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Letter to the Editor
Tapia syndrome following orotracheal intubation: a case report
Síndrome de Tapia tras intubación orotraqueal: a propósito de un caso
L. Silva-Hernández
Corresponding author
l.silva@ucm.es

Corresponding author.
, C. Gil Rojo, N. González García, J. Porta-Etessam
Hospital Clínico San Carlos, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tapia syndrome is defined as paralysis of one side of the tongue and the ipsilateral vocal cord&#44; with preserved soft palate motility&#44; secondary to concurrent lesions to the hypoglossal and vagus nerves &#40;the twelfth and tenth cranial nerves&#44; respectively&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Antonio Garc&#237;a Tapia&#44; a Spanish otorhinolaryngologist&#44; first described the syndrome in 1904 in a patient with an upper neck injury from a bull&#8217;s horn &#40;&#8220;matador&#8217;s disease&#8221;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; the eponym has been used in reference to a crossed syndrome of dorsal medullary origin &#40;with involvement of the hypoglossal and ambiguus nuclei and the pyramidal tract&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> and to describe peripheral involvement of the vagus and hypoglossal nerves at the cervical level&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The peripheral form has been observed after manipulation of the airway for orotracheal intubation&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the case of a 70-year-old man with history of dilated cardiomyopathy secondary to alcohol abuse&#44; who was admitted to our hospital due to cardiorespiratory arrest&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The cause of the attack was ventricular fibrillation&#59; the patient required emergency life support for 15&#8239;minutes&#44; with basic and advanced cardiopulmonary resuscitation&#46; The attack occurred in a public space&#44; and emergency intubation was performed before the patient was transferred to our hospital&#46; Upon arrival at the emergency department&#44; the patient was admitted to the coronary care unit&#44; where an emergency coronography was performed and a hypothermia protocol was initiated &#40;target temperature&#44; 33&#8239;&#176;C&#41;&#46; The patient was kept under sedation during the first days after arrival at hospital&#44; with no initial neurological assessment being performed at this time&#46; Incidentally&#44; a second orotracheal intubation procedure was required at 72&#8239;hours following obstruction of the first intubation tube&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">As the patient continued to need mechanical ventilation a week after admission&#44; a tracheostomy was performed to prevent airway lesions associated with orotracheal intubation&#46; At this point&#44; the patient continued to require sedation and parenteral feeding&#46; Ten days after admission to the coronary care unit&#44; the patient began to recover consciousness&#44; spontaneously opening his eyes&#59; brainstem reflexes were preserved&#44; including the pupillary reflex&#44; oculocephalic reflexes&#44; and the cough reflex&#46; Mechanical ventilation was suspended at 2 weeks and a silver tracheostomy tube was placed&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Two weeks after the attack&#44; an MRI study was performed as part of the coronary care unit&#8217;s protocol for the assessment of brain damage in patients recovering from cardiorespiratory arrest&#46; The study identified no acute or chronic ischaemic lesions in any region of the brain&#59; electroencephalography and somatosensory evoked potentials studies yielded no relevant findings&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient remained in the coronary care unit for the following 2 weeks&#44; showing satisfactory progression&#58; level of consciousness remained adequate at all times and he gradually recovered limb strength and mobility&#44; deglutition&#44; and phonation&#46; Dysphagia and dysphonia were not observed in early assessments&#46; The patient&#8217;s progression was considered to be excellent&#44; and he was transferred to the cardiology inpatient ward one month after the cardiorespiratory arrest&#46; The initial assessment conducted by the cardiology department included a basic neurological examination&#44; which detected reduced tongue mobility and hypophonia&#44; with no other focal neurological signs and a normal level of consciousness&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the light of these findings&#44; the patient underwent a comprehensive assessment by the neurology department&#44; which revealed dysphonia and hypophonia and paralysis of the left half of the tongue without atrophy&#46; We identified no other findings suggesting involvement of the brainstem&#44; pyramidal tracts&#44; or long sensory pathways&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The otorhinolaryngology department performed further testing of the patient&#44; and a fibre-optic laryngoscopy study identified vocal cord paralysis in adduction on the left side&#46; A second MRI study ruled out central origin of the symptoms&#44; as well as space-occupying lesions in the skull base&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The patient was diagnosed with peripheral Tapia syndrome secondary to trauma occurring after repeated orotracheal intubation&#59; we opted for conservative treatment with speech and swallowing rehabilitation&#46; Symptoms improved gradually&#44; fully resolving 4 months after onset&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">This is an illustrative case of Tapia syndrome of probable peripheral origin&#58; in this patient&#44; we suspect traumatic neuropathy involving the tenth and twelfth cranial nerves&#44; probably due to repeated orotracheal intubation&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">It is important to be familiar with the anatomy of the most common syndromes affecting the brainstem and the emergence of the cranial nerves&#44; both in the skull base and on their course along the upper cervical spine&#46; In the case of Tapia syndrome&#44; both cranial nerves &#40;X and XII&#41; emerge from the medulla oblongata&#44; passing through the skull base to the lateral pharyngeal or poststyloid space&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Cranial nerve X passes through the anterior compartment of the jugular foramen&#44; alongside the glossopharyngeal and accessory nerves &#40;nerves IX and XI&#41; and the jugular vein&#44; to the poststyloid space&#46; Upon entering the poststyloid space&#44; the nerve joins the carotid sheath&#44; where it runs posterior to the internal carotid artery and the internal jugular vein&#46; At this level&#44; the most important structure of the nerve is the inferior &#40;or nodose&#41; ganglion&#44; whose inferior part gives rise to the superior laryngeal nerve&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Cranial nerve XII presents a short trajectory through the subarachnoid space&#44; then passes through the hypoglossal canal into the poststyloid space&#46; There&#44; it initially descends posterior to the internal carotid artery&#46; It reaches 2 structures of anatomical interest&#58; the upper part of the superior cervical ganglion of the sympathetic trunk&#44; and then the posterior segment of the nodose ganglion&#44; to which it adheres &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Subsequently&#44; the nerve changes direction&#44; travelling ventrally then ramifying in its final &#40;suprahyoid&#41; segment&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Various proposed mechanisms of nerve trauma may explain the combined involvement of the tenth and twelfth cranial nerves during orotracheal intubation&#46; The first mechanism is related to the crossing of the hypoglossal and vagus nerves at the nodose ganglion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Here&#44; these structures are in close proximity to the transverse process of the C1 vertebra&#59; the sustained hyperextension of the neck needed for proper intubation may explain the direct trauma to both nerves&#44; due to contact against these bone structures&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The other mechanism proposed is a direct lesion simultaneously involving the suprahyoid portion of the hypoglossal nerve and the recurrent laryngeal nerve at the level of the hypopharynx &#40;pyriform sinus&#41;&#46; According to this hypothesis&#44; the passage of the intubation tube through the oropharynx would compress the hypoglossal nerve against the greater cornu of the hyoid&#44; and the subsequent inflation of the pilot balloon would cause the recurrent laryngeal nerve to contact the posteromedial edge of the thyroid cartilage&#44; constituting a mechanism of direct trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Treatment for Tapia syndrome secondary to orotracheal intubation is fundamentally supportive&#44; with speech and swallowing rehabilitation&#59; the use of intravenous corticotherapy with dexamethasone in the first 10 to 14 days is also accepted&#46; One article even proposes a classification of the syndrome according to the grade of difficulty swallowing&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Both the patient&#8217;s improvement with conservative treatment and the complete resolution of his symptoms indicate neurapraxia secondary to axonal damage as the probable aetiology&#59; neurotmesis is less probable&#44; as the damage to both nerves would have been irreversible&#46; Furthermore&#44; neurapraxia is the proposed aetiological mechanism in most of the reported cases of Tapia syndrome secondary to orotracheal intubation&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Silva-Hern&#225;ndez L&#44; Gil Rojo C&#44; Gonz&#225;lez Garc&#237;a N&#44; Porta-Etessam J&#46; S&#237;ndrome de Tapia tras intubaci&#243;n orotraqueal&#58; a prop&#243;sito de un caso&#46; Neurolog&#237;a&#46; 2020&#59;35&#58;421&#8211;423&#46;</p>"
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