Recurrent laryngeal palsy after ISB

[crazyoldgasdoc]

Wanted to get some opinions...

60 yr old guy for left rotator cuff repair, medical history of HTN, GERD, smoking and moderate alcohol use had U/S ISB pre-op with 25 ml 0.5% ropi, then propofol / fentanyl induction, ETT via GlideScope, grade 1 view, 3-4% desflurane, no issues introp. Patient positioned in beach-chair, head neutral entire time- case time roughly 3.5 hrs. Completely comfortable in PACU, no other meds given, D/C home same day. 2 days later, returns to ortho complaining of hoarseness and scratchy throat.

Sent to ENT today- left vocal cord paralyzed (one week out). Recurrent laryngeal nerve injury? Block completely resolved with no other issues, atraumatic intubation (GlideScope was used d/t extremely poor dentition). Ortho gave him trial of Medro-Dose pack with no change. ENT ordered CT of neck in 1-2 days.

I've seen temporary hoarseness or dysphagia from ISB local spread to RLN on occasion, but nothing that persisted beyond the block. Can't clearly remember if pt was hoarse immediately in PACU (he didn't complain about it for sure), but definitely was not this way pre-op. Reviewed U/S images- needle no where near vagus. Other etiologies? Was thinking maybe direct cuff pressure (but no nitrous used) since it took awhile? Surgical traction on the shoulder and brachial plexus?

(1) Other etiologies?
(2) Further suggestions for work-up or treatment options? Our ENT guy seems to have limited experience with non-cancerous etiologies of RLN dysfx. Want to make sure pt is getting the best chance for recovery.

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[Idiopathic]

Shoulder arthroscopy has been performed in beach-chair position. In our hospital, the postoperative complications of the airway were reported in the patients who had undergone the operation in this position (hoarseness: 4 cases, paralysis of recurrent nerve: 2 cases, arytenoids dislocation: 1 case). We assumed that the neck bending during operation causes these complications. We investigated the relationship between the neck position and the intra-cuff pressure of endotrachial tube. The results showed that the neck bending significantly increases the intra-cuff pressure of endotrachial tube. Therefore, we conclude that it is necessary to pay attention to neck position to avoid postoperative complications of the airway in the patients who have the operation in beach-chair position.

Masui. 2011 Jun;60(6):682-5.
[Airway problem during the operation with beach-chair position: a case of arytenoid dislocation and the relationship between intra-cuff pressure of endotrachial tube and the neck position].

 

[imfrankie]

Interesting. Sorry for your stress. 3+ hours in beach chair--ugh.

 

[BLADEMDA]

http://orthodoc.aaos.org/SportsMedDoc/Interscalene complications.pdf

 

[imfrankie]

Thanks for previous two references.

Abstract from Masui states with regard to beach chair shoulder: hoarseness: 4 cases, paralysis of recurrent nerve: 2 cases, arytenoids dislocation: 1 case

http://www.ncbi.nlm.nih.gov/pubmed/21710762

3+ hour beach chair shoulders. Talk about an orthopod that spreads the hurt around.

Ortho paper a bit chilling.

 

[BLADEMDA]

Thanks for previous two references.

Abstract from Masui states with regard to beach chair shoulder: hoarseness: 4 cases, paralysis of recurrent nerve: 2 cases, arytenoids dislocation: 1 case

http://www.ncbi.nlm.nih.gov/pubmed/21710762

3+ hour beach chair shoulders. Talk about an orthopod that spreads the hurt around.

Ortho paper a bit chilling.

Could this be another reason to choose an LMA/ISB combo when reasonable over an ETT/ISB?

 

[cincincyreds]

We do the shoulder cases in the lateral position, not beachchair. Wonder if that decreases the risk?

 

[crazyoldgasdoc]

Thanks for the references. Those were pretty much along the same line I'd seen when reviewing plus all the stuff on vocal cord paralysis after routine intubation. Results of the CT should be in tomorrow- hope they're able to see an arytenoid dislocation (if it's there) or normal course of the RLN.

I researched treatment options- it seems speech therapy to help patient improve phonation while it heals is a good idea but also laryngeal electromyography. Think we should have that done right away or wait another week or so? My partners suggest waiting another week, the ENT guy seems rather clueless. Seems like that would help narrow it down to a more exact etiology.