Right hypoglossal nerve paralysis after tracheal intubation for aesthetic breast surgery
A 24-year-old female Caucasian patient, 171 cm tall and weighing 60 kg, was to undergo bilateral breast augmentation, exchange of implants, and mammaplasty for bilateral breast ptosis and capsular contracture. Past medical history included bilateral breast augmentation in 2008 and abdominoplasty in 2007 after 90 kg weight loss, lower Cesarean section in 2004, and tonsillectomy as a child. She was otherwise well and did not take any regular medication. The pre-operative physical examination showed good neck extension and mouth opening, and a straightforward endotracheal intubation was anticipated. Two hours before the induction of anesthesia, she received chlorazepam 20 mg orally as premedication. General anesthesia was induced with fentanyl 0.1 mg and 200 mg propofol, and atracurium 25 mg was used to prevent laryngospasm during insertion of the endotracheal tube. At intubation, the Cormack and Lehane grade was described as 1, using a standard size 3 Macintosh blade. A 7.5-mm Magill tube was used. After intubation, proper placement of the endotracheal tube was confirmed by bilateral breath sounds. The endotracheal tube cuff was inflated with air until the cuff pressure was 30 cm H2O. During surgery, the patient received intermittent positive pressure ventilation with 67% nitrous oxide in oxygen, 0.8-1.2% isoflurane, supplemented with fentanyl 0.15 mg. The maximum endotracheal tube cuff pressure did not exceed 34 cm H2O. The patient was placed in a 30° elevated supine position and the head was supported in position with a donut-type pillow. Surgery was completed uneventfully within 90 min, blood loss was minimal, and fluid replacement was done with 1000 ml of full electrolyte solution Jonosteril (Fresnius, Bad Homburg, Germany) and 500 ml of conventional 6% hetastarch 130/0.4 (Tetraspan, B. Braun, Melsungen, Germany). No significant changes in cardiovascular or respiratory parameters occurred during the operation. When spontaneous respiration and muscle tone were considered to be adequate, the endotracheal tube was carefully removed and transferred to the recovery unit. After 35 min, the patient was discharged to the ward.\nThe next morning, she complained of slight difficulty in swallowing solid foods but was able to drink water. On clinical examination, her tongue deviated to the right on protrusion and she was unable to move it to the left; there were no further detectable cranial nerve abnormalities. Magnetic resonance imaging of her brain did not demonstrate any evidence of an ischemic event or focal abnormality. A neurologist diagnosed an isolated paralysis of the right hypoglossal nerve. The neurologist recommended supportive treatment and did not prescribe any pharmacological therapy. Two weeks post surgery, the patient attended the neurology out-patient clinic; at this time, she had complete resolution of symptoms and had made a complete recovery.