Department of Anaesthesiology and Intensive Care, Nice School of Medicine, University of Nice Sophia-Antipolis, Hôpital Archet II, 151 route Saint-Antoine de Ginestière, BP 3079, F-06202 Nice Cedex 3, CHU de Nice, France*Corresponding author
Accepted for publication: January 1, 2002
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Abstract |
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Br J Anaesth 2002; 88: 86970
Keywords: nerve, cranial; surgery, orthopaedic; position, sitting; complications, Tapias syndrome
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Introduction |
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Case report |
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Discussion |
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Poor body position during surgery can cause vascular, neurological or tissue damage. Dissection of the ascending pharyngeal branch of the carotid artery could partially explain the symptoms in our patient as it provides exclusive blood supply to Xth and XIIth cranial nerves. Excessive head rotation may provoke such vessel dissection.5 However, magnetic resonance angiography did not show any vascular or cerebral abnormalities. In addition, the absence of Horners syndrome, which is often seen after carotid dissection, would argue for another explanation.
Neural injury after malpositioning during surgery is well described.6 No report has been published or given an anatomical explanation for Tapias syndrome in relation to shoulder surgery. In our patient, marked lateral flexion of the head may have damaged several cranial nerves by a prolonged stretching mechanism. However, it seems unlikely that cranial nerves would be affected without involvement of brachial plexus nerves or the spinal cord.
The tracheal tube could have caused most of the findings in this patient such as disturbance of laryngeal function and swallowing. Nerve damage by pressure from the cuff within the larynx has been reported. In our patient, the pressure was checked and no nitrous oxide was given. However, because of excessive lateral flexion of the head, the tracheal tube may have pressed on a localized area just at the crossing of the vagal and hypoglossal nerves.7 The severe throat pain after surgery suggests laryngeal injury and the recovery time is typical of a compression injury.
When surgery is carried out with the patient in the fully upright sitting position, the patient is particularly susceptible to head misplacement. Keeping the head aligned is difficult because the body is generally out of view and direct access is not easy. To avoid these problems, special shoulder operating tables have been designed to improve the patient comfort and to improve body alignment. Also, to prevent such complication, it may be possible to keep the patient conscious throughout the procedure so that the patient can correct any undesirable head misplacement. If general anaesthesia is used, muscle relaxants can reduce muscle tone and increase the risk of head movement. We pay special attention to peak inflation pressure, as a sudden increase may suggest that the tracheal tube may be bent by neck and tracheal deviation. As described in this case report, selective intubation may occur and capnography analysis is also helpful.8
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References |
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4 Johnson TM, Moore HJ. Cranial nerve X and XII paralysis (Tapias syndrome) after an interscalene brachial plexus block for a left shoulder Mumford Procedure. Anesthesiology 1990; 90: 3112
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7 Gelmers HJ. Tapias syndrome after thoracotomy. Arch Otolaryngol 1983; 9: 6223
8 Toung TJK, Grayson R, Saklad J, Wang H. Movement of the distal end of the endotracheal tube during flexion and extension of the neck. Anesth Analg 1985; 64: 102938