Letters to the Editor
deformability after transfusion and the effects of erythrocyte storage duration. Anesth Analg 2013;116:975–81 4. Opdahl H, Strømme TA, Jørgensen L, Bajelan L, Heier HE. The acidosis-induced right shift of the HbO2 dissociation curve is maintained during erythrocyte storage. Scand J Clin Lab Invest 2011;71:314–21 5. Gladwin MT, Kim-Shapiro DB. Storage lesion in banked blood due to hemolysis-dependent disruption of nitric oxide homeostasis. Curr Opin Hematol 2009;16:515–23 6. Relevy H, Koshkaryev A, Manny N, Yedgar S, Barshtein G. Blood banking-induced alteration of red blood cell flow properties. Transfusion 2008;48:136–46 DOI: 10.1213/ANE.0b013e3182a4f11b
Tapia’s Syndrome: A Rare Complication of Airway Trauma To the Editor
4. Boisseau N, Rabarijaona H, Grimaud D, Raucoules-Aimé M. Tapia’s syndrome following shoulder surgery. Br J Anaesth 2002;88:869–70 5. Lim KJ, Kim MH, Kang MH, Lee HM, Park EY, Kwon KJ, Lee SK, Choi H, Moon HS. Tapia’s syndrome following cervical laminoplasty -A case report-. Korean J Anesthesiol 2013;64:172–4 6. Nalladaru Z, Wessels A, DuPreez L. Tapia’s syndrome–a rare complication following cardiac surgery. Interact Cardiovasc Thorac Surg 2012;14:131–2 7. Rotondo F, De Paulis S, Modoni A, Schiavello R. Peripheral Tapia’s syndrome after cardiac surgery. Eur J Anaesthesiol 2010;27:575–6 8. Sotiriou K, Balanika M, Anagnostopoulou S, Gomatos C, Karakitsos D, Saranteas T. Postoperative airway obstruction due to Tapia’s syndrome after coronary bypass grafting surgery. Eur J Anaesthesiol 2007;24:378–9 9. Lykoudis EG, Seretis K. Tapia’s syndrome: an unexpected but real complication of rhinoplasty: case report and literature review. Aesthetic Plast Surg (United States) 2012;36:557–9 10. Quattrocolo G, Giobbe D, Baggiore P. Tapia’s syndrome caused by a neurilemmoma of vagus and hypoglossal nerves in the neck. Acta Neurol (Napoli) 1986;8:535–40 DOI: 10.1213/ANE.0b013e3182a5c717
T
he recent article by Yan et al.1 describing airway trauma as a complication occurring during anesthesia does not mention Tapia’s syndrome, an additional rare complication of airway trauma that is often overlooked. The syndrome incorporates the signs and symptoms associated with unilateral extracranial tenth (recurrent laryngeal branch usually) and twelfth nerve palsy.2 This results in unilateral and occasional bilateral3 lingual as well as vocal cord paralysis. It usually occurs secondary to tracheal intubation, and the general consensus is that the inflated cuff of the tracheal tube compresses the extracranial X and XII nerves within the larynx and/or the pharynx, resulting in subsequent neuropraxia.4 Head position, especially neck hyperextension, during the duration of surgery has a significant impact on its incidence. Other procedures associated with this problem include rhinoplasty,3 extreme head positioning during shoulder surgery,5 cervical laminoplasty,6 cardiac pulmonary bypass,7 and surgical repair of a fractured mandible.8 Symptoms usually appear soon after tracheal extubation. The patient complains of hoarseness. Dyspnea on speaking may also be present.9 In addition, dysphagia and dysphonia may be present. Physical examination usually reveals lingual deviation on protrusion. The symptoms usually resolve spontaneously over a period of a week to 3 months. Steroid therapy may be necessary in some cases.10 Physicians, especially anesthesiologists, should be aware of this postoperative complication. Shailendra Kapoor, MD Private practice Mechanicsville, Virginia [email protected] REFERENCES 1. Yan Z, Tanner JW, Lin D, Chalian AA, Savino JS, Fleisher LA, Liu R. Airway trauma in a high patient volume academic cardiac electrophysiology laboratory center. Anesth Analg 2013;116:112–7 2. Cinar SO, Seven H, Cinar U, Turgut S. Isolated bilateral paralysis of the hypoglossal and recurrent laryngeal nerves (Bilateral Tapia’s syndrome) after transoral intubation for general anesthesia. Acta Anaesthesiol Scand 2005;49:98–9 3. Gevorgyan A, Nedzelski JM. A late recognition of tapia syndrome. Laryngoscope 2013;123:2423–7
November 2013 • Volume 117 • Number 5
In Response We thank Dr. Kapoor for his interest in our study of airway complications in patients undergoing electrophysiology procedures.1,2 In particular, Dr. Kapoor has drawn attention to the syndrome of palsy of the recurrent laryngeal and hypoglossal nerves, originally reported over a century ago by Dr. Tapia, an otolaryngologist.3,4 This rare syndrome has been reported as a complication after general anesthesia in patients in whom a tracheal tube or laryngeal mask airway (LMA) was present.3,5 It is generally thought to occur because of nerve compression or stretching as a result of tracheal tube malposition and/or neck hyperextension. While primarily associated with head or neck surgery, Dr. Kapoor cites several reports in cardiac surgery patients,6 who were probably similarly anticoagulated like those in our study population of cardiac electrophysiology patients. In our case-control study, no similar symptom was reported in any patients in whom tracheal tubes were inserted. The head and neck were in neutral position for patients in the electrophysiology lab. There was 1 patient in our series in whom an LMA was present and who developed hoarseness and dysphagia without tongue paralysis. Due to the nature of a retrospective study, we cannot rule in or rule out whether Tapia’s syndrome could be ascribed to the presence of the LMA. Dr. Kapoor’s point that anesthesiologists should be aware of this complication is well taken in patients undergoing electrophysiology procedures. Indeed, we stated that LMA might not be a good choice for airway management in anticoagulated electrophysiology patients.1
Jonathan W. Tanner, MD, PhD Department of Anesthesiology and Critical Care David Lin, MD Penn Heart and Vascular Center Renyu Liu, MD, PhD Department of Anesthesiology and Critical Care Hospital of the University of Pennsylvania Philadelphia, Pennsylvania [email protected]
www.anesthesia-analgesia.org 1261
deformability after transfusion and the effects of erythrocyte storage duration. Anesth Analg 2013;116:975–81 4. Opdahl H, Strømme TA, Jørgensen L, Bajelan L, Heier HE. The acidosis-induced right shift of the HbO2 dissociation curve is maintained during erythrocyte storage. Scand J Clin Lab Invest 2011;71:314–21 5. Gladwin MT, Kim-Shapiro DB. Storage lesion in banked blood due to hemolysis-dependent disruption of nitric oxide homeostasis. Curr Opin Hematol 2009;16:515–23 6. Relevy H, Koshkaryev A, Manny N, Yedgar S, Barshtein G. Blood banking-induced alteration of red blood cell flow properties. Transfusion 2008;48:136–46 DOI: 10.1213/ANE.0b013e3182a4f11b
Tapia’s Syndrome: A Rare Complication of Airway Trauma To the Editor
4. Boisseau N, Rabarijaona H, Grimaud D, Raucoules-Aimé M. Tapia’s syndrome following shoulder surgery. Br J Anaesth 2002;88:869–70 5. Lim KJ, Kim MH, Kang MH, Lee HM, Park EY, Kwon KJ, Lee SK, Choi H, Moon HS. Tapia’s syndrome following cervical laminoplasty -A case report-. Korean J Anesthesiol 2013;64:172–4 6. Nalladaru Z, Wessels A, DuPreez L. Tapia’s syndrome–a rare complication following cardiac surgery. Interact Cardiovasc Thorac Surg 2012;14:131–2 7. Rotondo F, De Paulis S, Modoni A, Schiavello R. Peripheral Tapia’s syndrome after cardiac surgery. Eur J Anaesthesiol 2010;27:575–6 8. Sotiriou K, Balanika M, Anagnostopoulou S, Gomatos C, Karakitsos D, Saranteas T. Postoperative airway obstruction due to Tapia’s syndrome after coronary bypass grafting surgery. Eur J Anaesthesiol 2007;24:378–9 9. Lykoudis EG, Seretis K. Tapia’s syndrome: an unexpected but real complication of rhinoplasty: case report and literature review. Aesthetic Plast Surg (United States) 2012;36:557–9 10. Quattrocolo G, Giobbe D, Baggiore P. Tapia’s syndrome caused by a neurilemmoma of vagus and hypoglossal nerves in the neck. Acta Neurol (Napoli) 1986;8:535–40 DOI: 10.1213/ANE.0b013e3182a5c717
T
he recent article by Yan et al.1 describing airway trauma as a complication occurring during anesthesia does not mention Tapia’s syndrome, an additional rare complication of airway trauma that is often overlooked. The syndrome incorporates the signs and symptoms associated with unilateral extracranial tenth (recurrent laryngeal branch usually) and twelfth nerve palsy.2 This results in unilateral and occasional bilateral3 lingual as well as vocal cord paralysis. It usually occurs secondary to tracheal intubation, and the general consensus is that the inflated cuff of the tracheal tube compresses the extracranial X and XII nerves within the larynx and/or the pharynx, resulting in subsequent neuropraxia.4 Head position, especially neck hyperextension, during the duration of surgery has a significant impact on its incidence. Other procedures associated with this problem include rhinoplasty,3 extreme head positioning during shoulder surgery,5 cervical laminoplasty,6 cardiac pulmonary bypass,7 and surgical repair of a fractured mandible.8 Symptoms usually appear soon after tracheal extubation. The patient complains of hoarseness. Dyspnea on speaking may also be present.9 In addition, dysphagia and dysphonia may be present. Physical examination usually reveals lingual deviation on protrusion. The symptoms usually resolve spontaneously over a period of a week to 3 months. Steroid therapy may be necessary in some cases.10 Physicians, especially anesthesiologists, should be aware of this postoperative complication. Shailendra Kapoor, MD Private practice Mechanicsville, Virginia [email protected] REFERENCES 1. Yan Z, Tanner JW, Lin D, Chalian AA, Savino JS, Fleisher LA, Liu R. Airway trauma in a high patient volume academic cardiac electrophysiology laboratory center. Anesth Analg 2013;116:112–7 2. Cinar SO, Seven H, Cinar U, Turgut S. Isolated bilateral paralysis of the hypoglossal and recurrent laryngeal nerves (Bilateral Tapia’s syndrome) after transoral intubation for general anesthesia. Acta Anaesthesiol Scand 2005;49:98–9 3. Gevorgyan A, Nedzelski JM. A late recognition of tapia syndrome. Laryngoscope 2013;123:2423–7
November 2013 • Volume 117 • Number 5
In Response We thank Dr. Kapoor for his interest in our study of airway complications in patients undergoing electrophysiology procedures.1,2 In particular, Dr. Kapoor has drawn attention to the syndrome of palsy of the recurrent laryngeal and hypoglossal nerves, originally reported over a century ago by Dr. Tapia, an otolaryngologist.3,4 This rare syndrome has been reported as a complication after general anesthesia in patients in whom a tracheal tube or laryngeal mask airway (LMA) was present.3,5 It is generally thought to occur because of nerve compression or stretching as a result of tracheal tube malposition and/or neck hyperextension. While primarily associated with head or neck surgery, Dr. Kapoor cites several reports in cardiac surgery patients,6 who were probably similarly anticoagulated like those in our study population of cardiac electrophysiology patients. In our case-control study, no similar symptom was reported in any patients in whom tracheal tubes were inserted. The head and neck were in neutral position for patients in the electrophysiology lab. There was 1 patient in our series in whom an LMA was present and who developed hoarseness and dysphagia without tongue paralysis. Due to the nature of a retrospective study, we cannot rule in or rule out whether Tapia’s syndrome could be ascribed to the presence of the LMA. Dr. Kapoor’s point that anesthesiologists should be aware of this complication is well taken in patients undergoing electrophysiology procedures. Indeed, we stated that LMA might not be a good choice for airway management in anticoagulated electrophysiology patients.1
Jonathan W. Tanner, MD, PhD Department of Anesthesiology and Critical Care David Lin, MD Penn Heart and Vascular Center Renyu Liu, MD, PhD Department of Anesthesiology and Critical Care Hospital of the University of Pennsylvania Philadelphia, Pennsylvania [email protected]
www.anesthesia-analgesia.org 1261
