Vocal cord paralysis following orthognathic surgery intubation
A healthy 24 year-old male presented to the Oral and Maxillofacial Surgery Department at Tufts Medical Center for evaluation and treatment of dental malocclusion with skeletal facial discrepancy by his orthodontist. The patient was diagnosed with masticatory dysfunction secondary to maxillary hypoplasia and transverse discrepancy as well as mandibular prognathism resulting in a severe class III malocclusion and elected to undergo orthognathic surgery for its correction. Before the surgery, he underwent leveling and alignment of both maxillary and mandibular arches and removal of all four third molars. The preoperative evaluation and work-up were performed by the surgical team and planned for a 2-piece Lefort I osteotomy for maxillary advancement of 3mm, a bilateral sagittal split osteotomy for mandibular setback of 6mm, an advancement genioplasty of 8mm and maxillo-mandibular fixation (MMF).\nTwo weeks prior to the procedure, he underwent a preoperative evaluation by the consultant physician and the concerned anaesthetist and was medically cleared by his primary care physician. On our preoperative assessment, the patient weighed 89 kg, was alert, awake, and oriented to person, place, and time. He denied any cardiovascular, pulmonary, renal, hepatic, gastrointestinal, genitourinary, hematologic, endocrine, or psychiatric disorders. He denied taking any medications and had no known reported drug allergies. Pertinent social history included being a fourth-year medical student with a supportive family structure, social alcohol use, and no tobacco or other illicit substances.\nIntravenous access was obtained in the preoperative holding area and the patient was transferred to the operating room. Intravenous induction was performed by the anesthesia team and the patient was easily intubated through the right nares with a number 8 size nasoendotracheal tube which was taped at the 29 cm mark by the oral and maxillofacial surgery team. Bilateral breath sounds and capnography confirmed tube placement. The patient underwent a 2-piece Lefort I osteotomy for advancement of 3 mm, a Bilateral Sagittal Split osteotomy for setback of 6 mm, an advancement genioplasty of 8mm and fixation of the osteotomized segments with 2.0 mm Titanium miniplates and 6.0 mm long titanium screws, followed by maxillo-mandibular fixation with elastics without complication. The surgical procedure lasted 3 hours 56 minutes. Based on the clinical evaluation of the patient at the conclusion of the procedure, we noted positive hemostasis at all incision sites and significant postoperative edema of the face and oral cavity and made the decision to keep the patient intubated and sedated overnight in the post-anaesthesia care unit (PACU). The patient was extubated the following morning at 7 am without complications. The remaining postoperative course in the hospital, a 2-day stay, was uneventful and the patient was discharged home and followed up in the oral and maxillofacial surgery clinic 1 week postoperatively. At the 1-week postoperative check, the patient noted features suggestive of mild bilateral paresthesia of cranial nerve V3 distribution and was optimizing his nutritional intake. Neither the patient nor his family observed any change in voice during the period that the patient was on MMF. At the 2 week postoperative evaluation, maxillo-mandibular fixation was removed. Two days after MMF removal we received a call from the patient's father with questions about changes in the quality of his son's voice, as the patient and his family noticed a change in his voice soon after the MMF was removed and the patient started speaking. We evaluated the patient and confirmed hoarseness of his vocal quality and noted mild coughing when taking thin liquids. He had no difficulty with swallowing thicker consistency preparations or any dyspnea. The otolaryngology voice department at Tufts Medical Center was consulted for evaluation of vocal cord function. The otolaryngology service performed a flexible fiberoptic laryngoscopy that showed normal abduction and adduction of the right true vocal cord, normal abduction of the left true vocal cord but very limited adduction. This left the patient with significant glottal incompetence and secondary muscle tension dysphonia. At that time the patient was offered a temporary vocal fold injection to help with his hoarseness but denied having the procedure at that time. We continued to follow the patient on a weekly basis, and 6 weeks postoperative the hoarseness completely resolved without medical or surgical intervention.