This article presents three cases of cranial nerve palsy following shoulder surgery with general anesthesia in the beach chair position. All patients underwent preoperative ultrasound-guided interscalene nerve block. Two cases of postoperative hypoglossal and one case of combined hypoglossal and recurrent laryngeal nerve palsies (Tapia’s syndrome) were identified. Through this case series, we provide a literature review identifying postoperative cranial nerve palsies in addition to the discussion of possible etiologies. We suggest that intraoperative patient positioning and/or airway instrumentation is most likely causative. We conclude that the beach chair position is a risk factor for postoperative hypoglossal nerve palsy and Tapia’s syndrome.
With the advent of the beach chair position, cranial nerve palsies have been rarely reported following shoulder surgery [
We present a series of three cases of cranial nerve palsy following shoulder surgery that occurred within a three-month timeframe. All patients underwent ipsilateral preoperative ultrasound-guided interscalene brachial plexus block with local anesthetic. The surgeries included two arthroscopic rotator cuff repairs and a total shoulder arthroplasty, all in the beach chair position. Affected nerves included ipsilateral hypoglossal, recurrent laryngeal, and contralateral hypoglossal.
This paper will discuss the possible mechanisms of injury resulting in postoperative hypoglossal and recurrent laryngeal nerve palsy in this clinical setting. In addition, we provide a literature review and discussion of postoperative cranial nerve palsy.
A 66-year-old 77-kilogram (kg) male with a history of gastroesophageal reflux and hypertension underwent arthroscopic repair of a right rotator cuff tear. Uncomplicated preoperative interscalene block was performed with real-time ultrasound guidance by an experienced anesthesiologist using a 22 gauge needle and thirty milliliters of 0.5% ropivacaine. Induction was with propofol, fentanyl, and succinylcholine. Mask ventilation was easy and uneventful. A MacIntosh blade was used and vocal cord visualization was a modified Cormack–Lahane grade 1, with subsequent successful placement of a 7.5 cm endotracheal tube (ETT) with one attempt [
Positioning of head and neck during the beach chair position, secured via soft Velcro strap across forehead and around the chin.
A typical beach chair position at our institution.
The following morning the patient was noticeably dysarthric. Examination revealed notable tongue weakness with rightward deviation on protrusion. The remaining neurologic and cranial nerve exam appeared normal. The preoperative block had resolved and he had normal upper extremity sensation. The neurology service was consulted and rendered a diagnosis of isolated right hypoglossal nerve palsy. Eight days after surgery, the patient noticed marked improvement in his symptoms, except slight tongue deviation to the right. All symptoms resolved by six weeks postoperatively (Table
Summary of our cases.
Case | Surgery | Position | Airway | Injury | IS block | Nitrous oxide used | |
---|---|---|---|---|---|---|---|
1 | Shoulder arthroscopy | Beach chair | Oral ETT | Ipsilateral hypoglossal | Yes | No | |
2 | Shoulder arthroscopy | Beach chair | Oral ETT | Ipsilateral Tapia’s syndrome | Yes | No | |
3 | Total shoulder | Beach chair | Oral ETT | Contralateral hypoglossal | Yes | No |
A 69-year-old, 93-kg male with past medical history significant for coronary artery disease, obstructive sleep apnea, gastroesophageal reflux, and dyslipidemia underwent left arthroscopic rotator cuff repair. Preoperative interscalene block was performed as described above. Induction was with propofol, fentanyl, and rocuronium. Mask ventilation was easy and intubation was uncomplicated in a single attempt with an Phillips blade and an 8.0 cm ETT. The glottis was anterior and a Corrmack–Lahane grade 2b arytenoid view was obtained. The patient was positioned in beach chair as described in case 1. Routine surgery followed and concluded at eighty minutes.
The patient noted dysphonia and dysphagia immediately following surgery but was otherwise stable for discharge. On his surgical follow-up he continued to have dysphonia and dysphagia and was referred to otorhinolaryngology (ENT). On postoperative day 8, he was evaluated by ENT, he had a whispering voice and leftward deviation of his tongue. Flexible laryngoscopy showed left true vocal fold immobility, fixed at a 45 degree position with inability to approximate the cords with attempted adduction. Combined left hypoglossal and left recurrent laryngeal nerve palsy was diagnosed. The patient had difficulty swallowing and fear of oral intake due to sensation of aspiration, which resulted in unintentional weight loss of fifteen pounds. Speech therapy evaluation led to a formal swallow study, which was normal. Because both cranial nerves X and XII were affected, a CT angiogram was obtained to rule out dissection or aneurysm, and was negative. He subsequently underwent office-based medialization with hyaluronic acid to bring the immobile left vocal fold to a midline position.
ENT evaluation seven weeks postoperative with flexible laryngoscopy showed continued immobility of the left true vocal fold. The vocal fold was in the midline position allowing for complete glottic closure with phonation. This patient reported significant improvement in voice and swallowing with full range of motion of his tongue without deviation on protrusion. Ten weeks after surgery, the patient reported his tongue, swallowing, and voice had all returned to normal. At that point, flexible laryngoscopy showed slight improvement in left true vocal cord mobility, though still hypomobile, and excellent glottic closure (Table
A 75-year-old 87-kg male with past medical history of hypertension, gastroesophageal reflux, dyslipidemia, and chronic shoulder pain underwent a right total shoulder arthroplasty for degenerative arthritis. Preoperative interscalene block was performed as above. Induction was with propofol, fentanyl, lidocaine, and rocuronium. Mask ventilation and intubation was uncomplicated in one attempt with a Miller blade and a 7.5 cm ETT. Anesthesia was maintained with sevoflurane in oxygen/air. The patient was positioned in the beach chair position at 45 degrees. Routine surgery followed with sixty-seven minutes operative time.
In recovery, the patient noted dysarthria, difficulty swallowing, and a subjectively heavy tongue. He was evaluated by the anesthesia team and observed. When his symptoms were not completely resolved at his postoperative follow-up, his surgeon obtained ENT evaluation on postoperative day 11. Exam revealed leftward deviation of the tongue with persistent glossal weakness. Left hypoglossal nerve palsy was diagnosed. Three weeks postoperatively, the patient continued to have persistent left sided deviation but improved bilateral mobility. Six weeks later, his symptoms completely resolved (Table
The hypoglossal nerve, or twelfth cranial nerve, is purely a motor nerve responsible for innervating the extrinsic and intrinsic muscles of the tongue. Functions include the articulation of speech and the act of swallowing. Altered function results in slurred speech and difficulty with mastication. Patients with hypoglossal palsy describe the tongue as thick, heavy, or clumsy. To test the status of the nerve, a patient is asked to protrude his or her tongue. If there is a unilateral loss of function, the tongue will deviate to the ipsilateral side on protrusions, whereas at rest, the tongue will deviate to the contralateral side of the injury [
The vagus nerve, or tenth cranial nerve, innervates the vocal folds via the recurrent laryngeal nerve branch. Our case series included hypoglossal and recurrent laryngeal nerve injuries following shoulder surgery. The combination of hypoglossal and recurrent laryngeal nerve injuries is called Tapia’s syndrome. This results in an adducted vocal cord causing hoarseness, unilateral paralysis of the soft palate, and ipsilateral deviation of the tongue [
Based on our observations and using information from the medical literature, several potential causes were identified: an injury related to the interscalene block, intubation trauma, compression by the ETT or laryngeal mask airway (LMA) cuff, positioning, or a combination of etiologies.
A literature search was conducted on PubMed databases from 1947 to September 2018. The keywords “Tapias syndrome”, “hypoglossal nerve palsy”, “recurrent laryngeal nerve palsy” were used. Only case reports on adults and written in English were included. Reference lists of cases identified were also used to find additional cases. In all, 28 cases of postoperative hypoglossal nerve palsy and 18 cases of postoperative Tapia’s syndrome were identified. Twelve of these case reports were following shoulder surgery.
Could these neurapraxias be related to an interscalene block where direct nerve injury is a known, although rare, complication? The brachial plexus at the interscalene block site in the inferolateral neck is positioned inferior and distant from the hypoglossal nerve (Figure
Hypoglossal, vagus, recurrent laryngeal nerves pictured. The brachial plexus between anterior and middle scalene is far caudal from the hypoglossal nerve.
In all three of our cases preoperative interscalene blocks were performed using ultrasound. Three different anesthesiologists performed the preoperative blocks and conducted the anesthesia in a team care model (Table
We have identified seven manuscripts describing eight cases [
Johnson et al. described a case of Tapia’s syndrome following left shoulder Mumford procedure (distal clavicle excision) in a patient who received an interscalene block [
In Wadelek et al.’s case of Tapia’s syndrome following shoulder arthroscopy with interscalene block, an MRI was performed which revealed a submucosal hematoma at the tongue base [
Unrelated isolated hypoglossal and recurrent laryngeal nerve injury in the same surgery from a block is highly unlikely.
Upon review of the literature, several cases concluded that airway manipulation and instrumentation may lead to injury of the hypoglossal and recurrent laryngeal nerves (see Tables
Case reports of cranial nerve palsy after shoulder surgery.
First author | Surgery | Position | Airway | Injury | IS block | Nitrous oxide used | Determined cause |
---|---|---|---|---|---|---|---|
Mullins [ |
Open repair or rotator cuff | Beach chair | Oral ETT | Contralateral hypoglossal | No | NA | Positioning |
Hwang [ |
Open repair of humeral fracture | Beach chair | Oral ETT | Hypoglossal | No | NA | Positioning |
Rhee [ |
Arthroscopy | Beach chair | Oral ETT | Contralateral hypoglossal | No | NA | Positioning |
Rhee [ |
Arthroscopy | Beach chair | Oral ETT | Contralateral hypoglossal | No | NA | Positioning |
Hung [ |
Arthroscopy | Semi-beach-chair | Oral ETT | Ipsilateral hypoglossal | No | No | Intubation or mask ventilation |
Nagai [ |
Total shoulder | Right lateral | LMA | Contralateral hypoglossal | No | Yes | LMA, N2O, change in position |
Cogan [ |
Arthroscopy | Beach chair | Oral ETT | Tapia’s syndrome | No | NA | Positioning |
Boisseau [ |
Arthroscopy | Beach chair | Oral ETT | Ipsilateral Tapia’s syndrome | No | No | Positioning |
Wadelek [ |
Arthroscopy | Semi-supine | LMA | Tapia’s syndrome | Yes | No | LMA and positioning |
Johnson [ |
Shoulder Mumford Procedure | NA | NA | Ipsilateral Tapia’s syndrome | Yes | NA | Dissection of the ascending pharyngeal artery |
Dziewas [ |
Arthroscopy | NA | Oral ETT | Hypoglossal | No | NA | laryngoscopy |
Haslam [ |
Total shoulder | Beach chair | Oral ETT | Contralateral hypoglossal | Yes | NA | ETT |
NA = not available; IS = interscalene block.
Additional case reports of postoperative Tapia’s syndrome.
First Author | Surgery | Position | Airway | Throat Pack | Nitrous Oxide Used | Determined Cause |
---|---|---|---|---|---|---|
Ota [ |
Le Fort osteotomy and genioplasty | NA | transnasal ETT | Yes | NA | Intubation and position |
|
Rhinoplasty | Semi-recumbent | Oral ETT | Yes | No | Excessive cuff pressure |
Poveda [ |
Rhinoplasty | Semi-supine | Oral ETT | Yes | No | Throat pack and positioning |
Yavuzer [ |
Septorhinoplasty | Unspecified | Oral ETT | Yes | NA | ETT |
|
Anterior mediastinotomy | NA | Oral ETT fiberoptic intubation | No | NA | ETT |
Nalladaru [ |
CABG | Supine | Oral ETT | No | NA | Intubation or positioning |
Park [ |
Posterior cervical spine | Concord position | Oral ETT | NA | NA | Positioning |
Lykoudis [ |
Rhinoplasty | NA | Oral ETT | Yes | NA | Throat pack |
Kashyap [ |
Repair of mandibular fracture | NA | Nasal ETT | NA | NA | Unclear |
Lim [ |
Cervical laminoplasty | Prone | Oral ETT | No | No | ETT and positioning |
Sotiriou [ |
CABG | Supine | Oral ETT | No | NA | positioning |
Bakhshaee [ |
Rhinoplasty | NA | Oral ETT | Yes | Yes | Intubation, ETT, throat pack, controlled hypotension |
Varedi [ |
Zygomatic arch repair | NA | Transnasal ETT | Yes | NA | Unclear |
Ghorbani [ |
Septorhinoplasty | Supine with head elevated | Oral ETT | Yes | NA | ETT, throat pack, position |
During intubation, the patient’s tongue is pushed forward and the neck can be extended, which results in traction on the hypoglossal nerve [
In Tapia’s syndrome, mechanical stress on both the hypoglossal and recurrent laryngeal nerves is likely the etiology. The two nerves are in close proximity at the base of the tongue and in the pyriform fossa. They also cross the lateral prominence of the anterior surface of the transverse process of C1. The nerves may be compressed between the ETT and a stiff structure such as greater cornu of the hyoid bone, thyroid cartilage, or cervical vertebrae [
Additional case reports of postoperative hypoglossal nerve palsy.
First author | Surgery | Position | Airway | Throat pack | Nitrous oxide used | Determined cause |
---|---|---|---|---|---|---|
|
Open AAA repair | NA | Oral ETT | No | NA | Excessive cuff pressure |
Streppel [ |
Sinus surgery | NA | Oral ETT | No | NA | Calcified ligamentum stylohoideum and intubation |
Dearing [ |
Molar surgery | NA | Nasal ETT | Yes | NA | Intubation or throat pack |
Dwiewas [ |
Esophageal resection | NA | Oral ETT | No | NA | laryngoscopy |
Evers [ |
Trans-spenoidal hypophysectomy | Supine | Oral ETT | Yes | Yes | Intubation or throat pack |
Ulusoy [ |
Septohinoplasty | Semi-supine | Oral ETT | Yes | Yes | Intubation or mask ventilation |
Venkatesh [ |
Craniotomy | NA | Oral ETT | No | Yes | Accidental extubation with inflated cuff |
King [ |
Removal of rush pins | NA | LMA | No | Yes | LMA |
Lopes [ |
Breast reconstruction | Lateral decubitus and sitting | Oral ETT | No | No | Positioning |
Lopes [ |
Breast reduction | Semi-sitting and dorsal decubitus | Oral ETT | No | No | Positioning |
Yelken [ |
Open septoplasty | NA | Oral ETT | Likely but unspecified | NA | Intubation and arnold chiari |
Michel [ |
Tonsillectomy | NA | Oral ETT | NA | NA | laryngoscopy |
Lo [ |
ORIF humerus | NA | LMA | No | NA | Malpositioned LMA |
|
Knee arthroscopy | NA | LMA | No | Yes | Excessive cuff pressure |
Baumgarten [ |
Septoplasty | NA | Oral ETT | NA | NA | Intubation |
Trumpelmann [ |
ORIF tibial plateau fracture | NA | LMA | NA | Yes | LMA and nitrous oxide |
Takahoko [ |
Hallux valgus correction | Supine | LMA | No | Yes | LMA and nitrous oxide |
Al-Benna [ |
Breast augmentation | 30 degree elevated supine | Oral ETT | No | Yes | ETT |
Slaats [ |
Exploratory laparoscopy | Supine | Oral ETT | No | NA | Intubation, hematoma near nerve |
|
Removal of scar tissue behind ears | Extreme side rotation of head | LMA | No | No | Positioning |
Two case reports of Tapia’s syndrome and isolated hypoglossal nerve palsy suggested that the ETT was left attached to a pressure gauge to maintain cuff pressure <20 cm H2O [
In our review, patient positioning was not clearly described in all cases. When it was reported, the beach chair, supine, and semi-supine positions were most common. While many reports provided varying possible mechanisms of injury, the beach chair position was used in 9 of 12 of cranial nerve palsy cases following shoulder surgery (Table
The hypoglossal nerve exits the skull and proceeds caudally between the internal carotid artery and internal jugular vein, and passes inferiorly to the angle of the mandible. While positioned in the beach chair position, a head strap is used to secure the head in a neutral position. Placing the strap too tightly at the angle of the mandible or manipulation during surgery, can cause direct compression or hyperextension to the hypoglossal nerve [
Surgical manipulation, such as a surgical assistant’s elbow, can compress the mandible angle during surgery [
Boisseau, et al. concluded that positioning was the cause of a patient’s postoperative Tapia’s syndrome as when the surgical drapes were removed at the conclusion of the case the patient’s head was noted with a pronounced right lateral flexion [
Fortunately, postoperative cranial nerve palsies generally have a good prognosis. They are often mild injuries to the myelin sheath that result from ischemia or mechanical compression. Neurapraxias typically resolve within three months, as is the situation with our three patients. Axonotmesis is more severe and caused by a crush injury or extreme traction on the nerve and has a more tenuous recovery. Complete recovery of the hypoglossal nerve function, if occurs, is expected within the first six months. Interventions are largely unnecessary. Several case reports describe the use of corticosteroids for several days after injury; however this is not supported in the literature. Patients may benefit from speech therapy to improve their ability to swallow by training to chew and manipulate food on the noninvolved side [
Cranial nerve palsy following shoulder surgery is rare. In our series, both ipsilateral and contralateral cranial neurapraxia occurred, which is consistent with previous reports in the literature. Intraoperative patient positioning and airway instrumentation, as opposed to preoperative regional nerve block or operative technique, is the most likely causative factor.
Based on our literature review, we conclude that the beach chair position is a risk factor for postoperative hypoglossal nerve palsy or Tapia’s syndrome. To prevent cranial nerve injury, the anesthesiologist and surgical team must be vigilant in positioning. In the beach chair position in particular we must respect the craniospinal axis. Head position should be verified for neutrality on initial positioning and frequently during the procedure. The anesthesiologist should monitor and minimize endotracheal cuff pressures, and avoid prolonged laryngoscopy.
The authors declare that there is no conflict of interest regarding the publication of this paper.