Transient hemi-diaphragmatic paralysis following neck surgery: report of a case and review of the literature

JAMES A. MCCAUL and W. STUART HISLOP
Department of Oral and Maxillofacial Surgery, Crosshouse Hospital, Kilmarnock UK

Introduction

Case report

Discussion

References

Diaphragmatic paresis following trauma to the phrenic nerves is a rare complication after neck surgery. The resulting elevation of the ipsilateral hemi-diaphragm is diagnosed on post-operative chest radiography and may be confirmed by ultrasound or fluoroscopy. When unilateral, this may lead to respiratory, cardiac or gastrointestinal symptoms and atelectasis and pulmonary infiltrates on radiography. If nerve damage is bilateral a period of ventilation may be required.

Keywords: Phrenic nerve, post-operative complications, radical neck dissection

J.R.Coll.Surg.Edinb., 46, June 2001, 186-188

INTRODUCTION

Neck dissection to remove cervical lymphatic tissue remains the most frequently performed procedure in units treating head and neck cancer. One of the least often reported complications is damage to the phrenic nerve. This may be asymptomatic but has potential to lead to further complications if not diagnosed and appropriately managed. We present a case of phrenic nerve neuropraxia and describe the aetiology, diagnosis, management, clinical course and outcome. The literature relating to this condition is reviewed.

CASE REPORT

A 68-year-old man underwent surgical treatment for a second primary carcinoma 4 years after initial diagnosis and management of squamous cell carcinoma of the right lateral border of the tongue. This lesion was excised from the left retro-molar trigone and a selective neck dissection (SND), removing nodes from levels 1 to 4, was carried out.

The initial lesion had been excised and reconstructed with a radial forearm flap. At this time a selective neck dissection of node levels 1-4 on the right was carried out. Only reactive nodes were found in the neck. In view of the primary site, surgery had been followed by a course of radiotherapy to the right side of the face and the right upper neck.

During dissection of the left neck at the most recent procedure, some troublesome bleeding was encountered during excision of a mass at levels 2-3. This was noted to be in close proximity to the phrenic nerve. Haemostasis was obtained by careful use of bipolar radiofrequency diathermy.

On day one post-operatively the patient had reduced expansion of the left hemi-thorax. The percussion note was dull at the left base and breath sounds were noted to be reduced. A postero-anterior radiograph of the chest at full inspiration obtained at that time confirmed paresis of the left hemi-diaphragm (Figure 1). Chest physiotherapy was carried out daily and his clinical condition carefully monitored. He continued to make an otherwise uneventful recovery. His chest steadily improved clinically and a further chest radiograph obtained 10 days post-operatively confirmed restoration of function of the left hemi-diaphragm (Figure 2).

Figure 1: Paresis of the left hemi-diaphragm

DeviceGray 8 bits

Figure 2: Confirmed restoration of function of the left hemi-diaphragm

DeviceGray 8 bits

DISCUSSION

Reports discussing phrenic nerve injury as a consequence of neck dissection are few in the literature.1-4 An incidence of 8% was reported in one retrospective study of 176 unilateral neck dissections.2

The phrenic nerve may well be encountered in the course of neck dissection and in the current case was closely associated with a mass at levels 2-3.

Diagnosis is made on the basis of clinical findings supported by radiographic assessment of the thorax. Plain radiography of the chest shows an elevated hemi-diaphragm. This can be further confirmed by fluoroscopy or by ultrasonography.4,5

Paralysis of the hemi-diaphragm causes the dome to lie high in the thorax producing atelectasis and shunting of pulmonary blood flow. The resulting hypoxaemia will have an effect on the patient which varies according to the pre-morbid state.

Management relies on a high index of clinical suspicion, which facilitates recognition. Physiotherapy should be instituted early and continued until the neuropraxia resolves.

In most affected patients, phrenic nerve damage produces asymptomatic paralysis of one hemi-diaphragm and only gives rise to problems in the presence of other respiratory compromise. Work in experimental animals has shown that bilateral phrenicotomy produces hypoxia and hypercarbia.5,6 Respiratory failure has, however, been reported in two cases of unilateral phrenic nerve palsy and, in one case, where nerve damage was bilateral.3,4

In the event of this complication occurring, the prospect for recovery of nerve function varies with the extent of nerve damage. Transient diaphragmatic paralysis has been recorded as taking between 3 days and 6 months to recover.8,9 In the report of bilateral injury producing respiratory failure the transient neuropraxia recovered within 10 days of surgery.4 This potential complication must be considered in any patient with unexplained respiratory difficulty after neck dissection. In many cases spontaneous recovery is likely and symptoms are not severe. It is clear that in certain cases a period of ventilation may be required.

REFERENCES

  1. Coleman J. Complications in head and neck surgery. Surg Clin N Amer 1986; 66: 149-67
  2. de Jong A, Manni J, Phrenic nerve paralysis following neck dissection. Eur Arch Otorhinolaryngol 1991; 248: 132-4
  3. Moorthy S, Gibbs PS, Losasso AM, et al. Transient paralysis of the diaphragm following radical neck surgery. Laryngoscope 1983; 93: 642-4
  4. Yaddanapudi S, Shah SC. Bilateral phrenic nerve injury after neck dissection: an uncommon cause of respiratory failure. J Laryngol and Otol 1996; 110: 281-3
  5. Ninane V, Farkas GA, Baer R, de Troyer A. Mechanism of rib cage inspiratory muscle recruitment in diaphragmatic paralysis. Am Rev of Respir Dis 1989; 139: 146-9
  6. Nachazel J, Palecek F. Hypoventilation after acute phrenicotomy of the urethane anaesthetised rats. Physiol Research 1992; 41: 375-80
  7. Fedullo AJ, Lerner RM, Gibson J, Shayne DS. Sonographic measurement of diaphragmatic motion after coronary artery bypass grafting. Chest 1992; 102: 1683-6
  8. Iverson LIG, Mittal A, Dugan DJ, Sampson PC. Injuries to the phrenic nerve resulting in diaphragmatic paralysis with special reference to stretch trauma. Am J Surg 1976; 132: 263- 9
  9. Rosett RL. An unusual cause of post-operative respiratory failure. Anaesthesiology 1987; 66: 695- 7

Copyright date: 27th March 2001

Correspondence: Mr J A McCaul, Department of Oral and Maxillofacial Surgery, Falkirk and District Royal Infirmary, Falkirk UK

E-mail: Jmccaul326@aol.com

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