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.
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Abstract |
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Keywords: equipment, laryngeal mask airway ; nerve, damage
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Introduction |
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Case report |
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Discussion |
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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 1015 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.
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Footnotes |
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References |
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