Shortly after a total thyroidectomy performed for follicular carcinoma, a 61-year-old woman is extubated. Her voice is initially hoarse, and shortly afterward there is a shrill high-pitched noise with each inspiration and she is observed to be gasping for air. There are no signs of swelling at the surgical site. The patient continues to have difficulty breathing and is re-intubated.
What is the most likely etiology of her symptoms?
A. HypocalcemiaNerve injury. Patients undergoing total thyroidectomy are at risk for developing a variety of complications. In this case the patient presents with signs of bilateral recurrent laryngeal nerve injury leading to vocal cord paresis, which is suggested by hoarseness and the development of stridor requiring re-intubation. Ultimately she will require direct laryngoscopy for visualization of the vocal folds to assess for paralysis. (A) While accidental removal of the parathyroids may lead to hypocalcemia, this effect would not be expected so rapidly after surgery and would not be expected to result in hoarseness or stridor. (B) Infection with Haemophilus influenzae may lead to stridor in pediatric patients, but this individual’s history of recent surgical intervention makes acute infection less likely. (D) There was no report of swelling at the surgical site, so a hematoma would be unlikely. (E) Anaphylaxis refers to immediate hypersensitivity to a foreign antigen. While anaphylaxis secondary to anesthesia medications is possible, it would have been expected to occur earlier in the patient’s time course.