Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 12146

AbstractCase ReportDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : UR01 - UR03 Full Version

Awake Fiberoptic Intubation in Vocal Cord Palsies


Published: November 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/58468.17102
Neeta Santha, Diksha Dmello, Pakhi Sharma

1. Associate Professor, Department of Anaesthesia, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India. 2. Postgraduate, Department of Anaesthesia, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India. 3. Postgraduate, Department of Anaesthesia, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India.

Correspondence Address :
Neeta Santha,
Associate Professor, Department of Anaesthesia, Kasturba Medical College, Mangalore, Karnataka, India.
E-mail: drneetas@yahoo.com

Abstract

Respiratory distress associated with vocal cord palsy can be attributed to recurrent laryngeal nerve injury. Bilateral vocal cord palsy can cause adduction of cords and respiratory distress. Airway, in these patients, can be compromised and result in unanticipated difficult intubation. The time frame to pass tube in such situations are less. This is a case series on successful airway management of three patients (71-year-old male, 37-year-old female, 70-year-old female) who presented with recurrent nerve palsy and airway obstruction. Thus the “cannot intubate-cannot oxygenate” situation was avoided in all the patients.

Keywords

Airway management, Intubate, Oxygenate

Recurrent laryngeal nerve injuries are a common cause for vocal cord paralysis. The causes include surgical intervention, malignancy, viral illness, diabetic neuropathy, and trauma. Endotracheal intubation is also responsible for significant number of recurrent laryngeal nerve palsies (1). Vocal cord paralysis is a lesser known, important complication of intubation. Its incidence ranges from 0.1%-0.2% (2). Such patients can present with an extremely narrow glottic opening and can result in unanticipated difficult airway. Awake fibreoptic intubation is an option in these situations which has a higher success rate. For any procedure to be successful, careful preoperative planning is essential. This is a case series on three patients who presented with vocal cord palsies. Proper airway assessment and preparation helped in successful intubations in these patients.

Case Report

Case 1

A 71-year-old male presented with left capsuloganglionic bleed. He was known to have bronchial asthma since childhood, and was on bronchodilators. The patient was intubated in the Intensive Care Unit (ICU) with oral endotracheal tube 8.0 mm Internal Diameter (ID), fixed at 23 cm in view of poor Glasgow Coma Scale score (GCS), and risk of aspiration. He was extubated after 3 days in view of improved GCS and intact gag reflex. He developed respiratory distress two hours later and was posted for emergency tracheostomy, under General Anaesthesia (GA). On preanaesthetic evaluation, the patient was in respiratory distress with hoarseness of voice, tachypnea with a respiratory rate of 40 breaths/min and a Oxygen Saturation (SpO2) of 97% with oxygen on flow with via face mask at 5 L/min. Video laryngoscopy under local anaesthesia showed oedematous vocal cords, in adducted position with poor cord movements on respiration (Table/Fig 1).

The patient was shifted to the operative room in a propped-up position. The plan of anaesthesia was awake Fibreoptic Intubation (FOI). Difficult airway cart was kept ready. After confirming nil per oral status, standard American Society of Anaesthesiologist (ASA) monitors were connected. The patient remained in propped-up position at a 45° angle on the operating table due to respiratory distress. Oxygen was supplemented with nasal prongs at 2 L/min. Nasal airway was prepared with lignocaine and adrenaline-soaked pledgets (1:2,00,000) kept for five minutes. Awake fibre optic intubation was carried out and the fibreoptic scope was introduced through the nasal passage. Airway was anaesthetised using the spray-as-you-go technique with 2% lignocaine solution. Even mild sedation was deferred as the patient had a compromised airway and was in respiratory distress. On bronchoscopy, vocal cords appeared in adducted position and the scope was passed between the cords. A 7.5 mm ID nasal Right Angle Endotracheal (RAE) tube was railroaded into the trachea under vision. There was difficulty in negotiating the tube via the narrow space in between the cords. Position of the endotracheal tube was confirmed with End Tidal Carbon Dioxide (ETCO2) tracing. Once the tube was secured, induction was done with inj. fentanyl 50 mcg, and 8% sevoflurane. After induction, paralysis was achieved using inj. atracurium 50 mg. Maintained with O2:N2O in the ratio of 1:1 with sevoflurane at 1%. The patient underwent tracheostomy and a size 8 tracheostomy tube was inserted and confirmed with ETCO2 tracing. Intraoperative vitals were stable and the procedure was uneventful. The patient was reversed after resuming spontaneous breathing. He was shifted to Medicine ICU on T piece at 6 L/min of oxygen.

Case 2

A 37-year-old female came with complaint of neck swelling since two years. Swelling was insidious in onset, gradually progressive, associated with dysphagia since 1 month; dysphagia was present more for solids than liquids. There was associated change in voice since 1 month but there were no complaints of difficulty in breathing. Patient also complained of cough with expectoration and fever for 1 day. She was tachypneic and room air saturation was 96%. She presented with low blood pressure of 86/50 mmHg and fine crepitations over right basal region.

Computed Tomography (CT) scan of the neck was done which showed peripherally enhancing multiloculated lesion with air foci within (6×7×8.2 cms) the anterior aspect of the neck arising from the thyroid gland and reaching upto left parapharyngeal space superiorly till hyoid bone, inferiorly to superior mediastinum into prevascular space, medially compressing and displacing trachea to the right, posteriorly loss of fat plane of isthmus; complete thrombosis of left Internal Jugular Vein (IJV) laryngeal inlet was compressed by the mass (Table/Fig 2).

Indirect laryngoscopy showed that there was posterior pharyngeal wall bulge, bulky arytenoids with fixed left vocal cord (Table/Fig 3). The right-sided cord was mobile on respiration and phonation.

Patient was posted for biopsy and tracheostomy under general anaesthesia (GA). The plan of anaesthesia was awake nasal fibreoptic intubation. The procedure was explained and consent was taken from the patient. Patient was given nebulisation with 3 mL of 2% lignocaine. Pledgets soaked in 4% lignocaine were inserted into the nasal cavity.

After preparation of the airway, patient was shifted to the operating table. Oxygen supplementation was done with 2 litres of oxygen by nasal prongs. Standard monitors were connected and difficult airway cart was kept ready. Premedication was done with 0.2 mg of glycopyrrolate, 0.5 mg midazolam and 25 μg fentanyl. Nasal RAE tube 7.5 mm, was railroaded into the insertion cord of the fibreoptic bronchoscope. The bronchoscope could be passed into the trachea but there was difficulty in inserting the endotracheal tube at the level of laryngeal inlet, as there was narrowing of airway at this level. There was difficulty in pushing the tube further down into trachea. The tube was kept at this position and the bronchoscope was withdrawn carefully. The circuit with ETCO2 was connected to confirm the tube position. Then an airway exchange catheter (Cooks Airway Exchange 14F) was passed through the tube into the trachea and tube was further pushed inside with the help of the catheter. Tube was fixed after confirming with ETCO2 and auscultation for bilateral air entry. Induction was done with propofol and relaxant used was atracurium. Anaesthesia was maintained with oxygen nitrous oxide and sevoflurane. Tracheostomy and biopsy was done. After the procedure, patient was reversed and shifted to postoperative ICU on T piece. Later biopsy confirmed anaplastic carcinoma of the postcricoid region.

Case 3

A 70-year-old female patient was posted for direct laryngoscopy and biopsy of the vocal cord growth. She had hoarseness of voice, for one year. Indirect laryngoscopy revealed a fixed left vocal cord and mobile right vocal cord. She didn’t have any other co-morbidities.

Plan of anaesthesia was awake fibreoptic intubation. Nebulisation of the airway was done with 4% lignocaine. The patient was shifted to the operating table. Oxygen was connected with nasal prongs at 2 L/min. Mild sedation was given with 0.5% midazolam. 7.5 mm nasal RAE tube was railroaded into the insertion cord of the fibreoptic bronchoscope. Spray-as-you-go technique with 2% lignocaine was done. Bronchoscope was passed through the nasal passage and once the tracheal entry was confirmed, endotracheal tube was inserted into trachea. After confirmation of tube placement, anaesthesia was introduced with fentanyl, propofol and atracurium. After the procedure patient was extubated fully awake.

Discussion

The larynx is the most common site of airway injury during endotracheal intubation, including haematoma, arytenoid subluxation and vocal cord paralysis (3). In the first case, the patient developed vocal cord palsy and stridor following intubation. Bilateral vocal cord paralysis following endotracheal intubation is much less appreciated, and often overlooked. When coupled with head and neck surgery, it causes diagnostic confusion (4). Hoarseness is a symptom that appears usually after intubation. There can be varied reason for the palsy. The cricoid cartilage or vocal cords can be pushed to the oblique position of the neck by the posterior surface of endotracheal tube cuffs, leading to neuropraxia (2).

Unilateral vocal cord paralysis as observed in the second case, manifests as change in voice quality, perceived as dysphonia, vocal fatigue, decreased range and fatigue that can affect communication skills. The unilateral paralysis of vocal fold can be due to injury that involves the vagus nerve, which can be proximal or distal. The most common cause is iatrogenic (5). Vocal cord palsy can also lead to an inefficient cough mechanism, which can lead to aspiration and pneumonia. A more serious complication is the development of obstruction, stridor and respiratory failure. There was difficulty in passing the tube down the trachea. Tube exchanger was the saviour in this scenario and with the help of this airway gadget, trachea was successfully intubated.

Nagata M et al., described a case of vocal cord palsy in a 32-month-old child with left recurrent laryngeal nerve palsy. The child was posted for endoscopic evaluation of vocal cords. The child was induced with sevoflurane and paralysed with rocuronium. After the procedure, the airway was extubated using an airway exchange catheter. After confirming adequate spontaneous breathing, the patient was observed in postoperative ICU. In the second case, as described in the case series an airway exchange catheter was used to push endotracheal tube further into the trachea (6).

In another case, a 57-year-old male patient, who had progressive breathlessness due to thyroid swelling, was posted for thyroidectomy. He was a known case of acromegaly with features of a difficult airway. The plan of anaesthesia was awake fibreoptic intubation. Aerosolisation of the airway with local anaesthesia was done. Intravenous sedation and sevoflurane inhalation was used to secure airway with video laryngoscopy assisted fibreoptic intubation. Here, in the second case, video laryngoscope was tried, but was unsuccessful in securing the airway. So awake fibreoptic was tried for the same (7).

Diagnostically, it is necessary to examine the structure and function of the larynx (8). The risk greatly increases with increasing age, diabetes mellitus, hypertension, and duration of surgery (9). In serious cases, reintubation or tracheostomy is required to relieve the obstruction. In the above case, incomplete bilateral recurrent laryngeal nerve palsy was suspected with vocal cord oedema most likely due to endotracheal intubation.

In another published report, a patient developed post-traumatic severe tracheal stenosis. His condition deteriorated suddenly and emergency intubation was tried, but endotracheal tube could not be pushed beyond the area of critical stenosis and it was 0.5 cm above the carina. Immediate extracorporeal circulation was established and trachea was exposed via thoracotomy incision and tracheal tube was inserted in the left main bronchus (10).

The intubating fibreoptic scope has a quoted success rate of 88-100% (11). Some authors still consider it to be the gold standard in anticipated difficult airway management. The introduction of supraglottic airway devices and video laryngoscope has dramatically changed airway management. Inspite of advances in these airway devices error in airway assessment and strategic planning can lead to devastating consequences. National Audit Project of the Royal College of Anaesthetists, United Kingdom, concluded that judgemental errors, inappropriate choice of equipment and inadequate training can be contributory factors in major airway complications (12). It is therefore imperative that fibreoptic intubation is considered in a clinical context as part of a complete airway strategy.

Conclusion

Vocal cord paralysis following endotracheal intubation is a lesser known pathology but is a worrisome situation in the postextubation period where there is risk of airway obstruction and losing the airway following repeated failed attempts. Emphasis on prevention and recognition of this entity is important for the anaesthesiologist to allow an informed decision and planned intervention in the setting of complications.

References

1.
Culp JM, Patel G. Recurrent Laryngeal Nerve Injury. In: StatPearls. Treasure Island (FL): StatPearls Publishing. 2022.
2.
Tasli H, Kara U, Gokogoz MC, Aydin U. Vocal cord paralysis following endotracheal intubation. Turk J Anaesthesiol Reanim. 2017;45(5):321-22. [crossref] [PubMed]
3.
Nazal CH, Vilches AA, Maran CV, Contreras KG, Valenzuela CN, Ventí PB, et al. Vocal cord paralysis after endotracheal intubation: An uncommon complication of general anaesthesia. Brazilian Journal of Anaesthesiology. 2018;68(6):637-40. [crossref] [PubMed]
4.
Matta RI, Halan BK, Sandhu K. Postintubation recurrent laryngeal nerve palsy. A review. J Laryngol Voice. 2017;7(2);25-28. [crossref]
5.
Williamson AJ, Shermetaro C. Unilateral Vocal Cord Paralysis. [Updated 2022 Feb 7]. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK535420/.
6.
Nagata M, Shimomura Y, Hara Y, Nakamura T, Hayakawa S, Komura H, et al. A devised strategy for tracheal extubation for predicted difficult airway in a child with unilateral vocal cord paralysis: A case report. JA Clin Rep. 2017;(21):02-04. [crossref] [PubMed]
7.
Sun X, Chen C, Zhou R, Chen G, Jiang C, Zhu T, et al. Anaesthesia and airway management in a patient with acromegaly and tracheal compression caused by a giant retrosternal goiter: A case report. Journal of International Medical Research. 2021;49(4):300060521999541. [crossref] [PubMed]
8.
Young VN, Smith LJ, Rosen C. Voice outcome following acute unilateral vocal cord paralysis. Ann Otol Rhinol Laryngol. 2013;122(3):197-04. [crossref] [PubMed]
9.
Kikura M, Suzuki K, Itagaki T, T Takada T, Sato S. Age and comorbidity as risk factors for vocal cord paralysis associated with tracheal intubation. Br J Anaesth. 2007;98:524-30. [crossref] [PubMed]
10.
Zhou YF, Zhu SJ, Zhu SM, An XX. Anaesthetic management of emergent critical tracheal stenosis. J Zhejiang Univ Sci B. 2007;8(7):522-25. [crossref] [PubMed]
11.
Wong J, Lee JSE, Wong TGL, Iqbal R, Wong P. Fiberoptic intubation in airway management: A review article. Singapore Med J. 2019;60(3):110-18. [crossref] [PubMed]
12.
Cook TM, Woodall N, Harper J, Benger J. Fourth National Audit Project. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: Intensive care and emergency departments. Br J Anaesth. 2011;106(5):632-42. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/58468.17102

Date of Submission: Jun 15, 2022
Date of Peer Review: Jul 06, 2022
Date of Acceptance: Jul 21, 2022
Date of Publishing: Nov 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 19, 2022
• Manual Googling: Jul 19, 2022
• iThenticate Software: Jul 20, 2022 (16%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com