Users Online: 382 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 

RSACP wishes to inform that it shall be discontinuing the dispatch of print copy of JOACP to it's Life members. The print copy of JOACP will be posted only to those life members who send us a written confirmation for continuation of print copy.
Kindly email your affirmation for print copies to [email protected] preferably by 30th June 2019.


Table of Contents
Year : 2013  |  Volume : 29  |  Issue : 2  |  Page : 272-274

Post-operative unmasked bilateral vocal cord palsy attributed to pre-operative radiotherapy

Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication13-May-2013

Correspondence Address:
P M Singh
Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9185.111736

Rights and Permissions

How to cite this article:
Singh P M, Borle A, Trikha A. Post-operative unmasked bilateral vocal cord palsy attributed to pre-operative radiotherapy. J Anaesthesiol Clin Pharmacol 2013;29:272-4

How to cite this URL:
Singh P M, Borle A, Trikha A. Post-operative unmasked bilateral vocal cord palsy attributed to pre-operative radiotherapy. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2021 Apr 19];29:272-4. Available from:

Dear Editor,

Radiotherapy used in head and neck cancers is capable of causing vocal cord palsy. [1] Any associated surgical damage to other vocal cord can cause severe obstruction in the post-operative period. Pre-operatively, unilateral vocal cord palsy may only present as minor voice change, and this symptom is often attributed to primary pathology, for which patient received radiotherapy.

A 40-kg, 38-year-old man was scheduled for right-sided radical neck dissection for non-keratinizing carcinoma of nasopharynx [T 2 N 3 M 0 ]. He had received 3 cycles of chemotherapy followed by radiotherapy (70 Gy in 30 fractions) 6 months earlier. Pre-operatively, he reported upper respiratory tract infection with mucopurulent sputum 6 weeks ago, which resolved after antibiotics and anti-histamines. There was no history of any other systemic illness. Systemic and airway examination was unremarkable.

Anesthesia was induced as per routine protocols, and no gross abnormality was noted in vocal cord position during laryngoscopy. Surgery lasted for 4.5 hours, after which neuromuscular blockade was reversed, and trachea was extubated at a Train of Four ratio of 0.9. Within 2 minutes of extubation, patient developed respiratory distress with tachycardia and desaturation. Respiratory distress continued to worsen with time, and the oxygen saturation (SpO 2 ) dropped to 82% despite administering 100% oxygen. The patient was fully awake with no signs suggestive of residual opioid effects or neuro-muscular blockade. The patient's trachea was re-intubated; subsequently, oxygen saturation rose to 100% on IPPV. He was shifted to the intensive care unit for further management.

As he could generate adequate tidal volume, he was allowed to breathe spontaneously with a continuous positive airway pressure of 5 cm of H 2 O on a 0.5 inspired oxygen fraction. Overnight elective ventilation was planned; his biochemical, hematological investigations, and chest X-ray were normal. After tracheal extubation the next day, he again developed labored breathing, chest retractions, was unable to vocalize, and SpO 2 fell to 90% in 10 minutes despite oxygen supplementation. Fiberoptic bronchoscopy showed bilateral vocal cord palsy without any apparent edema. The surgical team denied any possibility of surgical damage to left cord, as surgery was limited to right side only. A tracheostomy was done.

Pre-operatively, patient had no history suggestive of vocal cord paralysis, although such a condition can be present without any symptoms. [2] Neoplasms of nasopharynx can cause vocal cord palsy due to anatomical involvement of Vagus nerve of same side. The incidence of cranial nerve palsies after radiotherapy of the head and neck region is around 3%. [3],[4] Delayed recurrent laryngeal nerve involvement due to radiotherapy [>12 month] has already been reported. [1],[5]

Bilateral vocal cord palsies can also occur after prolonged intubation though unilateral palsy is more common but is unlikely after only 4.5 hours of intubation. [6] Idiopathic vocal cord paralysis is also seen after herpes infections and can remain asymptomatic with minor voice change. [4] Our patient had history of recent upper respiratory tract infection bacterial (muco-purulent) but did not have its sequelae. It is likely that our patient developed unilateral vocal cord paralysis following radiotherapy, and the surgical trauma lead to paralysis of the right vocal cord, which resulted in respiratory distress in the post-operative period.

We recommend that a routine pre-operative indirect laryngoscopy to be done in patients for neck surgery receiving radiotherapy in the head and neck region. This small intervention can avoid catastrophic post-operative obstruction. Both the surgeon and anesthesiologist can later be blamed to have caused the palsy.

  References Top

1.Stern Y, Marshak G, Shpitzer T, Segal K, Feinmesser R. Vocal cord palsy: Possible late complication of radiotherapy for head and neck cancer. Ann Otol Rhinol Laryngol 1995;104:294-6.  Back to cited text no. 1
2.Lu YH, Hsieh MW, Tong YH. Unilateral vocal cord paralysis following endotracheal intubation-a case report. Acta Anaesthesiol Sin 1999;37:221-4.  Back to cited text no. 2
3.Lin YS, Jen YM, Lin JC. Radiation-related cranial nerve palsy in patients with nasopharyngeal carcinoma. Cancer 2002;95:404-9.  Back to cited text no. 3
4.Tang SC, Jeng JS, Liu HM, Yip PK. Isolated vagus nerve palsy probably associated with herpes simplex virus infection. Acta Neurol Scand 2001;104:174-7.  Back to cited text no. 4
5.Takimoto T, Saito Y, Suzuki M, Nishimura T. Radiation-induced cranial nerve palsy: Hypoglossal nerve and vocal cord palsies. J Laryngol Otol 1991;105:44-5.  Back to cited text no. 5
6.Chen H-C, Jen YM, Wang CH, Lee JC, Lin YS. Etiology of vocal cord paralysis. ORL J Otorhinolaryngol Relat Spec 2007;69:167-71.  Back to cited text no. 6

This article has been cited by
1 Transient Aphonia After Mediastinoscopy
Frank O. Velez-Cubian,Kavian Toosi,Jessica Glover,Bharat Pancholy,Edward Hong
The Annals of Thoracic Surgery. 2017; 103(6): e549
[Pubmed] | [DOI]
2 Continuous Positive Airway Pressure with Pressure Support Ventilation Is Effective in Treating Acute-Onset Bilateral Recurrent Laryngeal Nerve Palsy
Yiuka Leung,Karim Fikry,Bhavika Shah,Manokanth Madapu,Randall D. Gaz,Lisa R. Leffert,Yandong Jiang
A & A Case Reports. 2015; 4(11): 155
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article

 Article Access Statistics
    PDF Downloaded263    
    Comments [Add]    
    Cited by others 2    

Recommend this journal