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A E R Editor‑in‑Chief :
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(KSA)
Open Access
HTML Format Anesthesia: Essays and
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Researches

Case Report
Management of bilateral recurrent laryngeal nerve
paresis after thyroidectomy
Anitha Sanapala, Male Nagaraju, Lella Nageswara Rao, Koteswar Nalluri1

Departments of Anesthesiology and 1Otolaryngology, Katuri Medical College and Hospital, Chinakondrupadu, Guntur, Andhra Pradesh, India
Corresponding author: Dr. Anitha Sanapala, Department of Anesthesiology, Katuri Medical College and Hospital, Chinakondrupadu, Guntur ‑ 522 019,
Andhra Pradesh, India. E‑mail: anithasanapala88@gmail.com

Abstract
Bilateral recurrent laryngeal nerve (RLN) injury is rare for benign thyroid lesions (0.2%). After
extubation‑stridor, respiratory distress, aphonia occurs due to the closure of the glottic aperture
necessitating immediate intervention and emergency intubation or tracheostomy. Intra‑operative
identification and preservation of the RLN minimizes the risk of injury. It is customary to expect
RLN problems after thyroid surgery especially if malignancy, big thyroid, distorted anatomical
problems and difficult airway that can lead to intubation trauma. Soon after extubating, it is essential
to the anesthetist to check the vocal cord movements on phonation and oropharyngeal reflexes
competency. But this case is specially mentioned to convey the message that in spite of absence
of above mentioned predisposing factors for complications and good recovery profile specific to
thyroid, there can be unanticipated airway compromise that if not attended to immediately may
cost patient’s life. This is a case of postextubation stridor following subtotal thyroidectomy due to
bilateral RLN damage and its management.

Key words: Bilateral recurrent laryngeal nerve paresis, postoperative vigilance, stridor,
tracheostomy

INTRODUCTION increased incidence of false negatives. Controlled trials


have shown no statistical reduction in paralysis, paresis,
Bilateral recurrent laryngeal nerve (RLN) injury following or total injury rates to the RLN with RLN monitoring.[1]
surgery for benign thyroid lesion is rare. Preoperative Intensive postoperative clinical monitoring is essential
indirect laryngoscopy is very essential. Intra‑operative even though there is a good recovery profile, apparently
identification of the nerve along its tract and preservation normal vocal cord movements on inspection and positive
minimizes the risk of injury. Intra‑operative continuous cuff leak test after thyroid surgeries. Careful postoperative
RLN monitoring may be useful in certain cases, but it is vigilance and timely response can mitigate life‑threatening
time‑consuming, requires spontaneous ventilation and complications.

Access this article online CASE REPORT


Website DOI Quick Response Code
www.aeronline.org 10.4103/0259-1162.152419 A 45‑year‑old, 50 kg female with multinodular goiter was
posted for subtotal thyroidectomy. The preanesthetic
assessment revealed no significant abnormality and
patient was in the euthyroid state  (T3‑1.26  ng/dl,
T4‑8.21 mcg/dl, thyroid‑stimulating hormone ‑ 4.0 mIU/ml).
Antero posterior and lateral radiographs of the neck

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Anesthesia: Essays and Researches; 9(2); May-Aug 2015 Sanapala, et al.: Management of bilateral RLN paresis after thyroidectomy

Figure 1: Tracheostomy being performed Figure 2: Patient after tracheostomy

showed no evidence of compression of the trachea. with a smaller size (7 mm ID) cuffed ET tube using bougie
Patient was referred to Department of Otolaryngology and connected to a T‑piece. Patient could maintain
for indirect laryngoscopy prior to surgery; that revealed stable vitals after the procedure. Bilateral RLN paresis
normal appearance and movements of vocal cords. was confirmed with flexible fiber optic laryngoscopy by
otolaryngologist (after trial extubation), and tracheostomy
The patient was scheduled for surgery. Nil per oral status
[Figure 1] was performed to prevent further respiratory
was maintained, and 0.25 mg tablet alprazolam was
complications and facilitate early mobilization [Figure 2].
given the night before surgery. General anesthesia was
Patient was de‑cannulated 14 days later with the return of
administered with 50 mg of injection ranitidine, 4 mg
adequate cord function.
of injection ondansetron, 1 mg of injection midazolam,
0.2 mg of injection glycopyrrolate intravenously as
premedications after attaching the monitors in the
DISCUSSION
preoperative room. Patient was shifted to the operation
The innervations of larynx are:
room. Induction was done with 250 mg of injection
• Superior laryngeal nerve gives sensory supply to the
thiopentone sodium intravenously, and relaxation was
supraglottic mucosa, and external branch gives motor
facilitated with 5 mg of injection vecuronium after
supply to the cricothyroid muscle
preoxygenating with 100% oxygen for 3  min. A  7½  mm
• RLN gives motor supply to intrinsic laryngeal muscles
ID cuffed reinforced endotracheal (ET) tube was
(abductors) and sensory supply to mucosa below vocal
inserted after gentle laryngoscopy. Maintenance was
cords.
done with vecuronium, N2O:O2  =  5:3 and sevoflurane
(0.25–0.5%). A 100 mcg of injection fentanyl was given Incidence of respiratory complications at extubation and
for intra‑operative analgesia. Subtotal thyroidectomy was in the recovery room is greater than at intubation that
performed and intra‑operative period was uneventful with are as follows:[2‑4]
minimal blood loss. At the end of the procedure, the • Hematoma (0.79–1.2%)
patient was reversed; cuff leak test was positive indicating • Laryngeal edema (0.19%)
no evidence of tracheomalacia and was extubated • Hypoparathyroidism, temporary: 0.9–8.3%, permanent:
successfully. Postextubation, direct laryngoscopy revealed <1.7%
the cords movements and appearances were normal. After • Stridor
ensuring thorough recovery and good vocalizing, patient • Hypocalcemia
was shifted to postoperative room. • Dysphagia (1.4%)
• Bilateral RLN palsy  (0.4–1.9%) and bilateral RLN
After an hour in the recovery room, patient had
paresis (0.2%) in thyroidectomies for benign lesions[5]
an inspiratory stridor with signs of respiratory
• Infection (0.3%)
distress (tachypnea, tachycardia, flaring of alar nasae,
• Tracheomalacia.
restlessness) and there was a gradual fall in the saturation
to high 80’s to low 90’s. There was no local swelling Injury to the RLN can occur by a number of mechanisms
at the surgical site. We tried to ventilate with a FiO2 of such as ischemia, irritation of the nerve without
100%, and Larson’s jaw thrust was applied, but saturation actual damage,[5] contusion, entrapment, and actual
did not improve much. After sedation, as vocal cords transection.[6] Higher risk of damage occurs in malignancy
were in adduction on laryngoscopy, patient was intubated and secondary operations.[6] Anatomic variability and

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Anesthesia: Essays and Researches; 9(2); May-Aug 2015 Sanapala, et al.: Management of bilateral RLN paresis after thyroidectomy

distortions will increase the risk of nerve injury.[6] This can complications like RLN palsies if unnoticed can occur in
be prevented by:[6] seemingly normal patients.
• Preoperative laryngoscopy: 1.9% of patients without and
3% of patients presenting with carcinoma of the thyroid REFERENCES
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after 6 to 9 months.[10]

CONCLUSION How to cite this article: Sanapala A, Nagaraju M, Rao LN,


Nalluri K. Management of bilateral recurrent laryngeal nerve
paresis after thyroidectomy. Anesth Essays Res 2015;9:251-3.
Careful postoperative observation is very essential in
patients undergoing thyroidectomy, as life threatening Source of Support: Nil, Conflict of Interest: None declared.

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