Anesth Analg 2004;98:1656-1657
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000114073.26682.A1
PEDIATRIC ANESTHESIA
Superficial Cervical Plexus Block for Vocal Cord Surgery in an Awake Pediatric Patient
Santhanam Suresh, MD, FAAP, and
Leah Templeton, MD
Department of Pediatric Anesthesiology, Children’s Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
Address correspondence and reprint requests to Santhanam Suresh, MD, FAAP, Department of Pediatric Anesthesiology, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614. Address e-mail to ssuresh{at}northwestern.edu
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Abstract
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Medialization thyroplasty is a surgical procedure that decreases the incidence of dysphonia and dysphagia in patients who have vocal cord paralysis. We report a case of a pediatric patient who underwent this procedure with minimal sedation and bilateral superficial cervical plexus blockade. The use of a regional technique provided analgesia while allowing the patient to phonate at the request of the surgeon.
IMPLICATIONS: Medialization thyroplasty is a surgical procedure that decreases the incidence of dysphagia and dysphonia in patients with vocal cord paralysis. This procedure is best performed in a patient who maintains the ability to phonate. We report a case of medialization thyroplasty in a pediatric patient after bilateral superficial cervical plexus blocks with minimal sedation.
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Introduction
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Medialization thyroplasty is performed to treat vocal cord paralysis. This is the preferred procedure to resolve severe dysphonia and to reduce the risk of aspiration in patients with vocal cord paralysis (1). This procedure is also used to treat vocal fold bowing, cricothyroid joint fixation, and defects that result from excision of tissue for pathologic diagnoses. This operation is technically difficult to perform and requires that the patient remain awake and cooperative so that the surgeon can continually assess phonation. In the past, medialization thyroplasty has been performed under monitored anesthesia care (MAC) with topical local anesthesia (2). This technique has proven less than optimal because patients often require large doses of IV propofol or equivalent sedation to achieve and maintain continued patient cooperation. However, the degree of sedation may make it difficult for the patients to vocalize on command during the operation.
Medialization thyroplasty is performed with a nasal fiberoptic scope positioned at the beginning of the procedure to allow for direct visualization of vocal cord function before and during the surgical procedure. A 5- to 6-cm incision is made through the platysma muscle; superior and inferior flaps are created that allow for exposure of the thyroid notch, as well as the inferior border of the thyroid cartilage. After exposure, the strap muscles are laterally retracted off of the thyroid lamina. A window is created in the thyroid lamina. A carved block of medical-grade silastic is created and positioned within the window. The final position of the silastic block is determined when the block is moved medially through the window in the thyroid cartilage by applying pressure on the vocal fold while the patient is actively phonating. The depth of medialization is determined by the optimal voice that is obtained. Once optimal position of the silastic material is determined, the incision is closed, and a dressing is applied to the wound. We report the use of bilateral superficial cervical plexus blocks with minimal sedation that provided analgesia and allowed patient cooperation, i.e., the ability to phonate on request.
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Case Report
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A 16-yr-old 79-kg boy presented to our institution for revision of a right medialization thyroplasty. The patient was initially diagnosed with a meningioma 1 yr before the current procedure, for which he underwent a craniotomy and tumor resection. His postoperative course was complicated by respiratory failure that required extended mechanical ventilation and prolonged endotracheal intubation, leading to a tracheostomy. The patient was subsequently decannulated from his tracheostomy tube and was found to have a right vocal cord paralysis that resulted in significant dysphonia, dysphagia, and chronic aspiration and necessitated repair by medialization thyroplasty. An initial prosthesis was removed secondary to infection. He was later scheduled for a revision medialization thyroplasty. During his initial medialization thyroplasty, the anesthesia was conducted with intermittent doses of IV propofol and opioids, with resultant waxing and waning of the sedation. The patient believed that the technique provided inadequate analgesia, and the surgeon believed that the operating conditions had not been optimal. Therefore, an alternative anesthetic approach was proposed for the revision thyroplasty.
After we obtained informed consent, the patient was taken to the operating room, and routine monitors were applied. The patient was pretreated with IV glycopyrrolate (0.2 mg) and sedated with IV midazolam (2 mg) and IV fentanyl (25 µg). The patient was positioned supine, and his head was gently turned opposite the side to be blocked. He was asked to lift his head slightly, and the posterior border of the sternocleidomastoid muscle was easily identified. A 27-gauge needle was placed subcutaneously and just to the depth of the sternocleidomastoid muscle at its midpoint (at the level of the cricoid cartilage). After negative aspiration for blood, 2 mL of bupivacaine (0.25% with 1:200,000 epinephrine) was injected posterolaterally. The needle was fanned superiorly and inferiorly, and an additional 2 mL of bupivacaine (0.25% with 1:200,000 epinephrine) was injected. The procedure was repeated on the opposite side. A total volume of 8 mL of bupivacaine (0.25% with 1:200,000 epinephrine) was injected; bilateral superficial cervical plexus blocks were performed without any adverse effects.
After placement of the blocks, a propofol infusion was initiated at 70 µg · kg–1 · min–1. The patient remained supine, and the surgeon topicalized the nares with oxymetazoline hydrochloride and lidocaine pledgets. A nasal fiberoptic scope was positioned to allow for continuous visualization of the larynx throughout the procedure. The neck was prepared in a sterile manner, and the anterior part of the neck superficial to the thyroid lamina was infiltrated with a total volume of 10 mL of lidocaine (1% with 1:200,000 epinephrine) for hemostasis. Over the next 30 min, the propofol infusion rate was decreased and was maintained at 25 µg · kg–1 · min–1 for the duration of the procedure. The patient was cooperative throughout the operation, allowing the surgeons to monitor his phonation during insertion of the silastic material. The patient was taken to the recovery room, where he did not receive any additional pain medications in the postanesthesia care unit or the short-stay unit. He was discharged the following day and had no complications associated with anesthesia or surgery.
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Discussion
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The superficial cervical plexus block along with a deep cervical plexus block is frequently performed for procedures on the neck, including carotid endarterectomy (3) and thyroidectomy (4). The superficial cervical plexus block provides anesthesia to the anterior wall of the neck and the strap muscles, primarily those regions innervated by C2 and C3. The four distinct branches of the superficial cervical plexus are the lesser occipital, the great auricular, the transverse cervical, and the supraclavicular nerves. For surgery on the thyroid gland, larynx, and trachea, the superficial cervical plexus block is successful when coupled with minimal IV sedation. The common risk after superficial cervical plexus block is blockade of the accessory nerve, which leads to weakness of the sternocleidomastoid and trapezius muscles. Complications from improper performance of the block include a deep cervical plexus block, which includes temporary Horner’s syndrome, phrenic nerve paralysis, and hoarseness from recurrent laryngeal nerve paralysis. A potential for systemic toxicity is present because of injection of the local anesthesia solution into the vertebral artery or the external or internal jugular veins.
The use of bilateral superficial cervical plexus blocks with MAC offers advantages over the performance of this operation with MAC and local infiltration. Although the use of superficial cervical plexus blocks has been reported in children for other procedures (5,6), its indication for medialization thyroplasty has not been described. The use of bilateral superficial cervical plexus blocks allows the patient to remain comfortable throughout the procedure without requiring large amounts of sedation. IV sedatives alone mandate the need to turn off the infusion to wake the patient to phonate and assess correct placement of the silastic implant. Bilateral superficial cervical plexus blocks enabled us to decrease the dose of propofol infusion, allowing improved patient cooperation and comfort throughout the procedure. Patient cooperation may result in decreased surgical time. Although this patient was 16-years-old and motivated to try this anesthetic technique, this approach may be useful in younger children who are mature and have the cognitive ability to understand the need to respond to the surgeon’s queries during the procedure. This is the first report of the use of bilateral superficial cervical plexus blocks for the management of medialization thyroplasty in a pediatric patient. We believe that the benefits gained from the use of the superficial cervical plexus block when it is performed by an experienced anesthesiologist are substantial and allow for optimal conditions, under which medialization thyroplasty can be safely and effectively performed.
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References
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- Link DT, Rutter MJ, Liu JH, et al. Pediatric type I thyroplasty: an evolving procedure. Ann Otol Rhinol Laryngol 1999; 108: 1105–10.[Web of Science][Medline]
- Donnelly M, Browne J, Fitzpatrick G. Anaesthesia for thyroplasty. Can J Anaesth 1995; 42: 813–5.[Web of Science][Medline]
- Pandit JJ, Bree S, Dillon P, et al. A comparison of superficial versus combined (superficial and deep) cervical plexus block for carotid endarterectomy: a prospective, randomized study. Anesth Analg 2000; 91: 781–6.[Abstract/Free Full Text]
- Dieudonne N, Gomola A, Bonnichon P, Ozier YM. Prevention of postoperative pain after thyroid surgery: a double-blind randomized study of bilateral superficial cervical plexus blocks. Anesth Analg 2001; 92: 1538–42.[Abstract/Free Full Text]
- Brownlow RC, Berman J, Brown RE Jr. Superficial cervical block for cervical node biopsy in a child with a large mediastinal mass. J Ark Med Soc 1994; 90: 378–9.[Medline]
- Tobias JD. Cervical plexus block in adolescents. J Clin Anesth 1999; 11: 606–8.[Web of Science][Medline]
Accepted for publication December 5, 2003.
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Abstract
Introduction
