Delayed bilateral vocal cord paresis after a continuous interscalene brachial plexus block and endotracheal intubation

Abstract

Rationale:Recurrent laryngeal nerve block is an uncommon complication that can occur after an interscalene brachial plexus block (ISB), which may lead to vocal cord palsy or paresis. However, if the recurrent laryngeal nerve is blocked in patients with a preexisting contralateral vocal cord palsy following neck surgery, this may lead to devastating acute respiratory failure. Thus, ISB is contraindicated in patients with contralateral vocal cord lesion. To the best of our knowledge, there are no reports of bilateral vocal cord paresis, which occurred after a continuous ISB and endotracheal intubation in a patient with no history of vocal cord injury or surgery of the neck.Patient concerns:A 59 year old woman was planned for open acromioplasty and rotator cuff repair under general anesthesia. General anesthesia was induced following an ISB using 0.2% ropivacaine and catheter insertion for postoperative pain control.Diagnoses:While recovering in the postanesthesia care unit (PACU), however, the patient complained of a sore throat and hoarseness without respiratory insufficiency. On the morning of the first postoperative day, she still complained of mild dyspnea, dysphonia, and slight aspiration. She was subsequently diagnosed with bilateral vocal cord paresis following an endoscopic laryngoscopy examination.Interventions:The continuous ISB catheter was immediately removed and the dyspnea and hoarseness symptoms improved, although mild aspiration during drinking water was still present.Outcomes:On the 4th postoperative day, a laryngoscopy examination revealed that the right vocal cord movement had returned to normal but that the left vocal cord paresis still remained.Lessons:When ISB is planned, a detailed history-taking and examination of the airway are essential for patient safety and we recommend that any local anesthetics be carefully injected under ultrasound guidance. We also recommend the use of low concentration of local anesthetics to avoid possible paralysis of the vocal cord.

Adverse events associated with continuous interscalene block administered using the catheter-over-needle method: a retrospective analysis

“…However, even if the catheter tip is in the correct position, local anesthetics may spread to the anterior part of the anterior scalene muscle, resulting in phrenic nerve block and dyspnea [16]. Similarly, when local anesthetics spread to the anterior part of the anterior scalene muscle through the prevertebral layer of the deep cervical fascia, the recurrent laryngeal nerve is blocked, resulting in hoarseness or cough reflex during drinking, or both [17].…”

Local Anesthetics and Steroids: Contraindications and Complications - Clinical Update

“…LA toxicity is most often caused by inappropriate LA administration such as accidental intravascular injection or multiple injections. Toxic events can occur very fast following intravascular injection or can be delayed when absorbed from local tissue injection ( 8 ). Maximal safety dose of LA should not exceed the recommended dose because morbidity and mortality from LA significantly increases in higher doses.…”

“…Park H-S et al ( 8 ) showed that interscalene brachial plexus block (ISB) is contraindicated in patients with preexisting contralateral vocal cord palsy or paresis. Recurrent laryngeal nerve block is rare, but it is a possible complication of continuous ISB for shoulder surgery which may lead to acute respiratory failure in patients with contralateral vocal cord palsy.…”

Adverse events associated with continuous interscalene block administered using the catheter-over-needle method: a retrospective analysis

“…However, even if the catheter tip is in the correct position, local anesthetics may spread to the anterior part of the anterior scalene muscle, resulting in phrenic nerve block and dyspnea [16]. Similarly, when local anesthetics spread to the anterior part of the anterior scalene muscle through the prevertebral layer of the deep cervical fascia, the recurrent laryngeal nerve is blocked, resulting in hoarseness or cough reflex during drinking, or both [17]. Moreover, when local anesthetics spread to the cervical sympathetic ganglion, ptosis is observed as part of Horner’s syndrome [18].…”