P021: PARADOXICAL VOCAL CORD MOVEMENT IN ELDERLY ORTHOPEDIC PATIENT
Najid M Ali, MD; Catherine Chen, MD; John Weir, MD; University of Miami
Introduction: We present a unique case of paradoxical vocal cord movement in the post operative period.
Methods: Patient is a 79 year old female with a history of dementia, chronic back pain, and hypertension who presented with right femoral neck fracture status post percutaneous screw fixation. There was no previous stridor or pulmonary issues noted on exam or history. Intraoperatively, there were multiple attempts at intubation by junior resident. There did not appear to be any difficult airway or difficulty with ventilation. She was intubated with an 8.0 endotracheal tube. No other airway complications or hemodynamic instability was found during the procedure. In PACU, the patient was noted to have increasing stridor with no obvious desaturation or increased work of breathing. She received an initial treatment of intravenous dexamethasone 8mg, racemic epinephrine via nebulizer, and albuterol. There was no significant improvement noted. Oral fiberoptic exam was conducted by the anesthesia team after the airway was sufficiently anesthetized with a combination of topical and nebulized lidocaine. No supraglottic abnormalities were noted. No positive pressure ventilator strategies were employed as there was no concern for the patient’s ventilatory status. ENT was urgently consulted due to concerns for sub-glottis pathology. A nasal fiberoptic exam was performed and no inflammation, edema, airway abnormality, or blood was found. They did note prominent paradoxical vocal cord movement. Lungs were clear to auscultation and initial blood gas showed CO2 retention (pH 7.09 and CO2 100). There were no changes in the patient’s baseline mental status or vitals during any point. The patient was placed on BiPAP after blood gas results were examined. Repeat blood gas results showed improvement of CO2 retention and acidosis with pH 7.37 and CO2 47. The patient was transferred to the ICU for further monitoring. Overnight, she developed worsening mental status and repeat blood gases showed increased CO2 retention, requiring intubation. Patient was extubated successfully 4 days later after an unimpressive bronchoscopy. She was not reevaluated by ENT and had no recurrence of paradoxical vocal cord movement.
Conclusions: Paradoxical vocal cord movement is a phenomenon in which the vocal cords adduct during inspiration. This phenomenon normally presents as stridor and wheezing, most closely resembles asthma until diagnosed by fiberoptic exam. The exact cause and mechanism is unknown. Some causes include exposure to irritants, psychological stress, or neurologic issues. It is thought that anxiety and airway irritants can precipitate the condition. Preoperative care should focus on anxiolysis and diminishing airway stimulation. Symptoms have shown improvement with CPAP and Heliox. It also appears to be more common in the age range of 30-40. It has also been shown to be more common in women than men, as in the case of our patient. Brugman’s study showed a 3:1 ratio and Morris et al showed a ratio of 2:1 female to male. In severe cases, botulinum toxin injections have been used for superior laryngeal nerve block. Commonly, the phenomenon resolves on its own. This case illustrates a classic presentation of paradoxical vocal cord movement in an uncommon age group.