UPPER airway obstruction in the immediate postoperative period necessitates expedious diagnosis and treatment. The differential diagnosis of acute upper airway obstruction is distinguished by airway trauma, vocal cord paralysis, vocal cord edema, foreign body aspiration, and anaphylaxis. The differential diagnosis also is distinguished by the possibility of nonorganic upper airway obstruction associated with paradoxical vocal cord adduction (PVCA) during inspiration. Most patients with this syndrome have a long-standing history of upper airway obstruction that has been diagnosed as asthma. We present a case of upper airway obstruction immediately after extubation that was the result of paradoxical vocal cord motion in a previously asymptomatic patient.
A 51-yr-old woman originally presented with hematuria and was scheduled to undergo transurethral resection of a bladder tumor. The patient’s medical history included intermittent tobacco use but no cardiac or respiratory disease. Surgical history included cesarean section and appendectomy, both of which were performed with general anesthesia. The patient was not taking medication and indicated an allergy to sulfa drugs.
Physical examination showed normal vital signs. The patient was 1.63 m tall and weighed 82 kg. Auscultation showed that the patient’s lungs were clear; her airway was normal, as was the rest of her physical examination. A preoperative electrocardiograph, chest radiograph, and laboratory data were all within normal limits.
On the morning of surgery, the patient was sedated with intravenous midazolam (2 mg) and taken to the operating room. After application of standard monitors, the patient was preoxygenated, and general anesthesia was induced using thiopental and fentanyl. Rocuronium was administered, and the patient was intubated by direct laryngoscopy, without apparent trauma. The patient tolerated the procedure well, which was completed approximately 50 min after induction. The patient was administered neostigmine and glycopyrolate and was extubated after following commands and performing a sustained head lift.
Immediately after extubation, the patient exhibited stridor. She was administered 100% oxygen with use of a positive-pressure face mask, and she maintained an oxygen saturation of 99–100% and hemodynamic stability. However, when positive pressure was released, the patient had increased stridor, and oxygen saturation decreased to 90–93%. The patient was not wheezing and was able to phonate. The patient showed a complete return of neuromuscular function; however, given the patient’s stridor, an additional dose of neostigmine and glycopyrolate was administered and a nasal airway was placed. Neither of these measures resulted in change in the patient’s clinical condition.
The patient was taken to the recovery room, where she was administered an aerosol treatment of racemic epinephrine, which did not significantly change her clinical condition. During this time, it was noted that the patient’s stridor occurred primarily during inspiration and did not continue through expiration.
An otolaryngologist was consulted to perform indirect laryngoscopy, which revealed adduction of the vocal cords during inspiration. The vocal cords were not edematous and moved freely, openly, and completely with expiration. No evidence of vocal cord trauma or ligamentous injury was noted. The patient was treated with 1 mg midazolam and 25 mg meperidine. The patient’s stridor began to subside within 1 or 2 min. She was allowed to rest undisturbed, and, within 10–15 min, her stridor subsided completely.
The patient was discharged to the hospital ward after an otherwise uneventful recovery period, and she was discharged from the hospital the next day, without further sequela.
Paradoxical vocal cord adduction is a relatively uncommon cause of upper airway obstruction. Several reports have described patients with functional upper airway obstruction, including patients who have shown PVCA. 1–7Patients presenting with PVCA have received a wide range of unnecessary treatments, from treatment for symptoms incorrectly diagnosed as asthma to intubation and tracheotomy, and the diagnosis of PVCA usually is made only after a long period of ineffective treatment. The case presented is unusual in that it involves a patient without a history of respiratory disease who was diagnosed with PVCA during a short-term episode of upper airway obstruction.
Many patients presenting with PVCA are diagnosed initially with other forms of airway disease and undergo years of treatment. Additionally, there have been several reports of patients who have undergone repeated intubation for acute exacerbation of symptoms incorrectly diagnosed as asthma, only to have complete resolution of their symptoms after intubation. 1–3
Most patients with PVCA have a long history of airway or respiratory complaints. Usually, these patients are female, are younger than 40 yr of age, and have jobs in the healthcare field. 4Furthermore, the appearance of hypoxemia is considered to be uncommon in these patients. 8PVCA is considered to be an hysterical conversion reaction, and many patients have been treated using speech therapy that involves relaxation techniques, verbal support, placebo treatment, phonation therapy, and psychiatric or psychologic support. 3
This case is unique in several respects. Although the patient was female, she did not have history of airway or respiratory disease, she was considerably older than most patients diagnosed with PVCA, and she was not involved in the healthcare industry. After extubation, the patient began to show signs of airway obstruction. The patient was oxygenated with supplemental oxygen, and treatments for possible causes of airway obstruction were instituted. During this time, otolaryngologic consultation was obtained, and the diagnosis was determined. This allowed treatment of the patient with use of sedatives and analgesics. Despite the continuation of the patient’s symptoms, she was allowed to rest undisturbed, and, gradually, her symptoms subsided.
Paradoxical vocal cord adduction is an uncommon cause of upper airway obstruction, especially in a previously asymptomatic patient. However, the diagnosis must be considered when other causes of acute airway obstruction appear unlikely. Prompt and early diagnosis of PVCA could allow treatment of the patient with use of sedatives at a time when sedation would otherwise be considered inadvisable. This may allow appropriate treatment of the patient’s condition and possibly spare the patient prolonged and repeated intubation.