Arytenoid Cartilage Dislocation After Laparoscopic Surgery for Treatment of Diabetes Kuo-Chuan Hung, MD I report the occurrence of left arytenoid dislocation in 2 patients undergoing laparoscopic surgical procedures formerly used only for weight loss and that are now being used for treatment of diabetes. After uncomplicated tracheal intubation, a calibrating orogastric tube was inserted into the esophagus blindly and without difficulty. On the second postoperative day, both patients complained of severe hoarseness, for which arytenoid dislocation was diagnosed. I suspect that the insertion of the calibrating orogastric tube in these nonobese patients may have led to the development of this rare complication. Recognition of its occurrence and subsequent treatment are important to preventing long-term consequences of arytenoid dislocation. (A&A Case Reports 2013;1:34–6)
L
aparoscopic surgical procedures commonly used to treat morbid obesity are now also being used in nonobese patients to treat type 2 diabetes mellitus (DM).1,2 Although this surgery is usually performed with few complications, the use of a calibrating orogastric tube to facilitate gastric pouch formation has been associated with procedural complications.3 Herein, I report 2 cases of arytenoid dislocation in diabetic patients undergoing laparoscopic surgery requiring insertion of a calibrating orogastric tube. I discuss the possible mechanisms for this rare complication. The patients’ written consent was obtained for publication of this report.
CASE DESCRIPTION
Patient 1 was a 60-year-old ASA physical status II woman (52 kg and 150 cm; body mass index [BMI]: 23 kg/m2) with a 7-year history of type 2 DM who was scheduled for laparoscopic Roux-en-y gastric bypass surgery. Patient 2 was a 37-year-old ASA physical status II woman (62 kg and 162 cm; BMI: 24 kg/m2) with an 8-year history of type 2 DM who was scheduled for laparoscopic loop duodenojejunal bypass with sleeve gastrectomy. Patient 1 had a long history of a light “breathy” voice. No other history of pharyngeal or laryngeal disorders was found in either patient. In both patients, preoperative laboratory examination was unremarkable and preoperative airway evaluation revealed a class 2 airway and no risk of difficult tracheal intubation. After standard monitoring, anesthesia was induced with fentanyl, propofol, and rocuronium. After complete muscle relaxation was achieved, a 7.0-mm tracheal tube with a Flexi-Slip stylet (Willy Rüsch AG, Kernen, Germany) was smoothly inserted into the trachea under direct vision with the aid of a Macintosh 3 laryngoscope blade. Anesthesia From the Department of Anesthesiology, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan, Republic of China. Accepted for publication March 20, 2013. Funding: None. The author declares no conflicts of interest. Address correspondence and reprint requests to Kuo-Chuan Hung, MD, Department of Anesthesiology, E-DA Hospital, 1, E-Da Road, Jiau-shu Tsuen, Yan-Chau Shiang, Kaohsiung, Taiwan 824, Republic of China. Address e-mail to [email protected]. Copyright © 2013 International Anesthesia Research Society DOI: 10.1097/ACC.0b013e3182944da3
34 cases.anesthesia-analgesia.org
was maintained with desflurane 7% to 9% (Fio2 = 0.8) in patient 1 and 3.0% to 3.5% sevoflurane (Fio2 = 0.5) in patient 2 with controlled pressure ventilation via a circle system. Additional neuromuscular blockade was administered intraoperatively. After tracheal intubation, a calibrating orogastric tube (36-Fr gauge; Obtech Medical Sàrl, Bern, Switzerland) was introduced into the esophagus blindly and left in place. The introduction of the orogastric tube was smooth, and no resistance was encountered in either patient. Both patients were positioned supine with their heads and necks kept in a neutral position. Pneumoperitoneum was established with CO2 at an intraabdominal pressure of 15 mm Hg. The operating table was adjusted to move the patients into reverse Trendelenburg position at an angle of 30° to 45° intraoperatively. Both patients tolerated the operation well, and the orogastric tube was removed without difficulty just before completion of the operation. After surgery, the trachea was extubated without difficulty. The total time for tracheal intubation was 305 minutes in patient 1 and 230 minutes in patient 2. Neither patient complained of hoarseness or other pharyngeal discomfort during their stay in the recovery room, but on the second postoperative day, both developed increasingly severe hoarseness. Patient 1 had a history of a breathy voice, and conservative therapy was used to treat the hoarseness. She was discharged on the 4th postoperative day but returned on the 34th day complaining of persistent hoarseness. An otorhinolaryngologist using fiberoptic laryngoscopy found limited left arytenoid movement. A dislocated arytenoid cartilage was suspected. Closed reduction of the displaced cartilage was performed under general anesthesia on the 36th postoperative day. Voice recovery was limited. When patient 2 developed severe hoarseness on the second postoperative day, the surgeon, aware of the complications of patient 1, requested an otorhinolaryngologist to perform fiberoptic laryngoscopy on the third postoperative day. The examination revealed left anterior dislocation of the arytenoid cartilage with nearby mucosal edema (Fig. 1). Closed reduction was performed under general anesthesia on the same day, and the voice quality improved after the operation. October 15, 2013 • Volume 1 • Number 2
Figure 1. Endoscopic view of larynx on the third day after bariatric surgery. Severe anterior dislocation of the left arytenoid cartilage (arrow) is clear.
DISCUSSION
Cricoarytenoid joint dysfunction can occur after atraumatic tracheal intubation4,5 or airway manipulation with the use of laryngeal mask airway, lighted stylet, double-lumen tube, or McCoy laryngoscope in patients receiving general anesthesia.6–9 The incidence of arytenoid dislocation associated with tracheal intubation has been reported as 0.097% (3/3093) in the general population.10 One potential predisposing factor for this complication, however, is reported to be insertion of transesophageal echocardiography probe into the larynx or esophagus.11 The primary symptom of arytenoid dislocation is persistent hoarseness, though acute respiratory failure is also possible.5 A delay in diagnosis and treatment of this complication can lead to vocal fold immobility. Because postoperative hoarseness after tracheal intubation is common,10 it is possible that this rare event may go unnoticed and untreated (patient 1). The cricoarytenoid articulation is a diarthrodial joint supported by a wide joint capsule lined with synovia. One previous study, investigating cadaver larynges subjected to simulated intubation and extubation trauma, found that injury to the synovial folds of the cricoarytenoid joint or the outermost layers of the articular cartilage could cause joint cavity hemorrhage or serosynovitis leading to fixation of the cricoarytenoid joint.12 Depending on the location of the lesion in the joint cavity, the arytenoid cartilage can slowly shift in an anterior-medial or posteriorlateral direction,12 which could lead to the development of hoarseness, as was found in our 2 patients on the second postoperative day. To date, 1629 patients (BMI ≥ 35 kg/m2: 1116; BMI < 35 kg/m2: 513) have undergone laparoscopic surgical procedures for treatment of morbid obesity or type 2 DM in our hospital. In most, the trachea was intubated with a styletted tracheal tube via Macintosh laryngoscopy after which a calibrating orogastric tube was used routinely and usually
October 15, 2013 • Volume 1 • Number 2
inserted blindly. In our 2 patients, although the cause of the complication may have been the distal orifice of the tracheal tube or tip of the stylet pressing against the arytenoid cartilage, this etiology was unlikely because tracheal intubation was straightforward and smooth. We suggest that the arytenoid dislocation may be a complication of inserting the calibrating orogastric tube. We suspected this possibility because the calibrating orogastric tube had a large diameter and was inserted blindly. In addition, the body of the tracheal tube may have exerted some force against the medial sides of the arytenoids cartilages. This has been reported in a cadaver study13 and has been suggested by 2 case reports in which no apparent trauma occurred.4,5 After prolonged tracheal intubation, the occurrence of hemorrhage, infection, inflammation, and fibrosis within the cricoarytenoid joint is possible,14 which was likely the cause of the arytenoid dislocation in our 2 patients. We suspect that the presence of a larger calibrating orogastric tube within the esophagus further contributed to cricoarytenoid joint dysfunction in our patients. It is possible that the arytenoid cartilage may have been compressed between the convex curvature of the tracheal tube anteriorly and the body of the calibrating orogastric tube posteriorly, leading to formation of a hemarthros or serosynovitis. Almost 50% of calibrating orogastric tubes may be displaced leftward when left in the esophagus.15 Our patients were both found to have left dislocation of arytenoids cartilage, further implicating the presence of the orogastric tube in the occurrence of this complication. Anesthesiologists and surgeons should be aware of the possibility of arytenoid dislocation when a calibrating orogastric tube has been used during laparoscopic surgery and is followed by prolonged hoarseness. E REFERENCES 1. Ramos AC, Galvão Neto MP, de Souza YM, Galvão M, Murakami AH, Silva AC, Canseco EG, Santamaría R, Zambrano TA. Laparoscopic duodenal-jejunal exclusion in the treatment of type 2 diabetes mellitus in patients with BMI35 and
L
aparoscopic surgical procedures commonly used to treat morbid obesity are now also being used in nonobese patients to treat type 2 diabetes mellitus (DM).1,2 Although this surgery is usually performed with few complications, the use of a calibrating orogastric tube to facilitate gastric pouch formation has been associated with procedural complications.3 Herein, I report 2 cases of arytenoid dislocation in diabetic patients undergoing laparoscopic surgery requiring insertion of a calibrating orogastric tube. I discuss the possible mechanisms for this rare complication. The patients’ written consent was obtained for publication of this report.
CASE DESCRIPTION
Patient 1 was a 60-year-old ASA physical status II woman (52 kg and 150 cm; body mass index [BMI]: 23 kg/m2) with a 7-year history of type 2 DM who was scheduled for laparoscopic Roux-en-y gastric bypass surgery. Patient 2 was a 37-year-old ASA physical status II woman (62 kg and 162 cm; BMI: 24 kg/m2) with an 8-year history of type 2 DM who was scheduled for laparoscopic loop duodenojejunal bypass with sleeve gastrectomy. Patient 1 had a long history of a light “breathy” voice. No other history of pharyngeal or laryngeal disorders was found in either patient. In both patients, preoperative laboratory examination was unremarkable and preoperative airway evaluation revealed a class 2 airway and no risk of difficult tracheal intubation. After standard monitoring, anesthesia was induced with fentanyl, propofol, and rocuronium. After complete muscle relaxation was achieved, a 7.0-mm tracheal tube with a Flexi-Slip stylet (Willy Rüsch AG, Kernen, Germany) was smoothly inserted into the trachea under direct vision with the aid of a Macintosh 3 laryngoscope blade. Anesthesia From the Department of Anesthesiology, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan, Republic of China. Accepted for publication March 20, 2013. Funding: None. The author declares no conflicts of interest. Address correspondence and reprint requests to Kuo-Chuan Hung, MD, Department of Anesthesiology, E-DA Hospital, 1, E-Da Road, Jiau-shu Tsuen, Yan-Chau Shiang, Kaohsiung, Taiwan 824, Republic of China. Address e-mail to [email protected]. Copyright © 2013 International Anesthesia Research Society DOI: 10.1097/ACC.0b013e3182944da3
34 cases.anesthesia-analgesia.org
was maintained with desflurane 7% to 9% (Fio2 = 0.8) in patient 1 and 3.0% to 3.5% sevoflurane (Fio2 = 0.5) in patient 2 with controlled pressure ventilation via a circle system. Additional neuromuscular blockade was administered intraoperatively. After tracheal intubation, a calibrating orogastric tube (36-Fr gauge; Obtech Medical Sàrl, Bern, Switzerland) was introduced into the esophagus blindly and left in place. The introduction of the orogastric tube was smooth, and no resistance was encountered in either patient. Both patients were positioned supine with their heads and necks kept in a neutral position. Pneumoperitoneum was established with CO2 at an intraabdominal pressure of 15 mm Hg. The operating table was adjusted to move the patients into reverse Trendelenburg position at an angle of 30° to 45° intraoperatively. Both patients tolerated the operation well, and the orogastric tube was removed without difficulty just before completion of the operation. After surgery, the trachea was extubated without difficulty. The total time for tracheal intubation was 305 minutes in patient 1 and 230 minutes in patient 2. Neither patient complained of hoarseness or other pharyngeal discomfort during their stay in the recovery room, but on the second postoperative day, both developed increasingly severe hoarseness. Patient 1 had a history of a breathy voice, and conservative therapy was used to treat the hoarseness. She was discharged on the 4th postoperative day but returned on the 34th day complaining of persistent hoarseness. An otorhinolaryngologist using fiberoptic laryngoscopy found limited left arytenoid movement. A dislocated arytenoid cartilage was suspected. Closed reduction of the displaced cartilage was performed under general anesthesia on the 36th postoperative day. Voice recovery was limited. When patient 2 developed severe hoarseness on the second postoperative day, the surgeon, aware of the complications of patient 1, requested an otorhinolaryngologist to perform fiberoptic laryngoscopy on the third postoperative day. The examination revealed left anterior dislocation of the arytenoid cartilage with nearby mucosal edema (Fig. 1). Closed reduction was performed under general anesthesia on the same day, and the voice quality improved after the operation. October 15, 2013 • Volume 1 • Number 2
Figure 1. Endoscopic view of larynx on the third day after bariatric surgery. Severe anterior dislocation of the left arytenoid cartilage (arrow) is clear.
DISCUSSION
Cricoarytenoid joint dysfunction can occur after atraumatic tracheal intubation4,5 or airway manipulation with the use of laryngeal mask airway, lighted stylet, double-lumen tube, or McCoy laryngoscope in patients receiving general anesthesia.6–9 The incidence of arytenoid dislocation associated with tracheal intubation has been reported as 0.097% (3/3093) in the general population.10 One potential predisposing factor for this complication, however, is reported to be insertion of transesophageal echocardiography probe into the larynx or esophagus.11 The primary symptom of arytenoid dislocation is persistent hoarseness, though acute respiratory failure is also possible.5 A delay in diagnosis and treatment of this complication can lead to vocal fold immobility. Because postoperative hoarseness after tracheal intubation is common,10 it is possible that this rare event may go unnoticed and untreated (patient 1). The cricoarytenoid articulation is a diarthrodial joint supported by a wide joint capsule lined with synovia. One previous study, investigating cadaver larynges subjected to simulated intubation and extubation trauma, found that injury to the synovial folds of the cricoarytenoid joint or the outermost layers of the articular cartilage could cause joint cavity hemorrhage or serosynovitis leading to fixation of the cricoarytenoid joint.12 Depending on the location of the lesion in the joint cavity, the arytenoid cartilage can slowly shift in an anterior-medial or posteriorlateral direction,12 which could lead to the development of hoarseness, as was found in our 2 patients on the second postoperative day. To date, 1629 patients (BMI ≥ 35 kg/m2: 1116; BMI < 35 kg/m2: 513) have undergone laparoscopic surgical procedures for treatment of morbid obesity or type 2 DM in our hospital. In most, the trachea was intubated with a styletted tracheal tube via Macintosh laryngoscopy after which a calibrating orogastric tube was used routinely and usually
October 15, 2013 • Volume 1 • Number 2
inserted blindly. In our 2 patients, although the cause of the complication may have been the distal orifice of the tracheal tube or tip of the stylet pressing against the arytenoid cartilage, this etiology was unlikely because tracheal intubation was straightforward and smooth. We suggest that the arytenoid dislocation may be a complication of inserting the calibrating orogastric tube. We suspected this possibility because the calibrating orogastric tube had a large diameter and was inserted blindly. In addition, the body of the tracheal tube may have exerted some force against the medial sides of the arytenoids cartilages. This has been reported in a cadaver study13 and has been suggested by 2 case reports in which no apparent trauma occurred.4,5 After prolonged tracheal intubation, the occurrence of hemorrhage, infection, inflammation, and fibrosis within the cricoarytenoid joint is possible,14 which was likely the cause of the arytenoid dislocation in our 2 patients. We suspect that the presence of a larger calibrating orogastric tube within the esophagus further contributed to cricoarytenoid joint dysfunction in our patients. It is possible that the arytenoid cartilage may have been compressed between the convex curvature of the tracheal tube anteriorly and the body of the calibrating orogastric tube posteriorly, leading to formation of a hemarthros or serosynovitis. Almost 50% of calibrating orogastric tubes may be displaced leftward when left in the esophagus.15 Our patients were both found to have left dislocation of arytenoids cartilage, further implicating the presence of the orogastric tube in the occurrence of this complication. Anesthesiologists and surgeons should be aware of the possibility of arytenoid dislocation when a calibrating orogastric tube has been used during laparoscopic surgery and is followed by prolonged hoarseness. E REFERENCES 1. Ramos AC, Galvão Neto MP, de Souza YM, Galvão M, Murakami AH, Silva AC, Canseco EG, Santamaría R, Zambrano TA. Laparoscopic duodenal-jejunal exclusion in the treatment of type 2 diabetes mellitus in patients with BMI35 and
