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Ann Thorac Surg 1996;62:1237
© 1996 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, St.Jude Medical Center, The University of California, Irvine Medical Center, 100 E Valencia Mesa Dr, Suite 301, Fullerton, CA 92635
To the Editor:
Hoarseness is a common minor complication after open heart operations [1]; it has an incidence of 11% and is usually attributed to endotracheal intubation [2]. Vocal cord paralysis after open heart operations is a much less frequent complication that may result in hoarseness and occasionally can cause aspiration. Its frequency varies between 0.6% and 2% [2, 3]. In most instances, however, it is self-limiting, with vocal cord function normalizing between 6 to 8 weeks from the time of injury [2]. In some instances, patients become asymptomatic despite the presence of unilateral vocal cord paralysis. However, on rare occasions hoarseness becomes permanent [1].
The mechanisms responsible for injury to the recurrent laryngeal nerve during open heart operations include (1) trauma due to the endotrachael tube cuff [4, 5], (2) median sternotomy retraction, which produces a lateral and anterior stretching of both subclavian arteries [3], (3) direct manipulation and inferior retraction of the heart [3], and (4) trauma during the dissection of the internal mammary arteries [6].
Most paralyzed vocal cords are found in either a median or a paramedian position. This depends on the branching pattern of the nerves, the degree of injury to the plexus, and the muscles involved [4]. In the median position, the patient often continues to have a reasonably normal voice despite the unilateral cord paralysis. When the cord is fixed in the paramedian position the normally functioning cord soon compensates for the deficiency on the contralateral side. It swings past the midline to make contact with its companion, and this produces a normal or nearly normal voice [5].
Chronic hoarseness of a completely different cause may occur as in the case of a 56-year-old East Indian man who presented to the emergency room with shortness of breath and substernal pain. The patient was found to be in congestive heart failure and urgently transferred to the catheterization laboratory. An intraaortic balloon pump was inserted and a coronary angiogram performed, which showed a 95% left main stenosis and diffuse coronary artery disease. Immediately after, the patient underwent uneventful sextuple coronary bypass grafting using saphenous vein grafts. The patient was extubated 35 hours postoperatively. At that point, it became evident that the patient was aphonic but without evidence of aspiration. He progressed well except for the persistent absence of voice and was discharged on the 6th postoperative day. After 4 weeks of aphonia, a laryngoscopic examination by an otolaryngologist showed adequate vocal cord function with minor swelling. Steroids were given with no response. At 10 weeks after the operation the patient was seen in India by an otolaryngologist who, after performing a laryngoscopy, told the patient he would never recover his voice. That same night the patient began to speak normally.
A conversion disorder is a defense mechanism by which intrapsychic conflicts that would otherwise give rise to anxiety are instead given symbolic external expression. These may include such symptoms as paralysis, pain, or loss of sensory function. The tendency to use physical complaints to express emotional distress may partly arise out of family dynamics relating to the concept of the "sick role." Within the family or society this role provides certain rights including release from normal obligations and absolution of blame for an individual's condition, thereby legitimizing acceptance of dependency. The sick role is welcomed by some individuals who have dependency needs that have never been met, using it as a socially acceptable way to be gratified. Hence, patient symptoms may be reinforced by the reactions of caretakers or family members perpetuating the conversion phenomenon [7].
In summary, although hoarseness is a trivial complication of open heart operations, aphonia of more than a week's duration can be a disturbing complication. Vocal cord evaluation should be performed and, if abnormal, repeated at 8 weeks from the time of injury despite normalization of voice. If the vocal cords, however, appear normal, hoarseness may represent a conversion disorder.
References
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