A 57-year-old Caucasian man with a body mass index of 28 (height 178 cm, weight 88.6 kg) presented for a left biceps tendon repair. His medical history was significant for asthma, OSA with loud snoring documented by a previous sleep study, hypercholesterolemia, and frequent alcohol use (8 beers daily). Medications at the time of admission were atorvastatin, aspirin, and albuterol inhaler. The patient denied any drug allergies. His surgical history was notable for an umbilical herniorraphy under subarachnoid block and molar teeth extraction without complications.
Vital signs at admission were blood pressure of 137/81 mm Hg, heart rate of 88 beats/min, respiratory rate of 16 breaths/min, and a room air pulse oximetry of 98%. The cardiac and pulmonary exams were unremarkable. The patient's airway was notable for a short neck with good range of motion, normal thyromental distance, a Malampati class II airway, multiple crowns, no pharyngeal erythema or exudates, and no rhinorrhea or recent upper respiratory tract infections.
After consent, and intravenous and monitor placement, midazolam (2 mg) and fentanyl (100 μg) were administered for sedation before placement of a peripheral nerve block. A left interscalene BPNB was placed by the neurostimulator technique with an insulated, 25-mm Stimuplex needle (B. Braun, Bethlehem, Pa). Aspiration for cerebrospinal fluid or blood was negative. A deltoid motor response was obtained at less than 0.6 mA. The motor response was extinguished with injection of a 1-mL local anesthetic test dose followed by 30 mL of a 1 : 1 solution (2% mepivacaine and 0.5% bupivacaine with 1 : 200,000 epinephrine) in divided doses with multiple negative aspirations. To ensure cutaneous anesthesia, a superficial cervical plexus block was placed with 5 mL of 2% lidocaine. Propofol (30 mg) was administered during block placement for supplemental sedation. Fifteen minutes after peripheral nerve block placement, the patient had complete motor and sensory nerve blockade (including the ulnar nerve). There were no signs or symptoms of dyspnea (secondary to phrenic nerve block). The patient was noted to have a marked change in phonation (recurrent laryngeal nerve blockade) and Horner syndrome. Vital signs were stable with pulse oximetry of 98% on 2 L/min nasal cannula oxygen.
The patient was transported to the operative theater, and the American Society of Anesthesiologists standard monitors and a BIS monitor (Aspect Medical Systems Inc, Newton, Mass) were reapplied. The patient requested additional sedation at this time, and a small dose of ketamine (25 mg) was administered while a propofol infusion (100 μg/kg/min) was initiated. An upper extremity tourniquet was inflated to 275 mm Hg. The patient was comfortable at skin incision. Sedation was maintained with the propofol infusion and intermittent ketamine bolus doses. A total of 90 mg ketamine was administered during the 130-minute case. No antibiotics or other medications were administered throughout the case. Although loud snoring was observed throughout the case, the respiratory rate remained stable at 10–14 breaths/min. No periods of apnea were noted. Pulse oximetry varied between 96% and 98% intraoperatively. The BIS monitor analysis was maintained between 86 and 90. There were no airway manipulations (eg, nasal or oral airway device) or suctioning of the airway during the case. The patient complained of a hoarse voice and mild difficulty swallowing while in the postoperative care unit. Oral and pharyngeal examination, including of the uvula, was without change compared with the preoperative examination. The patient required no supplemental analgesia or other medications in the postoperative care unit and was discharged home in stable condition.
The patient returned on the second postoperative day with a chief complaint of a painless mass in the back of his throat. The hoarseness had resolved on the first postoperative day. However, he had noticed that a pharyngeal mass had progressively enlarged since resolution of the pharyngeal sensory nerve blockade. The patient denied dyspnea or any other complaints. He was afebrile with blood pressure of 139/81 mm Hg, heart rate of 96 beats/min, respiratory rate of 16 breaths/ min, and a pulse oximetry of 97% on room air. Physical examination demonstrated an elongated, erythematous, and edematous uvula (see ). The remainder of the oropharyngeal tissue was normal and without erythema or exudates. There was no cervical lymphadenopathy. The interscalene BPNB had complete resolution after 24 hours. In the interim, the patient had taken 2 acetaminophen-hydrocodone tablets (Vicodin) for analgesia on the evening of the first postoperative day. He reported that the pharyngeal swelling was present before the Vicodin.
The patient's uvular edema and erythema on postoperative day 2. Note that the uvula has been retracted anteriorly and inverted superiorly for photographic purposes.
The patient was treated with nebulized aerosol of albuterol and racemic epinephrine along with dexamethasone (8 mg intravenously). The uvula was unchanged in appearance after this intervention. The patient was issued prescriptions for azithromycin (500 mg orally followed by 250 mg orally for 5 days) and methylprednisolone (4 mg orally for 7 days). He refused hospital admission from the ambulatory surgery center and was therefore discharged to home with soft diet and hydration instructions. He was reevaluated on the seventh postoperative day. The uvula had returned to normal appearance and architecture without erythema or exudates. The patient reported no respiratory difficulties during the entire postoperative period.