Lingual nerve injury associated with the ProSeal laryngeal mask airway: a case report and review of the literature

J. Brimacombe1,*, G. Clarke2 and C. Keller3

1 Department of Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns, Queensland, Australia. 2 Far North Queensland Anaesthesia and Intensive Care, Cairns Private and Day Surgery Hospitals, Cairns, Queensland, Australia. 3 Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria

* Corresponding author: Department of Anaesthesia and Intensive Care, Cairns Base Hospital, The Esplanade, Cairns 4870, Queensland, Australia. E-mail: jbrimaco{at}bigpond.net.au

Accepted for publication April 22, 2005.


    Abstract
 Top
 Abstract
 Introduction
 Footnotes
 Case report
 Discussion
 References
 
We present a case of lingual nerve injury that was associated with use of the ProSeal laryngeal mask airway during shoulder replacement in a 61-yr-old male. We also review other cases of cranial nerve injury, most of which were associated with use of the classic laryngeal mask airway. In principle, the frequency of cranial nerve injuries can be reduced by avoiding insertion trauma, using appropriate sizes, minimizing cuff volume, and early identification and correction of malposition.

Keywords: equipment, laryngeal mask airway ; nerve, damage


    Introduction
 Top
 Abstract
 Introduction
 Footnotes
 Case report
 Discussion
 References
 
Cranial nerve injuries are well-recognized complications of laryngoscopy and tracheal intubation1 2 and face mask ventilation.35 Recently, these have also been reported in association with extraglottic airway devices. Injuries to the lingual,610 hypoglossal1115 and recurrent laryngeal nerve1623 have been reported with the classic laryngeal mask airway (LMA®),{dagger} and to the lingual24 25 and glossopharyngeal nerve with the cuffed oropharyngeal airway (COPA).24 However, most of these injuries were thought to be related to suboptimal use of the LMA. The ProSealTM LMA is a relatively new device with a large, wedge-shaped cuff to improve the seal.26 There is one report of hypoglossal27 and one report of recurrent laryngeal nerve injury28 with the ProSeal LMA. We present a case of lingual nerve injury lasting 15 days associated with optimal use of the ProSeal LMA; in addition, we review the literature.


    Case report
 Top
 Abstract
 Introduction
 Footnotes
 Case report
 Discussion
 References
 
A male patient of age 61 yr, height 174 cm, weight 74 kg and ASA II underwent elective shoulder replacement in the semi-beach chair position. He had a past medical history of hypothyroidism, for which he was on replacement therapy, and had gastro-oesophageal reflux roughly once a week. On examination the airway was Mallampati grade 1. Anaesthesia was induced with propofol 180 mg. Face mask ventilation was easy. A ProSeal LMA, size 5, lubricated with a water-based gel was easily inserted by an experienced user (G.C.) at the first attempt using the digital technique. The cuff was inflated with air 20 ml and fixed to the face with adhesive tape, as recommended by the manufacturer.29 The mid-portion of the bite block was within the oral cavity. Care was taken to ensure that the tongue was not trapped between the bite block and the teeth. The head was placed on a head ring in the neutral position and held firmly against the table with adhesive tape across the forehead. The oropharyngeal leak pressure was 25 cm H2O and there was no air leak from the drain tube at this pressure. A size 14 Fr gastric tube was easily inserted via the drain tube at the first attempt, and a trace of clear fluid was suctioned from the stomach. Anaesthesia was maintained with sevoflurane 1–2% and nitrous oxide 66% in oxygen. Neuromuscular blockers were not given. The lungs were ventilated with a tidal volume of 8–10 ml kg–1 and peak airway pressures of 16–20 cm H2O using a fresh gas flow of 3 litre min–1 in a circle anaesthesia breathing system. Air was withdrawn from the cuff approximately every 30 min, so that the tension in the pilot balloon was similar to that at the start of the procedure.30 There were no adverse events during the maintenance of anaesthesia or emergence from it. In particular, there were no episodes of hypoxia, hypercarbia, gastric insufflation or displacement. Haemodynamic parameters remained within normal limits. The head and neck was not moved during the procedure. The ProSeal LMA was removed with the cuff semi-inflated when the patient opened his mouth to verbal command. There was no visible blood on the surface of the cuff at removal. The ProSeal LMA was in situ for a total of 2.5 h. Immediately after the operation, the patient noticed a 2 cm area of numbness to touch and taste on the left side of the tip of the tongue, which was confirmed on examination. All other cranial nerves were intact. The area of numbness started to improve after 8 days and was back to normal by 15 days. There were no other sequelae.


    Discussion
 Top
 Abstract
 Introduction
 Footnotes
 Case report
 Discussion
 References
 
On search of the literature, we found five reports of lingual nerve injury, six of hypoglossal nerve injury and 11 of recurrent laryngeal nerve injury (Table 1). All but two reports were in adults.15 23 All but two reports were with the classic LMA.27 28 The onset of symptoms ranged from immediately after anaesthesia to 48 h after surgery. One injury resolved within an hour17 and another had not resolved after 18 months and required thyroplasty.22 One injury required a cricothyrotomy to prevent aspiration.28 Both unilateral and bilateral injuries have been reported. In one patient, the LMA was inserted only briefly before the patient was intubated and it may not have been the cause.14 Potential predisposing factors included use of nitrous oxide,613 1619 2123 27 28 using an LMA that was too small,6 7 912 14 1622 28 the lateral position,1012 extreme head side rotation,15 anticoagulants,12 rheumatoid arthritis,11 ankylosing spondylitis,12 calcinosis, Raynaud phenomenon, [o]esophageal dysmotility, sclerodactyly, and telangiectasia (CREST) syndrome,28 overinflation of the cuff,20 21 lidocaine lubricant,17 cervical epidural,11 inexperience,21 difficult insertion14 and alternative insertion techniques.21


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Table 1 Cranial nerve injury after use of the LMA.

 
The most probable cause for cranial nerve injuries associated with LMA is a pressure neuropraxia from the tube (lingual) or cuff (hypoglossal and recurrent laryngeal). The lingual nerve is at risk of compression as it enters the mouth below the inferior border of the superior constrictor and continues against the periosteum of the mandible posterior to the third molar, the hypoglossal nerve as it crosses the hyoid bone, and the recurrent laryngeal nerve as it enters the larynx, where it passes deep to the lower border of the inferior constrictor.31 The lingual nerve injury usually presents as loss of taste, and sensation over the anterior tongue, hypoglossal nerve injury as difficulty in swallowing and recurrent laryngeal nerve injury as dysarthria, stridor or postoperative aspiration. Other possible causes are a stretch neuropraxia from head/neck/body positional changes, a chemical neuritis by use of the wrong lubricant or cleaning fluid, and local inflammation because of insertion trauma.31

Two predisposing factors common to most of the reported cases were that LMA size was too small and that nitrous oxide was used. If the LMA is too small there is increased frequency of malposition and a tendency for the clinician to overinflate the cuff in an attempt to improve the efficacy of the seal.32 If nitrous oxide is used, it rapidly diffuses into the cuff of reusable LMA devices, causing an increase in intracuff pressure.33 A notable difference between our case and most of the previous cases was that the LMA device was used optimally. It was inserted by an experienced user and the insertion was atraumatic. The size of LMA, cuff volume and fixation technique were appropriate, and any increases in intracuff volume due to diffusion of nitrous oxide were minimized by intermittent withdrawal of air. An example of malposition would be the cuff sitting in the oral cavity.34

Our patient had five factors that may have contributed to the injury: he was in a non-supine position; the head was firmly taped to the table; he was undergoing shoulder surgery; nitrous oxide was used; and the procedure was prolonged. The first four factors may have increased the compressive and/or stretching forces within the oral and pharyngeal cavities, and the fifth factor would have allowed the injury to develop. In principle, the risk of injury for the ProSeal LMA may be greater than the classic LMA, as it is more difficult to insert35 and the larger cuff will be in contact with a greater portion of the oral and pharyngeal cavities. However, the risk of injury may be smaller as mucosal pressures are lower than the classic LMA for a given seal pressure.36 Also, malposition is less likely with ProSeal LMA as it can be easily detected. We consider that ProSeal LMA was correctly positioned in our case since there was no drain tube air leak during positive pressure ventilation, the gastric tube was inserted easily, and the mid-portion of the bite block was within the mouth.37 Our case suggests that a correctly positioned ProSeal LMA can occasionally cause a cranial nerve injury.

Cranial nerve injuries are a well-established but rare complication of face mask ventilation (facial,3 lingual4 and greater occipital5) and laryngoscope-guided tracheal intubation.1 2 There are also two reports of cranial nerve injury with the cuffed oropharyngeal airway: one involving transient bilateral lingual and glossopharyngeal nerve injury24 and another a transient unilateral lingual nerve injury.25 There have been no reports of glossopharyngeal nerve injury with the LMA. The glossopharyngeal nerve may be vulnerable to compression as it passes between the superior and middle constrictor muscles near the hyoid bone. Interestingly, one study reported a 1% incidence38 and another a 2% incidence39 of tongue numbness lasting 10–15 min, but no neurological testing was performed. There are no reports of cranial nerve injuries with other LMA or extraglottic airway devices.

Cranial nerve injuries usually present within 48 h of surgery and resolve spontaneously over a period of weeks or months. Differentiating between recurrent laryngeal nerve injury and arytenoid dislocation20 40 is sometimes difficult, but can be facilitated by use of computer tomographic scanning and stroboscopic examination.

In summary, we present a case of lingual nerve injury after a shoulder replacement in a 61-yr-old male that was associated with the optimal use of ProSeal LMA. We also review 20 other cases of cranial nerve injury, most of which were associated with suboptimal use of the classic LMA. In principle, the frequency of cranial nerve injuries can be reduced by avoiding insertion trauma, using appropriate sizes, minimizing cuff volume, and early identification and correction of malposition.


    Footnotes
 Top
 Abstract
 Introduction
 Footnotes
 Case report
 Discussion
 References
 
{dagger} LMA® is the property of Intavent Ltd. Back


    References
 Top
 Abstract
 Introduction
 Footnotes
 Case report
 Discussion
 References
 
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29 LMA ProSealTM Instruction Manual, 1st Edn. Henley-on-Thames: The Laryngeal Mask Company, 2000

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41 Brimacombe J. Laryngeal Mask Anesthesia. Principles and Practice, 2nd Edn. Philadelphia: W.B. Saunders, 2005





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