Abstruse

Vocal string paralysis is a known entity oft described as a complexity of cervix surgery. A less frequent site of injury to the recurrent laryngeal nerve is the chest. The left side is ordinarily more affected than the right side in view of its long intrathoracic segment. Merely few cases of right vocal cord paralysis following open up-middle surgery are reported in the literature. The purpose of this article is to review the common possible mechanisms of injury to the right recurrent laryngeal nerve following open up-heart surgery in order to draw the attending of the caring physician to the clinical significance of such a complexity. In fact, transient hoarseness following open-center surgery may be an ominous sign of recurrent laryngeal nervus injury. It should non be assumed to be secondary to intralaryngeal edema. Several mechanisms of injury to the recurrent laryngeal nervus have been suggested: (1) through central venous catheterization; (2) past traction on the esophagus; (iii) by directly vocal cord damage or palsy from a traumatic endotracheal intubation; (four) trauma by compression of the recurrent laryngeal nervus or its anterior branch at the tracheoesophageal groove by an inappropriately sized endotracheal tube cuff; (five) by a faulty insertion of a nasogastric tube; (6) median sternotomy and/or sternal traction pulling laterally on both subclavian arteries; (7) straight manipulation and retraction of the centre during open-heart procedures; (8) hypothermic injury with ice/slush. If song cord paralysis was overlooked as a possible complication of open-center surgery, the patient may suffer from dysphonia in add-on to issues of paramount importance such as inefficient cough and aspiration. Although it is true that the incidence of song string paralysis remains very low, notwithstanding its presence is alarming and necessitates close follow up on the patient for the possible demand of surgical intervention if recovery fails.

ane Introduction

Vocal cord paralysis is a known entity frequently described as a complication of neck surgery, mainly thyroidectomy. A less frequent site of injury to the recurrent laryngeal nerve is the chest. Even though it is rare, vocal cord paralysis is a well documented complication of thoracic surgery [i–iii]. The left side is commonly more affected than the right side in view of its long intrathoracic segment. It is the about common post-operative complication of extended radical esophagectomy for thoracic esophageal cancer, with a rate of 45% as reported by Nishimaki [four]. Information technology has also been recognized as a belatedly complication of mediastinal irradiation secondary to severe fibrosis after ruling out disease recurrence [5].

Recurrent laryngeal injury afterward cardiac surgery is frequently overlooked as a cause of post-operative respiratory insufficiency or hoarseness. In the evolutionary surgical treatment of patent ductus arteriosis, a review of 231 cases of PDA undergoing surgical closure, three patients had vocal cord paralysis amid other complications [half dozen]. Phrenic nerve palsy is a more recognizable complication of open up-heart surgery with only little emphasis put on recurrent laryngeal nerve palsy. Only few cases of right vocal cord paralysis following open-eye surgery are reported in the literature [seven]. The very short form of the right recurrent laryngeal nerve around the subclavian artery before ascending into the neck makes it less decumbent to injury in thoracic surgery in general and more and then in coronary artery bypass surgery. The purpose of this review is to await at the clinical presentation of vocal cord dysfunction and at the common possible mechanisms of injury to the recurrent laryngeal nerve following open-middle surgery. An illustration of the etiology and clinical significance of such a complication is presented.

2 Incidence

The true incidence of vocal cord dysfunction may be hard to draw in instance of lack of a routine mail service-operative laryngeal examination for patients with dysphonia. The etiology well-nigh often remains unclear with inability to point out the exact crusade of the paralysis.

Vocal cord dysfunction post-obit open-heart surgery is most frequently overlooked as a complication. In a written report on 421 patients undergoing coronary avenue bypass graft surgery, simply 5 patients had unilateral vocal cord paralysis among other peripheral nervous system complications [8]. This is in accordance with other studies that have reported similar incidences of 1–ii% [ix,x]. The paralysis tin can be either isolated or in combination with other neuropathies such as phrenic nerve palsy [11]. Other peripheral nervous organisation complications include brachial radiculoplexopathy, saphenous, peroneal and ulnar mononeuropathies. Isolated Horner syndrome and facial neuropathy were also reported [8]. The dysfunction can touch one string with hoarseness being the complaint, or both cords with resultant respiratory insufficiency [9].

iii Clinical presentation

Patients with unilateral vocal string paralysis usually present with history of dysphonia, i.e. change in voice quality, perceived as hoarseness or breathiness. Moreover, symptoms such as song fatigue, loss of range and reduced intensity may impair their communication skills. In addition to these phonatory complaints, they may take inefficient cough and throat clearing, leading to major complications such as aspiration and recurrent pneumonia. This awareness of chocking on food or secretions may affect their feeding design and quality of life, necessitating surgical intervention. In most reports of unilateral song cord paralysis following open up-heart surgery, patients had hoarseness for one to few days after extubation [8,11]. In a review by Horn et al., four patients out of 193 had right song cord paralysis following open-middle surgery that subsided weeks after the onset [one].

On the other hand, patients with unilateral vocal string paralysis present with respiratory insufficiency, stridor and obstructive symptoms. This condition should not be overlooked and prompts immediate intervention. Following full general surgical procedures, the cause of stridor is oftentimes mistaken for laryngeal spasm. In a post-open-center surgery condition, it is more often overlooked and mistaken for cardiac or respiratory dysfunction. If not attended to on an urgent ground, patients may decompensate and require reintubation and ventilation. In a study conducted by Shafei et al. [three], five patients out of 270 had bilateral vocal cords paralysis post-obit open up-heart surgery. All patients were diagnosed belatedly. All patients had satisfactory weaning criteria from bogus ventilation, however in hours to days, they adult hoarseness and shortness of breath necessitating tracheotomy (Table i ).

Table 1

Clinical presentation of vocal cord paralysis following open-heart surgery

Clinical presentation of vocal cord paralysis post-obit open-centre surgery

Tabular array 1

Clinical presentation of vocal cord paralysis following open-heart surgery

Clinical presentation of vocal string paralysis post-obit open-heart surgery

4 Mechanisms of injury

Several mechanisms of injury to the recurrent laryngeal nerve take been suggested. The first mechanism is post-obit central venous catheterization, either through direct trauma from the puncture site or secondary to thrombosis, fibrosis or hematoma formation [12]. The 2d one is traction on the esophagus due to an unnatural position of the head and cervix during surgery. The third is straight song string harm or palsy from a traumatic endotracheal intubation [xiii,xiv]. The quaternary mechanism is trauma by compression of the recurrent laryngeal nerve or its anterior branch at the tracheoesophageal groove by an inappropriately sized endotracheal tube cuff [15]. The fifth is a faulty insertion of a nasogastric tube [12] and/or nasogastric tube syndrome whereby in that location is ulceration and infection of the post-cricoid area with resultant song cord abduction dysfunction [16]. The sixth mechanism is median sternotomy and/or sternal traction pulling laterally on both subclavian arteries. Sternotomy may cause direct trauma to the recurrent laryngeal nervus or indirect injury secondary to excessive sternal traction resulting in either neuropraxia or neurotmesis. The 7th is directly manipulation and retraction of the heart during open-centre procedures. With equal traction or pull on the recurrent laryngeal nerves transmitted from the center to the major vessels, the shorter right nerve has more than strength applied to its fibers with more than likelihood of beingness injured [7]. The eighth mechanism is hypothermic injury with ice/slush collecting in the pleural crenel in close proximity to the left recurrent laryngeal nerve [11,17]. This problem has decreased markedly with the usage of ice/saline slush instead (Table 2 ).

Table 2

Vocal cord paralysis following open-heart surgery

Vocal cord paralysis following open up-heart surgery

Table two

Vocal cord paralysis following open-heart surgery

Song cord paralysis following open up-heart surgery

Unlike thoracic operations for lung cancer where injury to the recurrent laryngeal nervus is predictable and a concomitant type I thyroplasty is recommended to prevent mail service-operative swallowing disability and respiratory complications [18], most of the injuries reported later on open up-heart surgery appear to be secondary to neuropraxia with no major irreversible damage to the recurrent laryngeal nervus except in few cases [8–10].

5 Evaluation and diagnosis

In the evaluation of vocal string dysfunction following open-heart surgery, the onset of hoarseness is very of import. A key signal is the premorbid condition and quality of phonation, a question that is frequently missed and unanswered. This brings up the importance of the pre-operative evaluation of the song cords in patients with dysphonia. The diagnosis starts with the perceptual evaluation of the vocalisation and is concluded with the physical exam. In patients with unilateral vocal cord paralysis, the vocal signal is by and large aperiodic and the voice is classified as rough, breathy or hoarse. This quality of phonation is due to the glottal incompetence secondary to vocal cord paresis or paralysis. Poor breath support and key neurologic diseases should be ruled out.

In patients with bilateral vocal string paralysis, the voice may exist normal if the cords are in the midline, i.e. in the phonatory position, or breathy and hoarse if they are in the paramedian or lateral position.

For the laryngeal test, two ways of visualizations are available. I is the fiber optic laryngoscope and the other a rigid telescope with lxx or 90° views. These can be adapted to a single- or three-bit compact charge-coupled device camera to provide a video-laryngoscopic examination. The overall architecture of the larynx, mainly supraglottic and glottis, is inspected for whatsoever variations or anomalies. Following open-heart surgery, the vocal cords are inspected for any paresis or paralysis. Laryngeal video-endostroboscopy is besides existence used to diagnose vocal string impaired mobility and differentiate paralysis from paresis [19].

6 Conclusion

Transient hoarseness following open up-heart surgery may exist an ominous sign of recurrent laryngeal nervus injury. It should not exist assumed to exist secondary to intralaryngeal edema. If disregarded, in add-on to the dysphonia, complications of paramount importance may occur secondary to the inadequate cough and aspiration. Although it is true that the incidence of vocal cord paralysis remains very low, still its presence is alarming and necessitates close follow up on the patient for the possible need of surgical intervention if recovery fails. In cases of unilateral paralysis, vocal cord medialization via endoscopic injection or thyroplasty is usually washed if spontaneous recovery fails. In cases of bilateral vocal cord paralysis, lateralization procedures such light amplification by stimulated emission of radiation arytenoidectomy can exist washed.

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© 2002 Elsevier Science B.V. All rights reserved.

Elsevier Science B.V.