RevBrasAnestesiol.2016;66(3):321---323
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologia www.sba.com.brCLINICAL
INFORMATION
Aphonia
after
shoulder
surgery:
case
report
Carlos
Alberto
da
Silva
Soares
Moreno
∗,
Sara
Fonseca
HospitalSãoJoão,Porto,Portugal
Received8August2013;accepted19September2013 Availableonline23November2014
KEYWORDS Block;
Interscalenebrachial plexus;
Aphonia; I-Gel; Choking;
Recurrentlaryngeal nerve
Abstract Inthiscasereportwehighlighttheuniquenessofaphoniaas,tothebestofour knowl-edge,casesofaphoniarelatedtointerscalenebrachialplexusblock(IBPB)arenotdescribedin theliterature.AlthoughhoarsenessisacommoncomplicationofIBPB,aphoniaisnot. There-fore,wethinkitisimportanttopublicizethefirstcaseofaphoniaafterIBPB,whichmayhave arisenonlybecauseofarecurrentlaryngealnervechronicinjurycontralateraltotheIBPBsite. © 2014SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
PALAVRAS-CHAVE Bloqueio;
Plexobraquial interescalênico; Afonia;
I-Gel;
Engasgamento; Nervolaríngeo recorrente
Afoniaapóscirurgiadoombro:relatodecaso
Resumo Relativamenteaesterelatodecasodestacamosasuasingularidade,umavezque nãoseencontramdescritosnaliteratura,tantoouquantoosautorespuderaminvestigar,casos deafoniaapósumaanestesiacombinadacombloqueiodoplexobraquialviainterescalénica (BPBI).Emboraarouquidãosejaumacomplicac¸ãofrequentedoBPBI,aafonianãooé.Desse modo,pensamosserimportantedaraconheceroprimeirocasodeafoniaapósoBPBI,quena opiniãodosautoressurgiuapenasporcausadeumalesãocrônicadonervolaríngeorecorrente contralateralaolocaldoBPBI.
©2014SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
∗Correspondingauthor.
E-mail:[email protected](C.A.S.S.Moreno).
Background
and
objective
Shouldersurgeryisthemainindicationoftheinterscalene brachialplexusblock(ISBPB).1Althoughsafeandeffective,
thistechniqueisnotfreeofcomplications.2---4
Currently,thereisagrowinginterestintheuseof ultra-soundguidanceforregionalanesthesiaproceduressuchas
http://dx.doi.org/10.1016/j.bjane.2013.09.014
322 C.A.S.S.Moreno,S.Fonseca
peripheral nerve blocks(PNB),but itssuperiority to neu-rostimulationisstillcontroversial.5Recent studiessuggest
that ultrasound can improve the effectiveness of periph-eralnerveblockcomparedwithneurostimulation.However, thereisnoevidencethatitsusecandecreasethenumber ofcomplication,suchasnerveinjuryorsystemictoxicityof localanesthetics.5,6TheConcomitantuseofultrasoundand
neurostimulationisacommon,reliable,andvalidpractice forPNB.
Sincethe1990s,thesupraglotticairwaydevicesareoften usedforairwaymanagementinpatientsundergoinggeneral anesthesia.Itisasafedevice,althoughsomecomplications associatedwithitsusehavebeendescribed.7
Theaimofthisstudywastoanalyzethefirstcaseof apho-niadescribedinliterature,whichemergedaftercombined anesthesia(ISBPBandbalancedgeneralanesthesia[BGA])in shoulderarthroscopytocorrectrotatorcuffsyndrome.
Case
report
Female patient, 52 years old, 65kg; scheduled for right shoulder arthroscopic rotator cuff repair. Personal his-tory of controlled hypertension medicated with losartan 50mgday−1, physical status ASA II (American Society of Anesthesiologists, ASA classification); no surgical history and/orrelevantanesthetics.Physicalexaminationand pre-operative tests(blood count,biochemistry, blood clotting tests,andelectrocardiogram)showednochanges.
Combined anesthesia was proposed: ISBPB under mild sedation and BGA. After obtaining informed consent, standard monitoring (electrocardiogram, pulse oximetry, noninvasive blood pressure) and supplemental oxygen (3Lmin−1)via nasal cannula,sedation withIV midazolam (2mg) and ISBPB were performed: Echoplex® Vygon
nee-dle 50mm 22G guided by ultrasound (Sonosite M-Turbo®)
and neurostimulation (Plexygon® 7501.31, Vygon). After
ultrasoundidentification,andthroughbrachialplexus neu-rostimulation(forearmmusclecontraction,motorresponse upto 0.36mA, pulse duration of 0.1ms, and 2Hz of fre-quency),infiltrationwasperformed withropivacaine0.5% (30mL),undervisualization.Sensoryblocklevel2andMBS 1(ModifiedBromageScale)wereobtainedafter20min.BGA was then performed: IV fentanyl 2gkg−1 and IV propo-fol2.5mgkg−1;thesupraglotticdeviceI-Gel4introduction was uneventful; maintenance performed with desflurane 6% in oxygen/air (40%/60%). Concomitant analgesia per-formed with IV paracetamol 1g and IV parecoxib 40mg. Surgerylasted80min.Therewerenoanestheticorsurgical complications.Emergencefromanesthesiaandremovalof I-Gel4wereuneventful.Transporttopost-anesthesiacare unit(PACU)wasperformedwiththepatientspontaneously breathing,withoutrespiratorydistress.
In thePACU, withthe patientfully awake, inability to makesoundsassociatedwithptosis,miosis,and enophthal-moswereobserved.Neurologicalexaminationrevealed no otherchanges,andtherewerenohemodynamicor respira-torychangestoo.Theinitialreversalofsymptomsoccurred twohoursafterarrivalinthePACU,butthehoarseness per-sisted.Thepatientwastransferredtotheorthopedicward sevenhoursafterISBPB,withMBS0andhoarseness.Onthe firstpostoperativeday(POD1),thepatientwasevaluated
bytheAcutePainFunctionalUnit(APFU),alreadyshowing completeclinicalreversalofneurologicaldisorders.During this consultation, a review of the clinical conditions pre-sentedinthefirsthoursaftersurgerywasperformed,with confirmationofnosoundtransmission/vocalizationandany other associatedneurological symptoms. The patientwas dischargedonPOD2.
Thefollow-upvisitwasconducted30daysafterdischarge intheAPFU,notingtheabsenceofneurological abnormal-ities and appropriate surgical recovery. A more detailed explorationofthepatient’shistoryoffrequentchokingwith saliva for more than10 years, whichwas associatedwith intermittenthoarsenesswasperformed.
Discussion
Tothebestofourknowledge,thereisnotacasesimilarto oursdescribedintheliterature.Aphonia(completeinability touttersounds)occursafterbilateralpalsyinabductionof vocalfolds.Theipsilateralrecurrentlaryngealnerve(RLN) is responsible for the motor innervation of the vocal fold muscles.UnilateralRLNinjuryparalyzestheipsilateralvocal fold,andtheclinicalsymptomsofdysphoniaorhoarseness appear.8IftheRLNparalysisorinjuryisbilateral,bothvocal
foldsareparalyzedandaphoniadevelops.
A surgical cause seems less likely, given the type and location of the surgery. Among other possible causes, we highlightthebilateralblockadeoftheRLNwithropivacaine, ipsilateralblockadeoftheRLNinthepresenceofaprior con-tralateralRLNinjury,larynxregiontrauma/injurycausedby thesupraglotticdeviceI-Gel4,andintraoperative neurolog-icalevent.
The neurological examination performed in the PACU after the diagnosis of aphonia did not reveal any other changes, only upper limb motor block on the ISBPB side. Weemphasizethepreservationofthemimicandface mus-cles, equally photoreactive and symmetric pupils, which makestheoccurrenceofanintraoperativeneurologicevent unlikely.
RegardingtheuseofI-Gel,themostfrequentlydescribed complications are oropharyngeal pain/inflammation and dysphagia.9Reneetal.reportedacaseofnerveinjurywith
itsintroduction.Themaininjurednerveisthelingual,which isonlyresponsibleforthetonguesensoryinnervation.10 In
literature,therearenocasesreportingaphoniaassociated withtheuseofthistypeofdevice.However,withtheuse of cuffed laryngeal mask, there arecase reports of tran-sienthoarsenessduetoRLNparalysis.Jonesetal.justified hoarsenessbycuffhyperinflation,withtemporary compres-sionof the RLNand vocal folds.11 Inomata etal.justified
transient hoarseness by vocal cord trauma after the LMA cuffhyperinflation,buttheyalsosuggestedthepossibility ofvocalfoldsinjurycausedbythelaryngoscopyperformed priortotherespectiveLMAplacement.12
Aphoniaaftershouldersurgery 323
anatomicalstructuresthatthelocalanestheticwouldhave tocrosstoreachthecontralateralRLNmakethishypothesis unlikely.We foundnoreportsintheliteratureabout local anestheticleakageaftercontralateralISBPB.
The clinical history of facility to choke and frequent intermittent hoarseness for more than ten years, which neverbotheredthepatient,suggeststhepresenceof unilat-eralparalysisofavocalfold,whichpreventstheeffective airway protective reflexes and enables the development offrequentintermittenthoarseness.The reversalofISBPB began approximately two hours after the predicted time for motor nerve fibers blockade and for the beginning of aphoniareversal.Thesedataallowaphoniajustificationas aresultofaright ISBPBinapatientwithpreviouschronic injuryofleftRLN.Theabsenceofrespiratorydifficultyraises thepossibilitythatthevocalcordparalysishasoccurredin abduction,andnotinadduction,whichallowedspontaneous ventilation.
Weconsiderthatthemostlikelycauseforthetransient aphoniainourpatientwastheRLNtemporaryblockadeby ropivacaine,in thepresenceofaunilateralpriorinjuryof contralateralRLN.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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