord paralysis, the left vocal cord is more was confirmed and the neck was not overextended. Also, the frequently injured than the right vocal cord because the head and endotracheal tube were not moved during surgery. laryngoscope is typically held in the left hand with the Because of no hematoma, laceration or granuloma of the endotracheal tube being inserted from the right side [1,10]. laryngeal mucosa, we could rule out traumatic intubation and Males are affected more frequently than females [10]. In this extubation in this case. However, a mechanical injury to the case, the patient was old aged male with no underlying laryngeal nerve could not be excluded. disease such as hypertension or diabetes mellitus and Several risk factors for vocal cord injury and postoperative especially, vocal cord paralysis involved right vocal cord. The hoarseness include endotracheal tube size, cuff design, and cuff other causes of recurrent laryngeal nerve damage are a toxic pressure, and demographic factors such as sex or age [1]. neuritis which may occur during influenza, diphtheria, malaria, Gibbin and Egginton [9] reported bilateral vocal cord paralysis or exposure to cold. Usually, these produce unilateral lesion following endotracheal intubation with too large endotracheal [2]. tube in relation to the subglottic region. In this case, we could In spite of known risk factors, the cause of the vocal cord rule out the cause of vocal cord paralysis was the use of the paralysis remains unknown in some cases. Faabrog-Anderson large endotracheal tube because that the trachea was intubated [11] reported recurrent laryngeal paralysis of unknown etiology. with ease with 8-mm cuffed endotracheal tube. Insufficient Salem et al. [12] reported a number of cases of unilateral and microcirculatory supply to the recurrent laryngeal nerve and its bilateral vocal cord paralysis following the use of non-cuffed peripheral branches in the larynx due to the over-expanded tubes in pediatric patients. Vocal cord paralysis after spinal endotracheal cuff pressure may cause ischemic neuronal anesthesia was reported [10]. The diagnosis is relatively easy degeneration and subsequent recurrent nerve paralysis and vocal and is obtained by direct laryngoscopy and rigid or flexible cord immobility [4]. Irregular inflation of a cuff, due to a bronchoscopy and tracheography, if necessary. The movement defect in manufacture or following many sterilizations, may of the vocal cords is observed by a small, flexible fiberoptic also exert excessively high pressure localized to the anterior bronchoscope. With a complete unilateral paralysis of the branch of the recurrent laryngeal nerve and damage from gas recurrent laryngeal nerve, abductor and adductor fibers are sterilization, like ethylene oxide, may be a cause of vocal cord affected and the vocal cord assumes a paramedian position paralysis if the sterilized material has not been well aerated with the vocal cord neither abducted nor adducted. In this [2,3]. The more worsening of the nerve injury could be situation, on phonation the unaffected vocal cord crosses the induced by the cuff, since it diffuses rapidly into the cuff midline to meet the affected vocal cord, and on inspiration the increasing cuff pressure when nitrous oxide is used during unaffected vocal cord moves to full abduction [13]. In this general anesthesia [3]. For preventing these problems, we used case, we also suspected a complete unilateral paralysis of the the disposable endotracheal tube with low pressure, high recurrent laryngeal nerve due to a paramedian position with residual volume cuffs and eliminated the use of endotracheal the right vocal cord neither abducted nor adducted. 70 Anesth Pain Med Vol. 7, No. 1, 2012
Vocal cord paralysis recovers spontaneously under most 98: 1049-56. circumstances. The duration of recovery varies from days to 2. Holley HS, Gildea JE. Vocal cord paralysis after tracheal intubation. JAMA 1971; 215: 281-4. months [14]. Wason et al. [6] reported the symptoms of 3. Minuck M. Unilateral vocal-cord paralysis following endotracheal hoarseness and coughing on swallowing subsided in about six intubation. Anesthesiology 1976; 45: 448-9. weeks without any active intervention. Mostly, the unilateral 4.Kikura M, Suzuki K, Itagaki T, Takada T, Sato S. Age and vocal cord paralysis returns to normal within three months and comorbidity as risk factors for vocal cord paralysis associated with sometimes, the voice returns to normal within the first year tracheal intubation. Br J Anaesth 2007; 98: 524-30. after damage in some cases [3]. Therefore, the initial treatment 5. Mun CS, Kim HT, Heo HE, Lee JH, Kwon YE. Unilateral vocal cord palsy occurred after difficult endotracheal intubation using includes observation, and if indicated, speech therapy. But intubating laryngeal mask airway. Korean J Anesthesiol 2009; 56: routine tracheal assessment should be performed 4-6 weeks 200-3. after extubation for every patients exposed to factors 6. Wason R, Gupta P, Gogia AR. Bilateral adductor vocal cord predisposing to laryngotracheal injury [15]. Whereas, if bilateral paresis following endotracheal intubation for general anaesthesia. vocal cord paralysis is diagnosed, tracheostomy or transient Anaesth Intensive Care 2004; 32: 417-8. endotracheal intubation would be the correct treatment despite 7. Yamashita T, Harada Y, Ueda N, Tashiro T, Kanebayashi H. Recurrent laryngeal nerve paralysis associated with endotracheal the possibility of quick recovery. In this case, the symptoms anaesthesia. Nihon Jibiinkoka Gakkai Kaiho 1965: 68: 1452-9. of hoarseness and coughing on swallowing subsided in about 8. Ellis PD, Pallister WK. Recurrent laryngeal nerve palsy and six weeks with rehabilitative dysphagia therapy and vital endotracheal intubation. J Laryngol Otol 1975; 89: 823-6. stimulation therapy for dysphagia rehabilitation. 9. Gibbin KP, Egginton MJ. Bilateral vocal cord paralysis following In conclusion, unilateral or bilateral vocal cord paralysis endotracheal intubation. Br J Anaesth 1981; 53: 1091-2. 10. Mass L. Unilateral vocal-cord paralysis. Anesthesiology 1977; 46: following endotracheal intubation is rare but the most serious 374-5. complications in patients with surgical procedures unrelated to 11. Faaborg-Anderson E. Recurrent laryngeal paralysis of unknown the neck. In spite of the known risk factors of the vocal cord etiology. Acta Otolaryngol Suppl 1954; 118: 68-75. paralysis, the cause of the vocal cord paralysis remains 12. Salem MR, Wong AY, Barangan VC, Canalis RF, Shaker MH, undetermined such as this case. For preventing the vocal cord Lotter AM. Postoperative vocal cord paralysis in pediatric patient. paralysis following endotracheal intubation, we have to bear in Reports of cases and a review of possible etiologic factors. Br J Anaesth 1971; 43: 696-700. mind that avoiding traumatic intubation, adequate positioning of 13. Feldman MA, Patel A. Anesthesia for eye, ear, nose, and throat endotracheal tube, eliminating the use of endotracheal tubes surgery. In: Anesthesia. 7th ed, Edited by Miller RD, Eriksson LI, with uneven inflated cuffs, preventing tube migration and Fleisher LA, Winer-Kronish JP, Young WL: Philadelphia, monitoring and adjusting cuff pressure regularly during general Churchill Livingstone. 2010, pp 2357-88. anesthesia, especially if nitrous oxide is used. 14. Laursen RJ, Larsen KM, MØlgaard J, Kolze V. Unilateral vocal cord paralysis following endotracheal intubation. Acta Anaes- thesiol Scand 1998; 42: 131-2. REFERENCES 15. Kastanos N, Estopá Miró R, Marín Perez A, Xaubet Mir A, Agustí-Vidal A. Laryngotracheal injury due to endotracheal 1. Mencke T, Echternach M, Kleinschmidt S, Lux P, Barth V, intubation: Incidence, evolution, and predisposing factors. A Plinkert PK, et al. Laryngeal morbidity and quality of tracheal prospective long-term study. Crit Care Med 1983; 11: 362-7. intubation. A randomized controlled trial. Anesthesiology 2003;