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Bilateral palsy of the hypoglossal nerve following general anesthesia for emergency surgery. A case report. Int J Surg Case Rep 2022; 96:107387. [PMID: 35803095 PMCID: PMC9284038 DOI: 10.1016/j.ijscr.2022.107387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Hypoglossal nerve palsy is a rare condition usually associated with tumors, trauma, stroke or multiple sclerosis. It can be associated with other cranial nerve palsies while injury to this nerve typically affects a patient's articulation by causing lingual motility disturbance and swallowing difficulty. Bilateral isolated hypoglossal nerve palsy is an even more infrequent condition, which can occasionally be due to airway manipulation. CASE PRESENTATION We describe a case of bilateral hypoglossal nerve damage following general anesthesia for emergency surgery, presenting with dysarthria, immobility of the tongue and dysphagia after extubation. The patient had a gradual recovery of all lost functions during the next four months. CLINICAL DISCUSSION Bilateral hypoglossal nerve palsy is a very rare entity and tracheal tube malposition or prolonged but unnoticed tracheal cuff pressure especially in the face of low blood pressure, should be considered as possible causative mechanisms for this condition. This underlines the importance of careful positioning of the patient's head and neck during surgery as well as the meticulous and correct performance of routine maneuvers of airway management. CONCLUSION Bilateral hypoglossal nerve palsy is a very rare entity. Diagnosis and management of twelfth nerve palsy require a multidisciplinary approach to achieve the best patient outcome.
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Unilateral Hypoglossal Nerve Palsy in a Patient with a Difficult Airway Requiring Prolonged Intubation. Case Rep Anesthesiol 2021; 2021:8842503. [PMID: 33680517 PMCID: PMC7906798 DOI: 10.1155/2021/8842503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/28/2021] [Accepted: 02/09/2021] [Indexed: 11/17/2022] Open
Abstract
Isolated cranial nerve injury is a very rare complication of anesthesia. Specifically, hypoglossal nerve palsy affects mobility of the tongue and basic functions of swallowing and speech, and injury can be associated with placement and/or positioning of the endotracheal tube. Many etiologies are described that are unrelated to anesthesia such as tumors, stroke, trauma, or surgical dissection. Identification of hypoglossal neuropraxic-type injury from compression or stretching during anesthetic procedures can be difficult and tends to be a diagnosis of exclusion. Here, we present a case of a unilateral isolated hypoglossal nerve palsy following prolonged intubation in a surgery that involved large fluid shifts resulting in tongue swelling, in which establishment of the airway was initially difficult requiring two attempts. We suggest it is equally as possible that stretch injury occurred during airway instrumentation versus prolonged compression of the nerve between the endotracheal tube and the hyoid bone, possibly relating to a swollen tongue. We outline some treatments that have been used in previous reports and analyze their relation to improvements in symptoms. We conclude that instrumentation of the airway and prolonged intubation are both potential risk factors for hypoglossal nerve palsy, and identification of these risk factors can improve patient care by prompting patient discussions, guiding intraoperative management, and initiating earlier therapies.
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Tongue Tied after Shoulder Surgery: A Case Series and Literature Review. Case Rep Anesthesiol 2019; 2019:5392847. [PMID: 31781403 PMCID: PMC6855057 DOI: 10.1155/2019/5392847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 06/23/2019] [Indexed: 12/14/2022] Open
Abstract
This article presents three cases of cranial nerve palsy following shoulder surgery with general anesthesia in the beach chair position. All patients underwent preoperative ultrasound-guided interscalene nerve block. Two cases of postoperative hypoglossal and one case of combined hypoglossal and recurrent laryngeal nerve palsies (Tapia's syndrome) were identified. Through this case series, we provide a literature review identifying postoperative cranial nerve palsies in addition to the discussion of possible etiologies. We suggest that intraoperative patient positioning and/or airway instrumentation is most likely causative. We conclude that the beach chair position is a risk factor for postoperative hypoglossal nerve palsy and Tapia's syndrome.
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Rojas J, Familiari F, Bitzer A, Srikumaran U, Papalia R, McFarland EG. Patient Positioning in Shoulder Arthroscopy: Which is Best? JOINTS 2019; 7:46-55. [PMID: 31879731 PMCID: PMC6930847 DOI: 10.1055/s-0039-1697606] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 08/06/2019] [Indexed: 11/24/2022]
Abstract
When performing diagnostic and surgical arthroscopic procedures on the shoulder, the importance of patient positioning cannot be understated. The optimum patient positioning for shoulder arthroscopy should enhance intraoperative joint visualization and surgical accessibility while minimizing potential perioperative risk to the patient. Most shoulder arthroscopy procedures can be reliably performed with the patient either in the lateral decubitus (LD) or beach chair (BC) position. Although patient positioning for shoulder arthroscopy has been subject of controversy, there is no conclusive evidence to suggest superiority of one position versus another. Each position offers advantages and disadvantages and surgeon's experience and training are pivotal on selecting one position versus another. Regardless of the position, a proper positioning of the patient should provide adequate access to the joint while minimizing complications. The purpose of this review is to summarize setup and technical aspects, the advantages and disadvantages, and the possible complications of the LD and BC positions in shoulder arthroscopy.
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Affiliation(s)
- Jorge Rojas
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, United States
| | - Filippo Familiari
- Department of Orthopaedic and Trauma Surgery, "Villa del Sole" Clinic, Catanzaro, Italy
| | - Alexander Bitzer
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, United States
| | - Uma Srikumaran
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, United States
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Edward G McFarland
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, United States
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Orebaugh S, Palmeri S, Lin C, YaDeau J. Daring discourse: is nerve block with sedation the safest anesthetic for beach chair position? Reg Anesth Pain Med 2019; 44:707-712. [PMID: 30928909 DOI: 10.1136/rapm-2018-100230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 03/02/2019] [Accepted: 03/06/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Steven Orebaugh
- Anaesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shawn Palmeri
- Anaesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Charles Lin
- Anaesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jacques YaDeau
- Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, New York City, New York, USA
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Kim JY, Rhee YG. Ocular surface injury after shoulder surgery in the beach-chair position. INTERNATIONAL ORTHOPAEDICS 2018; 42:2891-2895. [PMID: 29946741 DOI: 10.1007/s00264-018-4044-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE During shoulder surgery in the beach-chair position, head fixation can sometimes cause rare complications. The authors share their experience in treating ocular injury due to improper head fixation during surgery in the beach-chair position. METHODS The study investigated consecutively 6075 patients who underwent shoulder surgery in the beach-chair position between March 2007 and March 2016, those patients who saw an ophthalmologist with a complaint of post-operative ocular discomfort. In the beach-chair position, surgery is performed with the patient's upper body raised by 70°. RESULTS A total of seven patients saw an ophthalmologist due to post-operative ocular discomfort, and a total of five patients (0.082%) had corneal abrasion. Three of these patients underwent arthroscopic surgery, and the other two underwent open surgery. The mean surgery duration for the five patients was 45.0 ± 14.68 minutes. Of these patients, four were male and one was female, and their average age was 46 ± 22.24 years (range: 18-69 years). All patients complained of unbearable ophthalmodynia immediately after surgery that was not resolved using analgesics. The ophthalmodynia resolved immediately after wearing corneal protective lenses. CONCLUSION Unlike typical surgery, when shoulder surgery is performed in the beach-chair position, there is a risk of ocular surface injury due to improper head fixation; one manifestation of this problem is corneal injury. If a severe ophthalmodynia that cannot be controlled using analgesics occurs immediately after surgery in the beach-chair position, a corneal injury should be suspected, and the patient should wear a corneal protective lens. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jung Youn Kim
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Yong Girl Rhee
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea.
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Holtzman AJ, Glezos CD, Feit EJ, Gruson KI. Prevalence and Risk Factors for Lateral Femoral Cutaneous Nerve Palsy in the Beach Chair Position. Arthroscopy 2017; 33:1958-1962. [PMID: 28969950 DOI: 10.1016/j.arthro.2017.06.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 04/22/2017] [Accepted: 06/16/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To report on the prevalence of lateral femoral cutaneous nerve (LFCN) palsy in patients who had undergone shoulder surgery in the beach chair position and to identify patient and surgical risk factors for its development. METHODS We retrospectively reviewed the medical records of 397 consecutive patients who underwent either open or arthroscopic shoulder surgery in the beach chair position by a single surgeon. Patient demographic and surgical data including age, gender, weight, body mass index (BMI), diabetes, procedure duration, and anesthesia type (general, regional, regional/general) were recorded. LFCN palsy symptoms were recorded prospectively at the initial postoperative visit and identified clinically by focal pain, numbness, and/or tingling over the anterolateral thigh. RESULTS The median patient age was 59.0 years and consisted of 158 males (40%) and 239 (60%) females. Five cases of LFCN palsy were identified for a prevalence of 1.3%. These patients had a higher median weight (108.9 kg vs 80.7 kg, P = .005) and BMI (39.6 vs 29.4, P = .005) than the patients who did not develop LFCN palsy. Median age, gender, diabetes, and surgical time were not significantly different between the groups. All cases resolved completely within 6 months. CONCLUSIONS LFCN palsy after shoulder surgery in the beach chair position in our study has a prevalence of 1.3%, making it an uncommon complication. Patients with elevated BMI should be counseled about its possible occurrence after shoulder surgery in the beach chair position. LEVEL OF EVIDENCE Level IV, prognostic.
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Affiliation(s)
- Ari J Holtzman
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York, U.S.A
| | - Christopher D Glezos
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York, U.S.A
| | - Eric J Feit
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York, U.S.A
| | - Konrad I Gruson
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York, U.S.A..
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Joshi M, Cheng R, Kamath H, Yarmush J. Great auricular neuropraxia with beach chair position. Local Reg Anesth 2017; 10:75-77. [PMID: 28790863 PMCID: PMC5529604 DOI: 10.2147/lra.s138998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Shoulder arthroscopy has been shown to be the procedure of choice for many diagnostic and therapeutic interventions. Neuropraxia of the great auricular nerve (GAN) is an uncommon complication of shoulder surgery, with the patient in the beach chair position. We report a case of great auricular neuropraxia associated with direct compression by a horseshoe headrest, used in routine positioning for uncomplicated shoulder surgery. In this case, an arthroscopic approach was taken, under regional anesthesia with sedation in the beach chair position. The GAN, a superficial branch of the cervical plexus, is vulnerable to neuropraxia due to its superficial anatomical location. We recommend that for the procedures of the beach chair position, the auricle be protected and covered with cotton and gauze to avoid direct compression and the position of the head and neck be checked and corrected frequently.
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Affiliation(s)
- Minal Joshi
- Department of Anesthesiology, New York Methodist Hospital, New York, NY, USA
| | - Ruth Cheng
- School of Medicine, St. George's University, Grenada, West Indies
| | - Hattiyangadi Kamath
- Department of Anesthesiology, New York Methodist Hospital, New York, NY, USA
| | - Joel Yarmush
- Department of Anesthesiology, New York Methodist Hospital, New York, NY, USA
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Kim CJ, Oh HS, Park JJ, Chung MY. Cranial nerve XII (hypoglossal nerve) palsy after arthroscopic shoulder surgery under general anesthesia combined with sono-guided interscalene brachial plexus block -A case report-. Anesth Pain Med (Seoul) 2016. [DOI: 10.17085/apm.2016.11.3.322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Chang Jae Kim
- Department of Anesthesiology and Pain Medicine, St' Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Seok Oh
- Department of Anesthesiology and Pain Medicine, St' Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun-jae Park
- Daejeon St' Mary Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Mee Young Chung
- Department of Anesthesiology and Pain Medicine, St' Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Shah AC, Barnes C, Spiekerman CF, Bollag LA. Hypoglossal nerve palsy after airway management for general anesthesia: an analysis of 69 patients. Anesth Analg 2015; 120:105-120. [PMID: 25625257 DOI: 10.1213/ane.0000000000000495] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Isolated hypoglossal nerve palsy (HNP), or neurapraxia, a rare postoperative complication after airway management, causes ipsilateral tongue deviation, dysarthria, and dysphagia. We reviewed the pathophysiological causes of hypoglossal nerve injury and discuss the associated clinical and procedural characteristics of affected patients. Furthermore, we identified procedural factors potentially affecting HNP recovery duration and propose several measures that may reduce the risk of HNP. While HNP can occur after a variety of surgeries, most cases in the literature were reported after orthopedic and otolaryngology operations, typically in males. The diagnosis is frequently missed by the anesthesia care team in the recovery room due to the delayed symptomatic onset and often requires neurology and otolaryngology evaluations to exclude serious etiologies. Signs and symptoms are self-limited, with resolution occurring within 2 months in 50% of patients, and 80% resolving within 4 months. Currently, there are no specific preventive or therapeutic recommendations. We found 69 cases of HNP after procedural airway management reported in the literature from 1926 to 2013.
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Affiliation(s)
- Aalap C Shah
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; and Institute for Translational Health Sciences, University of Washington, Seattle, Washington
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Cogan A, Boyer P, Soubeyrand M, Hamida FB, Vannier JL, Massin P. Cranial nerves neuropraxia after shoulder arthroscopy in beach chair position. Orthop Traumatol Surg Res 2011; 97:345-8. [PMID: 21459065 DOI: 10.1016/j.otsr.2010.09.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 08/31/2010] [Accepted: 09/20/2010] [Indexed: 02/02/2023]
Abstract
We report a case of neuropraxia of the 9th, 10th and 12th cranial nerve pairs after arthroscopic rotator cuff repair in the beach chair position. The elements in the medical file seem to exclude an intracranial cause of the lesions and support a mechanical, extracranial cause due to intubation and/or the beach chair position. This clinical case report shows the neurological risks of the beach chair position during arthroscopic shoulder surgery and presents the essential safety measures to prevent these risks.
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Affiliation(s)
- A Cogan
- Department of Orthopaedic Surgery, Bichat Claude Bernard Teaching Hospital Center, Paris-7 University, 46, avenue Henri-Huchard, 75018 Paris, France.
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Rains DD, Rooke GA, Wahl CJ. Pathomechanisms and complications related to patient positioning and anesthesia during shoulder arthroscopy. Arthroscopy 2011; 27:532-41. [PMID: 21186092 DOI: 10.1016/j.arthro.2010.09.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Revised: 08/31/2010] [Accepted: 09/09/2010] [Indexed: 02/02/2023]
Abstract
The lateral decubitus and beach-chair positions each offer unique benefits to the shoulder surgeon with respect to visualization, efficiency, and ease during arthroscopic shoulder procedures. The purpose of this article was to comprehensively review the reports and studies documenting independent and dependent complications related to patient positioning and anesthesia during arthroscopic shoulder surgery. The lateral decubitus position has been associated with the potential for peripheral neurapraxia, brachial plexopathy, direct nerve injury, and airway compromise. The beach-chair position has been associated with cervical neurapraxia, pneumothorax, and the potential for end-organ hypoperfusion injuries (when deliberate hypotension is used). Potentially concerning are hypotensive bradycardic events, which may be relatively common in association with the use of epinephrine-containing interscalene anesthetics in beach chair-positioned patients. Irrigant complications (fluid spread, ventricular tachycardia) are avoidable risks not unique to either specific position. Although minor transient anesthetic- and position-related complications (neurapraxia, hypotension) may occur in as many 10% to 30% of patients, major complications such as end-organ damage or permanent impairments are exceedingly rare. Regardless of position, complications are almost uniformly avoidable if surgeon and anesthetist exercise care and prudent attention to position and anesthetic choices. The purpose of this article is to review the potential for position- and anesthesia-related complications and acquaint the shoulder surgeon with the proposed pathophysiologic mechanisms that can lead to them.
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Affiliation(s)
- Derek D Rains
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, 98195-4060, USA
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