Abstract Introduction Recurrent laryngeal nerve (RLN) injury is a rare complication of endobronchial valve (EBV) placement, with only five cases previously reported in the literature. Case Report A 76-year-old man with chronic obstructive pulmonary disease and obstructive sleep apnea presented to a university hospital for elective bronchoscopic lung volume reduction with EBV placement. He had three years of progressive dyspnea on exertion that did not improve with completion of a pulmonary rehabilitation program. A comprehensive pre-procedural evaluation showed severe pulmonary function derangements (FEV1 37% predicted), heterogenous emphysema on chest imaging, and absence of contraindications to BLVR. Under general anesthesia, four Zephyr EBVs were placed into the left upper lobe without immediate complications. He was extubated and admitted for observation. Post procedural chest x-ray showed atelectasis of the left upper lobe without pneumothorax. Three days later, he developed increasing oxygen requirements, diffuse wheezing, and was incidentally noted to have difficulty speaking. Physical Examination Vital signs recorded a blood pressure 118/88, heart rate 121 beats per minute, respiratory rate 20 breaths per minute, and SpO2 90 % on high flow nasal cannula with 50% FiO2 and flow rate of 30 L/min. He exhibited increased respiratory effort with diffuse wheezing. Dysphonia was so severe that he was using a dry erase board to communicate. Fiberoptic laryngoscopy by otolaryngology demonstrated immobility of the left vocal cord. Diagnostic Studies Chest CT scan showed a new small left pleural effusion and atelectatic lung segments distal to the emplaced valves (Fig 1). Discussion With this rare complication, all reported cases involved left upper lobe valve placement, as in the present case. The RLN, a branch of the vagus nerve, innervates most of the intrinsic laryngeal muscles. Injury can occur from impingement, inflammation, or injury at any point along the course of this long nerve, and may present with hoarseness, altered vocal pitch, or noisy breathing. Diagnosis is via fiberoptic laryngoscopy. The authors had not seen RLN paralysis associated with BLVR prior to this case. After considering the timing of the dysphonia in relation to the BLVR, an association between the two was immediately expected, and prior case reports identified, leading to a confident diagnosis. Newer procedures often have an unknown range of complications, and physicians should have a high index of suspicion for causal links between novel techniques and downstream findings, even if they are not widely recognized complications. This abstract is funded by: None
Billingslea et al. (Fri,) studied this question.