Unilateral laryngeal hematoma after combined carotid endarterectomy and off-pump coronary artery bypass grafting surgery

Airway injuries are potentially serious and costly adverse events of anesthesia care. Although the majority of airway injuries are not serious; 5% of the injuries are permanent and disabling, with 8% of those resulting in death [1]. According to an epidemiological study involving 563,190 patients, the risk of airway injury for patients undergoing major surgical procedures was approximately 1 in 500 [2]. We present a case in which laryngeal hematoma developed postoperatively after simultaneous carotid endarterectomy (CEA) and off-pump coronary artery bypass graft (OPCAB) surgery. A 75-year-old male was scheduled for concurrent left CEA and OPCAB, under general anesthesia. His medical history included diabetes mellitus, hypertension, and lower extremity vascular occlusive disease. He was taking aspirin and clopidogrel for anticoagulation medication. He was 163 cm in height and 61 kg in weight. There were no physical signs predicting difficulties in airway management. General anesthesia was induced with midazolam, etomidate, sufentanil and rocuronium. Orotracheal intubation was successfully done in a single attempt with a Macintosh laryngoscope. His airway showed Mallampati class I and Cormack-Lehane grade I under direct laryngoscopy. A size 8.0 mm cuffed endo tracheal tube (Hi-Lo TM , Mallinckrodt Medical, Athlone, Ireland) was used and fixed on the right side of the mouth. First, left carotid endarterectomy was started by a vascular surgeon. After the carotid vessel identified, 4,000 units of heparin were administered intravenously. The CEA procedure took an hour. After the vascular surgery was finished, an adult multiplane 7 to 2 MHz transesophageal echocardiography (TEE) probe (Philips iE33 × 7-2t xMATRIX array, Tip; 1.7 × 3.8 cm WxL, Shaft; 1 cm diameter, 1 m length) lubricated with lidocaine jelly (Arlico Lidocaine HCI Jelly 2%) was placed gently into the esophagus. When the TEE probe was first inserted, there was a little resistance. However, the insertion proceeded easily after elevation of the mandible. There was no evidence of oropharyngeal mucosal bleeding. Another bolus of 9,000 units of heparin was injected during the OPCAB after dissecting the internal mammary artery, and activated clotting time (ACT) was 445 seconds. At the end of the surgery, 50 mg of protamine was given to reverse the heparin and the ACT was 103 seconds. The TEE was removed 7 hours after its insertion. There was no blood at the tip of the TEE probe when it was removed. The total anesthesia duration was 10.5 hours.