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Anesth Analg 2001;92:1422-1423
© 2001 International Anesthesia Research Society

CARDIOVASCULAR ANESTHESIA

Transient Recurrent Laryngeal Nerve Palsy After Failed Placement of a Transesophageal Echocardiographic Probe in an Anesthetized Patient

Gabriela Zwetsch, MD*, Miodrag Filipovic, MD*, Karl Skarvan, MD*, Atanas Todorov, MD{dagger}, and Manfred D. Seeberger, MD*

Departments of *Anesthesia and {dagger}Surgery, Division of Cardiothoracic Surgery, University of Basel/Kantonsspital, Basel, Switzerland

Address correspondence and reprint requests to Manfred Seeberger, MD, Department of Anesthesia, University of Basel, Kantonsspital, CH-4031 Basel, Switzerland. Address e-mail to mseeberger{at}uhbs.ch


   Introduction
Top
 Introduction
Case Report
 Discussion
 References
 
Palsy of the recurrent laryngeal nerve is a well known complication after open heart surgery (1,2) and may result in postoperative respiratory insufficiency (3). We report a case of transient recurrent laryngeal nerve palsy that was most likely caused by failed attempts to place a transesophageal echocardiographic (TEE) probe.


   Case Report
Top
 Introduction
 Case Report
Discussion
 References
 
We performed aortic valve replacement in an otherwise healthy 25-yr-old man (181 cm, 63 kg) with congenital aortic valve disease without intraoperative TEE monitoring because TEE probe insertion (5.0/3.7 TEE probe; Hewlett-Packard, Andover, MA) in this anesthetized patient was unsuccessful. When a paravalvular leak was suspected 4 days after uneventful surgery, TEE examination with an identical probe was feasible in the left-sided, awake patient. A paravalvular leak with a regurgitation volume of 50% was confirmed, and the patient was scheduled for reoperation. Again, the perioperative plan included TEE monitoring.

General anesthesia was induced, and the patient’s trachea was intubated with an 8.5-mm inner diameter, low-pressure, high-volume cuff tube. Central venous access was achieved by cannulation of the right internal jugular vein. Blind insertion of a slightly smaller TEE probe (6.2/5.0 TEE probe; Hewlett Packard, Andover, MA) than had been previously used was attempted but was unsuccessful. Laryngoscopy allowed visualization of the larynx, but insertion of the TEE probe into the esophagus was stopped after 1 cm by a hard resistance. The echocardiographer’s impression was that the probe was stuck between the anterior thyroid and cricoid cartilages and the posterior vertebra of the extremely lean patient. Several ways of repositioning the patient’s head and neck did not resolve the problem, and the intention to monitor by TEE had to be abandoned again.

The same surgeon performed the second uneventful surgical procedure, and the same technique was used for preparation of the heart and for myocardial protection (cold cardioplegia without local cooling). After extubation in the intensive care unit, the sufficiently breathing patient complained about hoarseness. A laryngeal examination revealed palsy of the left recurrent laryngeal nerve without any other pathology. Recurrent laryngeal nerve palsy and hoarseness resolved by themselves on the eighth postoperative day.


   Discussion
Top
 Introduction
 Case Report
 Discussion
References
 
The left recurrent laryngeal nerve has a long course, making it susceptible to damage at various sites (4,5). The nerve descends the aorta immediately after leaving the vagus nerve. At this location it can be compressed by an enlarged left atrium (6), and it may be damaged by surgical manipulation (2,5) or by cold temperature during external cooling of the heart (7). None of these mechanisms is likely in our patient; the left atrium was not enlarged, the same surgeon performed an identical procedure, and no external cooling of the heart was used.

After crossing the aortic arch, the left laryngeal nerve reaches the groove between the esophagus and trachea. At this site, the nerve can be damaged by a needle used for cannulation of the internal jugular vein (8–10), by a displaced (1) or excessively inflated cuff (11), or by pressure applied during difficult gastric tube insertion (12). All these mechanisms are unlikely in our patient because the right internal jugular vein was cannulated, a high-volume, low-pressure cuff tube was used, the cuff pressure was monitored during and after the operation and kept <20 mm Hg, and there were no problems with the insertion of a nasogastric tube, which was identical to the one used during the previous surgery.

When the nerve ascends through the groove between the trachea and esophagus, it enters the larynx behind the thyroid and the cricoid cartilages. At this site, the nerve may be damaged by a foreign body pressing the nerve to the thyroid or cricoid cartilage, e.g., by a laryngeal mask airway (13).

Because all of these other causes for recurrent laryngeal nerve palsy are very unlikely, the latter mechanism must be considered as being responsible for the nerve palsy in our case. During the repeated and unsuccessful attempts of intubating the esophagus, the tip of the TEE probe most likely compressed the nerve at its entry into the larynx.

Although one prospective study (2) found no correlation between placement of a TEE probe and incidence of recurrent laryngeal nerve palsy, it is not in contrast to our findings because the previous study did not include patients with failed placement of a TEE probe, and its sample size was insufficient to reliably exclude a rare complication of TEE.

In summary, we report a case of transient recurrent laryngeal nerve palsy most likely caused by unsuccessful attempts to place a TEE probe. Although unsuccessful placement of a TEE probe is uncommon, this mechanism of laryngeal nerve injury is of potential importance because laryngeal nerve palsy can cause postoperative respiratory insufficiency. The combination of anesthesia, muscle relaxation, and supine positioning may complicate probe insertion in rare cases; but it is even more important to note that it deprives the echocardiographer of patient feedback, such as expression of pain. The present case thus reinforces the importance of inserting TEE probes smoothly and avoiding any forceful or repeated attempts.


   Acknowledgments
 
The authors thank Joan Etlinger for editorial assistance.


   References
Top
 Introduction
 Case Report
 Discussion
 References
 

  1. Inada T, Fujise K, Shingu K. Hoarseness after cardiac surgery. J Cardiovasc Surg 1998; 39: 455–9.[Medline]
  2. Kawahito S, Kitahata H, Kimura H, et al. Recurrent laryngeal nerve palsy after cardiovascular surgery: relationship to the placement of a transesophageal echocardiographic probe. J Cardiothorac Vasc Anesth 1999; 13: 528–31.[Web of Science][Medline]
  3. Shafei H, el-Kholy A, Azmy S, et al. Vocal cord dysfunction after cardiac surgery: an overlooked complication. Eur J Cardiothorac Surg 1997; 11: 564–6.[Abstract]
  4. Ramadan HH, Wax MK, Avery S. Outcome and changing cause of unilateral vocal cord paralysis. Otolaryngol Head Neck Surg 1998; 118: 199–202.[Web of Science][Medline]
  5. Titche LL. Causes of recurrent laryngeal nerve paralysis. Arch Otolaryngol 1976; 102: 259–61.[Abstract/Free Full Text]
  6. Zamora Mestre S, Ladron de Guevara Bravo F, Acosta Varo M. Paralysis of the left recurrent laryngeal nerve secondary to periprosthetic mitral insufficiency. Rev Esp Cardiol 1997; 50: 902–3.[Web of Science][Medline]
  7. Tewari P, Aggarwal SK. Combined left-sided recurrent laryngeal and phrenic nerve palsy after coronary artery operation. Ann Thorac Surg 1996; 61: 1721–2.[Abstract/Free Full Text]
  8. Sim DW, Robertson MR. Right vocal cord paralysis after internal jugular vein cannulation. J Laryngol Otol 1989; 103: 424.[Web of Science][Medline]
  9. Rigg A, Hughes P, Lopez A, et al. Right phrenic nerve palsy as a complication of indwelling central venous catheters. Thorax 1997; 52: 831–3.[Abstract]
  10. Martin-Hirsch DP, Newbegin CJ. Right vocal fold paralysis as a result of central venous catheterization. J Laryngol Otol 1995; 109: 1107–8.[Web of Science][Medline]
  11. Otani S, Fujii H, Kurasako N, et al. Recurrent nerve palsy after endotracheal intubation. Masui 1998; 47: 350–5.[Medline]
  12. Ibuki T, Ando N, Tanaka Y. Vocal cord paralysis associated with difficult gastric tube insertion. Can J Anaesth 1994; 41: 431–4.[Web of Science][Medline]
  13. Lloyd Jones FR, Hegab A. Recurrent laryngeal nerve palsy after laryngeal mask airway insertion. Anaesthesia 1996; 51: 171–2.[Web of Science][Medline]
Accepted for publication February 9, 2001.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press