AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 3 10 – 3 1 1
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Dysphagia, hoarseness, and globus in a postoperative patient☆ Russel Kahmke, MD 1 , Charles R. Woodard, MD⁎ Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Duke University Health System, Durham, NC
ARTI CLE I NFO
A BS TRACT
Article history:
Sore throat, hoarseness, and dysphagia are known and recognized postoperative
Received 11 November 2014
complications of laryngeal mask airway use during operative procedures. The patient's symptoms, present immediately after surgery, are thought related to airway manipulation. Airway foreign bodies, although low on the differential, can cause similar symptoms. We present a case of a single patient who presented to a tertiary care center after an elective outpatient procedure with postoperative sore throat, hoarseness, and dysphagia. A foreign body was found lodged in the patient's hypopharynx. The differential diagnosis of sore throat, hoarseness, and dysphagia in the postoperative patient is explored in further detail. Published by Elsevier Inc.
1.
Introduction
The laryngeal mask airway (LMA) was developed by British anesthesiologist Archie Brain in the 1980s and has been available to American anesthesiologists since 1992. With a greater than 99% success rate [1], the LMA has proven to be safe and effective, even in difficult airway situations [2]. Sore throat, hoarseness, and dysphagia are well known and recognized postoperative complications from LMA use. When these symptoms persist or worsen outside of the immediate perioperative period, alternative diagnoses, like airway foreign bodies, should be considered.
2.
Case report
Institutional review board (IRB) approval was obtained from the Duke University School of Medicine; the requirement for written consent given the retrospective nature was waived. The patient was a 61-year-old male who underwent an elective right knee arthroscopy two days prior to arrival. Upon emergence from anesthesia, he noted a sore throat, globus sensation and odynophagia. He discussed his concerns with his anesthesiologist, who informed the patient that placement of the LMA was difficult, requiring removal and reinsertion. The patient was reassured and given chloroseptic
☆ This submission was presented as listed below: Differential Diagnosis of Dysphagia, Hoarseness, and Globus in a Post-Operative Patient: A Case Report and Review of Literature. 6th Annual Alliance for Surgery and Anesthesia Presence Meeting, September 2013, Durham, NC. ⁎ Corresponding author at: DUMC 3805. Tel.: + 1 919 684 6968; fax: +1 919 684 9108. E-mail addresses: [email protected] (R. Kahmke), [email protected] (C.R. Woodard). 1 Mailing Address: DUMC 2824, Durham, NC 27710.
http://dx.doi.org/10.1016/j.amjoto.2014.11.011 0196-0709/Published by Elsevier Inc.
AM ER IC AN JOURNAL OF OT OLARYNGOLOGY – H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 3 10– 3 1 1
Fig. 1 – Electrocardiogram lead electrode backing.
spray. Over the next 48 hours, he developed worsening globus, hoarseness, odynophagia, and dysphagia to solids. He denied respiratory distress, fever, chills, palpitations, and chest pain. He presented to the emergency department at a tertiary referral center for evaluation. The vital signs were within normal limits; he was not stridulous or in respiratory distress. His neck was flat and without crepitus. Upon flexible fiberoptic laryngoscopy, the true vocal folds were fully mobile without evidence of arytenoid dislocation but an opaque circular foreign body was noted within the hypopharynx overlying the arytenoids and contacting the lateral borders of the epiglottis. Attempts at bedside removal with Magill forceps under fiberoptic guidance were unsuccessful. The patient was taken to the operating room for a direct laryngoscopy with removal of the foreign body. An electrocardiogram lead electrode backing was removed from the hypopharynx without incident (see Fig. 1). Direct examination afterwards revealed erosion of the posterior pharyngeal wall and edema of the arytenoids. The patient noted immediate resolution of the globus sensation, dysphagia, and hoarseness after removal of the foreign body. He maintained a mild sore throat. The patient was given a 10 day course of prednisone and amoxicillin/clavulanate and was discharged to home in stable condition. There was no long term sequela noted on follow-up.
3.
Discussion
LMA has been shown to be a safe and effective alternative to endotracheal intubation for procedures requiring general anesthesia. The incidence of sore throat, hoarseness, and
311
cough has been shown to be lower when an LMA is used compared to a endotracheal tube [3]. Verghese and Brimacombe showed a complication rate of 0.37% with LMA use in their series of over 11,000 patients [1]. Grady and colleagues showed that a larger LMA was associated with a higher incidence of sore throat in both men and women and hoarseness in men at 2 hours postoperatively [4]. A larger LMA was also associated with a higher incidence of sore throat at 24 hours. Inappropriate size, cuff overinflation, aspiration of gastric contents, local irrigation, direct trauma, improper placement, positive pressure, and bronchoconstriction have all been postulated as causes of postoperative complications [5]. When symptoms persist or worsen after 24 hours, additional diagnoses like arytenoid dislocation, vocal fold immobility, and airway foreign bodies should be considered. The 61-year-old patient above was noted to have a difficult airway, requiring removal of the LMA prior to replacement. The electrocardiogram lead electrode backing likely became attached to the LMA when it was set down prior to reinsertion. The initial postoperative symptoms of sore throat, globus, odynophagia, and hoarseness were expected by the anesthesiologist and considered routine. After 48 hours of progressive worsening of symptomatology, the patient sought evaluation. Overall, sore throat, hoarseness, and dysphagia are well known complications from LMA use during both routine and urgent airway management. Persistent or worsening symptoms outside of the immediate postoperative window warrant additional work-up and expansion of the differential diagnosis to include airway foreign bodies.
REFERENCES
[1] Verghese C, Brimacombe JR. Survey of laryngeal mask airway usage in 11,910 patients: safety and efficacy for conventional and nonconventional usage. Anesth Analg 1996;82:129–33. [2] Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251–70. [3] Ryu JH, Yom CK, Park DJ, et al. Prospective randomized controlled trial on the use of flexible reinforced laryngeal mask airway (LMA) during total thyroidectomy; effects of postoperative laryngopharyngeal symptoms. World J Surg 2013 [Epub ahead of print]. [4] Grady DM, McHardy F, Wong J, et al. Pharyngolaryngeal morbidity with the laryngeal mask airway in spontaneously breathing patients: does size matter? Anesthesiology 2001;94: 760–6. [5] Pollack Jr CV. The laryngeal mask airway: a comprehensive review for the emergency physician. J Emerg Med 2001;20: 53–66.
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Dysphagia, hoarseness, and globus in a postoperative patient☆ Russel Kahmke, MD 1 , Charles R. Woodard, MD⁎ Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Duke University Health System, Durham, NC
ARTI CLE I NFO
A BS TRACT
Article history:
Sore throat, hoarseness, and dysphagia are known and recognized postoperative
Received 11 November 2014
complications of laryngeal mask airway use during operative procedures. The patient's symptoms, present immediately after surgery, are thought related to airway manipulation. Airway foreign bodies, although low on the differential, can cause similar symptoms. We present a case of a single patient who presented to a tertiary care center after an elective outpatient procedure with postoperative sore throat, hoarseness, and dysphagia. A foreign body was found lodged in the patient's hypopharynx. The differential diagnosis of sore throat, hoarseness, and dysphagia in the postoperative patient is explored in further detail. Published by Elsevier Inc.
1.
Introduction
The laryngeal mask airway (LMA) was developed by British anesthesiologist Archie Brain in the 1980s and has been available to American anesthesiologists since 1992. With a greater than 99% success rate [1], the LMA has proven to be safe and effective, even in difficult airway situations [2]. Sore throat, hoarseness, and dysphagia are well known and recognized postoperative complications from LMA use. When these symptoms persist or worsen outside of the immediate perioperative period, alternative diagnoses, like airway foreign bodies, should be considered.
2.
Case report
Institutional review board (IRB) approval was obtained from the Duke University School of Medicine; the requirement for written consent given the retrospective nature was waived. The patient was a 61-year-old male who underwent an elective right knee arthroscopy two days prior to arrival. Upon emergence from anesthesia, he noted a sore throat, globus sensation and odynophagia. He discussed his concerns with his anesthesiologist, who informed the patient that placement of the LMA was difficult, requiring removal and reinsertion. The patient was reassured and given chloroseptic
☆ This submission was presented as listed below: Differential Diagnosis of Dysphagia, Hoarseness, and Globus in a Post-Operative Patient: A Case Report and Review of Literature. 6th Annual Alliance for Surgery and Anesthesia Presence Meeting, September 2013, Durham, NC. ⁎ Corresponding author at: DUMC 3805. Tel.: + 1 919 684 6968; fax: +1 919 684 9108. E-mail addresses: [email protected] (R. Kahmke), [email protected] (C.R. Woodard). 1 Mailing Address: DUMC 2824, Durham, NC 27710.
http://dx.doi.org/10.1016/j.amjoto.2014.11.011 0196-0709/Published by Elsevier Inc.
AM ER IC AN JOURNAL OF OT OLARYNGOLOGY – H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 3 10– 3 1 1
Fig. 1 – Electrocardiogram lead electrode backing.
spray. Over the next 48 hours, he developed worsening globus, hoarseness, odynophagia, and dysphagia to solids. He denied respiratory distress, fever, chills, palpitations, and chest pain. He presented to the emergency department at a tertiary referral center for evaluation. The vital signs were within normal limits; he was not stridulous or in respiratory distress. His neck was flat and without crepitus. Upon flexible fiberoptic laryngoscopy, the true vocal folds were fully mobile without evidence of arytenoid dislocation but an opaque circular foreign body was noted within the hypopharynx overlying the arytenoids and contacting the lateral borders of the epiglottis. Attempts at bedside removal with Magill forceps under fiberoptic guidance were unsuccessful. The patient was taken to the operating room for a direct laryngoscopy with removal of the foreign body. An electrocardiogram lead electrode backing was removed from the hypopharynx without incident (see Fig. 1). Direct examination afterwards revealed erosion of the posterior pharyngeal wall and edema of the arytenoids. The patient noted immediate resolution of the globus sensation, dysphagia, and hoarseness after removal of the foreign body. He maintained a mild sore throat. The patient was given a 10 day course of prednisone and amoxicillin/clavulanate and was discharged to home in stable condition. There was no long term sequela noted on follow-up.
3.
Discussion
LMA has been shown to be a safe and effective alternative to endotracheal intubation for procedures requiring general anesthesia. The incidence of sore throat, hoarseness, and
311
cough has been shown to be lower when an LMA is used compared to a endotracheal tube [3]. Verghese and Brimacombe showed a complication rate of 0.37% with LMA use in their series of over 11,000 patients [1]. Grady and colleagues showed that a larger LMA was associated with a higher incidence of sore throat in both men and women and hoarseness in men at 2 hours postoperatively [4]. A larger LMA was also associated with a higher incidence of sore throat at 24 hours. Inappropriate size, cuff overinflation, aspiration of gastric contents, local irrigation, direct trauma, improper placement, positive pressure, and bronchoconstriction have all been postulated as causes of postoperative complications [5]. When symptoms persist or worsen after 24 hours, additional diagnoses like arytenoid dislocation, vocal fold immobility, and airway foreign bodies should be considered. The 61-year-old patient above was noted to have a difficult airway, requiring removal of the LMA prior to replacement. The electrocardiogram lead electrode backing likely became attached to the LMA when it was set down prior to reinsertion. The initial postoperative symptoms of sore throat, globus, odynophagia, and hoarseness were expected by the anesthesiologist and considered routine. After 48 hours of progressive worsening of symptomatology, the patient sought evaluation. Overall, sore throat, hoarseness, and dysphagia are well known complications from LMA use during both routine and urgent airway management. Persistent or worsening symptoms outside of the immediate postoperative window warrant additional work-up and expansion of the differential diagnosis to include airway foreign bodies.
REFERENCES
[1] Verghese C, Brimacombe JR. Survey of laryngeal mask airway usage in 11,910 patients: safety and efficacy for conventional and nonconventional usage. Anesth Analg 1996;82:129–33. [2] Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251–70. [3] Ryu JH, Yom CK, Park DJ, et al. Prospective randomized controlled trial on the use of flexible reinforced laryngeal mask airway (LMA) during total thyroidectomy; effects of postoperative laryngopharyngeal symptoms. World J Surg 2013 [Epub ahead of print]. [4] Grady DM, McHardy F, Wong J, et al. Pharyngolaryngeal morbidity with the laryngeal mask airway in spontaneously breathing patients: does size matter? Anesthesiology 2001;94: 760–6. [5] Pollack Jr CV. The laryngeal mask airway: a comprehensive review for the emergency physician. J Emerg Med 2001;20: 53–66.
