Botulinum toxin/general anaesthetics
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Bilateral vocal fold paralysis and lack of efficacy: case report A 57-year-old woman developed bilateral vocal fold paralysis following botulinum toxin injections for dropped head syndrome (DHS) and general anaesthesia with fentanyl, propofol and rocuronium bromide during posterior spinal correction for DHS. She also exhibited lack of efficacy during treatment with botulinum toxin injections for DHS. The woman presented to the spinal surgery clinic at a tertiary spine unit with DHS. Her electromyography had shown dystonia of the bilateral sternocleidomastoid muscles and the splenius and levator capitis on the left side. She had been receiving botulinum toxin injections and physical therapy for a period of several months; but the condition had been refractory to the therapy. She had developed symptoms of DHS 2 months following pedicle subtraction osteotomy of a fractured first lumbar vertebra. Following presentation, posterior spinal correction for DHS was planned. General anaesthesia was induced with administration of IV fentanyl, propofol and rocuronium bromide [rocuronium; dosages not stated; not all routes stated]. The intubation was done without incident. In order to maintain a mean arterial pressure, phenylephrine was administered. During the surgery, fresh frozen caput femoris homologous bone grafts were morselised, washed in a solution of vancomycin and implanted in contact with decorticated bone on the posterolateral aspects. The surgery was completed without adverse events. However, despite a smooth extubation process, dyspnoea and stridor was observed while on the way to the postoperative observation department. Thus, an awake nasotracheal fiberoptic intubation was immediately performed to secure the airway. During this surgery, an assessment of the vocal folds was done. Both were placed medially. The right fold was totally immobile, and the left fold revealed a slight adduction, but no abduction [time to reactions onsets not stated]. Therefore, she was admitted to an ICU. On the following day, an endoscopic right side arytenoid lateral fixation was done through a rigid Lindholm laryngoscope. Under manipulation to achieve access with the laryngoscope, a loosening of the right incisor occurred without fracture of the tooth. Additionally, small lacerations on the tongue were sutured with resorbable thread. Following the procedure, she was able to maintain a free airway, but had mucous accumulation, combined with an ineffective cough owing to incomplete glottic closure, prompted reintubation within 1 day. Five days later, she was found to have diffuse arytenoid cartilage swelling and a folded epiglottis, which was promptly repositioned. During the follow-up examination the next day, no regression of the swelling was observed; thus, tracheostomy was done. Subsequently, the woman was admitted to the ear, nose and throat department. On postoperative day 18, signs of swelling and infection were present around the tracheostomy, which was treated with cefotaxime. On postoperative day 21, she was decannulated
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