|Year : 2023 | Volume
| Issue : 1 | Page : 23-25
Anaesthetic concerns in a case of spasmodic dysphonia
Priya Rudingwa, Rajasekar Ramadurai, Banupriya Ravichandrane, Kishore Kumar Madhanagopal
Department of Anaesthesiology and Critical Care, JIPMER, Puducherry, India
|Date of Submission||27-Dec-2022|
|Date of Acceptance||20-Feb-2023|
|Date of Web Publication||20-Apr-2023|
Dr. Rajasekar Ramadurai
Senior Resident, Department of Anaesthesiology and Critical Care, JIPMER, Dhanvantri Nagar, Gorimedu, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
Spasmodic dysphonia (SD) is a voice disorder resulting from involuntary laryngeal muscle movements. An anaesthesiologist might encounter patients with SD arriving for surgical treatment of the primary pathology or other surgical procedures. One must exercise caution while providing anaesthesia to such patients and consider any factor that may precipitate airway obstruction. Symptoms might get exacerbated following anaesthesia involving airway intervention that might warrant immediate airway control. Airway techniques that have minimal manipulation and vigilant observation of the patient for any symptom of airway compromise postextubation are recommended. SD, though manifesting just as a voice change, has a significant impact on anaesthesia management, and as an anaesthesiologist, one should be aware of its implications while handling these patients.
Keywords: Airway management, dysphonia, laryngeal mask, neurology, otolaryngology, perioperative care
|How to cite this article:|
Rudingwa P, Ramadurai R, Ravichandrane B, Madhanagopal KK. Anaesthetic concerns in a case of spasmodic dysphonia. Airway 2023;6:23-5
|How to cite this URL:|
Rudingwa P, Ramadurai R, Ravichandrane B, Madhanagopal KK. Anaesthetic concerns in a case of spasmodic dysphonia. Airway [serial online] 2023 [cited 2023 Jun 4];6:23-5. Available from: https://www.arwy.org/text.asp?2023/6/1/23/374370
| Introduction|| |
Spasmodic dysphonia (SD) is a voice disorder that results from involuntary movements of the laryngeal muscles. The symptoms might vary from a minimal phonation abnormality to life-threatening respiratory distress. An anaesthesiologist might encounter patients with SD arriving for surgical treatment of the primary pathology or other surgical procedures. The limited literature available on the anaesthetic management of SD discloses critical complications in the perioperative period. Hence, SD, despite being a benign presentation, deserves more vigilance. This report discusses the incidental diagnosis and successful management of a patient with SD and illustrates how a detailed preanaesthetic assessment and formulation of a safe anaesthetic plan can prevent catastrophic complications.
| Case Report|| |
A 57-year-old female with carcinoma of the left breast was scheduled for modified radical mastectomy surgery. She had a history of bronchial asthma for the past 10 years and was on metered-dose inhalers of formoterol and budesonide. The patient was compliant with her medications and had no history of recent hospitalisation for exacerbation of asthma. During the workup for her respiratory ailment, a computed tomography scan of the thorax showed fibrotic changes in the upper lobe of her right lung. This warranted us to carry out a pulmonary function test, which she was unable to perform due to lack of cooperation.
During the preoperative assessment, the patient had a low-pitched voice and was unable to complete sentences, and blinked excessively. Initially, we attributed it to poor respiratory reserve, but on further examination, we found that her breath-holding time was >20 s, and respiratory auscultation was unremarkable. The patient was not tachypneic and was able to generate a flow of 900 ml/s in incentive spirometry. A neurological consultation was obtained for the speech problem, and the patient was diagnosed with SD (adductor type) with blepharospasm of unknown aetiology, for which an ENT opinion was advised. An indirect laryngoscopic examination showed bilateral mobile vocal cords with no other abnormalities, and the patient was advised for speech therapy. As no further optimisation was possible, the patient was prepared for the surgery with written informed consent for the need for reintubation in the immediate postoperative period.
On the day before the surgery, the patient's bronchodilators were continued, and premedications were given as per hospital protocol. Preinduction midazolam was administered in the operation room to alleviate anxiety, and the patient was counselled for events during extubation. For intraoperative airway management, supraglottic airway (SGA) was chosen over more invasive endotracheal intubation. Anaesthesia was induced with fentanyl, propofol and vecuronium. Adequate depth of anaesthesia was maintained with sevoflurane. Insertion of a ProSeal #3 laryngeal mask airway (LMA) was unsuccessful in the first attempt; however, in the second attempt with a nasogastric tube in situ, the device was positioned appropriately.
Under ultrasound guidance, the serratus anterior plane block was administered on the operative side with 25 ml of 0.25% bupivacaine. Intraoperatively, the airway pressures were within the normal limits, and analgesia was supplemented with intravenous paracetamol and fentanyl boluses. Injection dexamethasone was administered to reduce postoperative nausea and vomiting and any airway oedema due to airway manipulation. The LMA cuff pressure was checked at regular intervals to avoid possible sore throat. All measures were taken to avoid laryngeal injury and adequate neuromuscular recovery. Following the reversal of neuromuscular block (train-of-four ratio of 95%), the patient was given enough time to become awake. The SGA was removed after deflation, and the patient was allowed to breathe spontaneously with a minimal positive pressure of 5 cm H2O. The patient was able to generate adequate tidal volume and did not manifest any sign of respiratory distress. The patient was observed for 20 min and later shifted to the intensive care unit for further observation. The postoperative course was uneventful, and the patient was transferred to the ward on the same day.
| Discussion|| |
SD is a focal dystonia of the laryngeal muscles characterised by deficits in speech production. It can be classified depending on the pathology of the laryngeal muscles. Adductor SD is characterised by hyperadduction of the vocal cords, causing a strangled voice quality with pitch breaks. Abductor SD results from hyperactivity of the posterior cricoarytenoids leading to effortful phonation interrupted by whispered or voiceless segments. It is thought that SD is caused by defective motor control of speech involving systems in the pallidosubthalamic-supplementary motor area of the midbrain. In the majority of the patients, associated tremors or spasms of facial and pharyngeal muscles are also noted. The treatment involves a multimodal approach ranging from speech therapy, psychotherapy, deep brain stimulation, Botox injection and surgical interventions like recurrent laryngeal nerve (RLN) sectioning.
These patients may present with symptoms in voice which may be intermittent and in some cases with no evidence of respiratory distress. However, symptoms might get exacerbated following anaesthesia involving airway intervention that might warrant an immediate airway control. It has been found that negative airway pressure associated with the start of ventilation may precipitate reflex glottic closure. A preoperative assessment of laryngeal function with a telelaryngoscopy is necessary to look for any airway abnormality like narrowing of the laryngeal vestibule, which may make management more difficult. Patients who would have received treatment for SD with RLN interruption, or Botox or Teflon injection of the vocal cord could have scarring or limited abduction of the vocal cords or could have anatomical distortion of laryngeal apparatus, which should be evaluated in telelaryngoscopy preoperatively.
One must exercise caution while providing anaesthesia to such patients and take into consideration any factor which may precipitate airway obstruction. Stress, anxiety and airway manipulation are triggers for spasms. As per the literature available, all cases of SD-related laryngospasm were intubated, suggesting that laryngeal oedema coupled with laryngeal narrowing due to SD triggered by various perioperative stressors may limit airflow through a narrowed orifice. With an intention to keep airway manipulation to a minimum, we used SGA to avoid any form of airway oedema associated with intubation. In addition, this allows smooth recovery from anaesthesia, avoiding unnecessary bucking and anxiety. It is important to note that even previous uneventful general anaesthesia (GA) exposure might not guarantee a lack of airway complications. Case reports are available where patients have needed tracheostomy even without any prior airway complication following GA. Caution should be taken to avoid anxiety and a lighter anaesthetic plane. Airway techniques that have minimal manipulation are to be employed wherever possible. In the postoperative period, a careful observation of the patient for any symptom of airway compromise is recommended. Preoperative laryngoscopy to grade laryngeal narrowing, avoidance of endotracheal tube placement or usage of endotracheal tubes of smaller diameter and employing nasal continuous positive airway pressure therapy after extubation are a few safer strategies to counter patients with SD.
All necessary precautions to ensure minimal airway manipulations, adequate analgesia and anxiolysis were made sure in our patient, which may have averted any episode of laryngospasm postSGA removal. However, it is always safer to anticipate and be prepared for airway compromise beforehand. SD, though manifesting just as a voice change, has a significant impact on anaesthesia management, and as an anaesthesiologist, one should be aware of its implications while handling these patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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