Case 47: Postoperative Vocal Cord Paralysis
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You are scheduled to anesthetize a 65-year-old woman (ASA 2) for a left carotid endarterectomy (CEA). She has hypertension, which is well controlled medically. Her past surgical history is significant for a thyroidectomy 17 years previously. Otherwise she is well, with no known allergies. Her physical exam is normal and she has no stridor or hoarseness. She prefers to be awake for the surgery, and you do a deep and superficial cervical plexus block with 1.5% lidocaine with 1:200,000 epinephrine. Six ml is injected at C3, C4, and C5, while 14 ml is injected into the superficial plexus. The surgery starts with the patient awake, as she has only received midazolam 2 mg and 50 ug of fentanyl for the block. After a Pilling retractor is inserted, pushing the internal jugular vein and sternocleidomastoid laterally and thyroid and trachea medially, the patient coughs repeatedly. The surgeon injects 6 ml of plain lidocaine 1% around the common carotid artery, but this does not help as the patient now develops stridor and becomes agitated. The retractor is removed and within a few minutes she feels much better. The surgeon inserts the retractor again, but once again the patient develops severe coughing and stridor. The patient is told that a general anesthesia is needed and she reluctantly agrees. She is anesthetized without any problems with fentanyl 200 ug, etomidate 18 mg, and vecuronium 7 mg. She is easy to mask ventilate. You have a grade 1 view of interest is the fact that your resident notes that the right vocal cord seems to less away from the midline than the left. You have a look and agree with his assessment. An endotracheal tube (ETT) is placed uneventfully. The anesthetic is maintained with oxygen-nitrous-isoflurane. The surgery is completed uneventfully and a special note is made by the surgeon that the vagus nerve is intact. Both a nonrecurrent laryngeal nerve and a recurrent laryngeal nerve are not seen.
KeywordsVocal cord paralysis Stridor Agitation Endotracheal tube Recurrent laryngeal nerve Cervical plexus block Laryngeal mask airway LMA Fiber-optic bronchoscope Supraglottic edema Tracheostomy Carotid endarterectomy Thyroidectomy
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