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Management of bilateral recurrent laryngeal nerve paresis after thyroidectomy.

Sanapala A, Nagaraju M, Rao LN, Nalluri K - Anesth Essays Res (2015 May-Aug)

Bottom Line: Soon after extubating, it is essential to the anesthetist to check the vocal cord movements on phonation and oropharyngeal reflexes competency.But this case is specially mentioned to convey the message that in spite of absence of above mentioned predisposing factors for complications and good recovery profile specific to thyroid, there can be unanticipated airway compromise that if not attended to immediately may cost patient's life.This is a case of postextubation stridor following subtotal thyroidectomy due to bilateral RLN damage and its management.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Katuri Medical College and Hospital, Chinakondrupadu, Guntur, Andhra Pradesh, India.

ABSTRACT
Bilateral recurrent laryngeal nerve (RLN) injury is rare for benign thyroid lesions (0.2%). After extubation-stridor, respiratory distress, aphonia occurs due to the closure of the glottic aperture necessitating immediate intervention and emergency intubation or tracheostomy. Intra-operative identification and preservation of the RLN minimizes the risk of injury. It is customary to expect RLN problems after thyroid surgery especially if malignancy, big thyroid, distorted anatomical problems and difficult airway that can lead to intubation trauma. Soon after extubating, it is essential to the anesthetist to check the vocal cord movements on phonation and oropharyngeal reflexes competency. But this case is specially mentioned to convey the message that in spite of absence of above mentioned predisposing factors for complications and good recovery profile specific to thyroid, there can be unanticipated airway compromise that if not attended to immediately may cost patient's life. This is a case of postextubation stridor following subtotal thyroidectomy due to bilateral RLN damage and its management.

No MeSH data available.


Related in: MedlinePlus

Tracheostomy being performed
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Figure 1: Tracheostomy being performed

Mentions: After an hour in the recovery room, patient had an inspiratory stridor with signs of respiratory distress (tachypnea, tachycardia, flaring of alar nasae, restlessness) and there was a gradual fall in the saturation to high 80's to low 90's. There was no local swelling at the surgical site. We tried to ventilate with a FiO2 of 100%, and Larson's jaw thrust was applied, but saturation did not improve much. After sedation, as vocal cords were in adduction on laryngoscopy, patient was intubated with a smaller size (7 mm ID) cuffed ET tube using bougie and connected to a T-piece. Patient could maintain stable vitals after the procedure. Bilateral RLN paresis was confirmed with flexible fiber optic laryngoscopy by otolaryngologist (after trial extubation), and tracheostomy [Figure 1] was performed to prevent further respiratory complications and facilitate early mobilization [Figure 2]. Patient was de-cannulated 14 days later with the return of adequate cord function.


Management of bilateral recurrent laryngeal nerve paresis after thyroidectomy.

Sanapala A, Nagaraju M, Rao LN, Nalluri K - Anesth Essays Res (2015 May-Aug)

Tracheostomy being performed
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4563973&req=5

Figure 1: Tracheostomy being performed
Mentions: After an hour in the recovery room, patient had an inspiratory stridor with signs of respiratory distress (tachypnea, tachycardia, flaring of alar nasae, restlessness) and there was a gradual fall in the saturation to high 80's to low 90's. There was no local swelling at the surgical site. We tried to ventilate with a FiO2 of 100%, and Larson's jaw thrust was applied, but saturation did not improve much. After sedation, as vocal cords were in adduction on laryngoscopy, patient was intubated with a smaller size (7 mm ID) cuffed ET tube using bougie and connected to a T-piece. Patient could maintain stable vitals after the procedure. Bilateral RLN paresis was confirmed with flexible fiber optic laryngoscopy by otolaryngologist (after trial extubation), and tracheostomy [Figure 1] was performed to prevent further respiratory complications and facilitate early mobilization [Figure 2]. Patient was de-cannulated 14 days later with the return of adequate cord function.

Bottom Line: Soon after extubating, it is essential to the anesthetist to check the vocal cord movements on phonation and oropharyngeal reflexes competency.But this case is specially mentioned to convey the message that in spite of absence of above mentioned predisposing factors for complications and good recovery profile specific to thyroid, there can be unanticipated airway compromise that if not attended to immediately may cost patient's life.This is a case of postextubation stridor following subtotal thyroidectomy due to bilateral RLN damage and its management.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Katuri Medical College and Hospital, Chinakondrupadu, Guntur, Andhra Pradesh, India.

ABSTRACT
Bilateral recurrent laryngeal nerve (RLN) injury is rare for benign thyroid lesions (0.2%). After extubation-stridor, respiratory distress, aphonia occurs due to the closure of the glottic aperture necessitating immediate intervention and emergency intubation or tracheostomy. Intra-operative identification and preservation of the RLN minimizes the risk of injury. It is customary to expect RLN problems after thyroid surgery especially if malignancy, big thyroid, distorted anatomical problems and difficult airway that can lead to intubation trauma. Soon after extubating, it is essential to the anesthetist to check the vocal cord movements on phonation and oropharyngeal reflexes competency. But this case is specially mentioned to convey the message that in spite of absence of above mentioned predisposing factors for complications and good recovery profile specific to thyroid, there can be unanticipated airway compromise that if not attended to immediately may cost patient's life. This is a case of postextubation stridor following subtotal thyroidectomy due to bilateral RLN damage and its management.

No MeSH data available.


Related in: MedlinePlus