Tapia’s Syndrome: Clinical Insights

Dear Editor

We read with great interest the review by Steehler et al. about Tapia’s syndrome, recently published in this journal. ¹ Tapia’s syndrome was first described in 1904 and may seem quite a rare adverse event related to general anesthesia and airways’ manipulation ² ; however, we think that it may be underreported in clinical practice. The review of the literature describes severe cases of Tapia’s syndrome, which have been reported in a wide range of procedures including cardiac, neurological, and otolaryngologic surgeries.

In our Tertiary Academic Hospital, we recently had 2 confirmed cases of Tapia’s syndrome: both patients underwent routine breast surgery under general anesthesia with uncomplicated endotracheal intubation. Patients’ position was mainly supine with several back-up phases at 75 degrees. After extubation, both patients presented dysphagia, dysphonia, and left-sided tongue deviation on protrusion. Flexible laryngoscopy showed left vocal cord immobility in the intermediate position. In both cases, CT-scan and magnetic resonance imaging did not show ischemic/hemorrhagic brain events.

Despite the absence of conclusive evidence, patients received medical therapy consistent with what was reported for other cases in the literature ³ : intra-venous steroids (methylprednisolone and dexamethasone) and vitamins B1/6. Both received a diet adapted for dysphagic patients during hospitalization and followed speech language therapy for several months after hospital discharge.

These 2 very similar cases spurred us to look for a common cause for the onset of this syndrome. The greatest similarity was the peculiar position in which supination phases were alternated with back-up at 75 degrees during surgeries. These maneuvers could lead to an unpredictable mobilization of the endotracheal tube, producing a leverage effect in the airways; this could eventually press and damage important spots supposed to be directly involved in pathogenesis of the syndrome, such as pyriform sinus and base of tongue.

While our internal debriefing was mainly focused on the therapeutic approach, it is reasonable to underline also preventive measures that could limit the occurrence of Tapia’s syndrome during the most at-risk procedures, avoiding incorrect laryngoscope and laryngeal mask use; endotracheal tube cuff overinflation and tube mispositioning; and neck hyperextension.

That being said, anesthesia community should be aware that, to avoid complications related to airways manipulation, it could be advisable to 1) exert light pressure with the laryngoscope during intubation maneuvers; 2) use a manometer to avoid endotracheal tube cuff hyperinflation, with a suggested cuffing pressure of 25–30 cmH₂O; and 3) implement an efficient endotracheal tube fixing system. In our experience, we have started using tools like tube holders with flexible shafts, helmets to maintain the correct head position during surgeries, and systems for continuous control and monitoring of cuff pressure.

Tapia’s syndrome is a rare and unpredictable complication of general anesthesia and endotracheal intubation and may have long-term sequelae, affecting full recovery of patients and increasing health system costs. It may be advisable to find and implement easy and feasible methods to prevent this syndrome, these may include correct fixing of endotracheal tube and head during patients' mobilization and maintenance of adequate cuff pressure.