Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Submission | Subscribe | Advertise | Contact | Login 
Users online: 4911 Small font size Default font size Increase font size Print this article Email this article Bookmark this page


    Advanced search

    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  

    Article Figures

 Article Access Statistics
    PDF Downloaded76    
    Comments [Add]    

Recommend this journal


Table of Contents
Year : 2022  |  Volume : 25  |  Issue : 1  |  Page : 123-124
Tapias syndrome after cardiac surgery

Department of Cardiac Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India

Click here for correspondence address and email

Date of Submission17-Aug-2020
Date of Decision28-Dec-2020
Date of Acceptance30-Apr-2021
Date of Web Publication21-Jan-2022

How to cite this article:
Jose RL, Gopan G, Kasthuri P, Madathil T. Tapias syndrome after cardiac surgery. Ann Card Anaesth 2022;25:123-4

How to cite this URL:
Jose RL, Gopan G, Kasthuri P, Madathil T. Tapias syndrome after cardiac surgery. Ann Card Anaesth [serial online] 2022 [cited 2022 Jun 30];25:123-4. Available from:

To the editor,

Tapia's syndrome is a rare complication with injury to the hypoglossal (XIIth) and vagus (Xth) nerves resulting in a weak voice, increased predilection for aspiration, and difficulty in swallowing. Antonio Garcias Tapia first named this syndrome in a bullfighter with Xth and XIIth nerve palsy after sustaining carotid artery injury resulting in compromised neural blood supply.

Here, we describe the case of a 72-year-old diabetic and hypertensive patient who developed Tapia's syndrome after mitral valve repair. For the procedure, he was intubated with an 8.5 mm ID endotracheal tube (ETT) with cuff pressure maintained below 20 mmHg. A transesophageal echocardiography (TEE) probe was also inserted. The surgical position was optimized using a shoulder roll. The surgery lasted for 7 h. Postoperatively, he was extubated following 6 h of ventilation. A weak voice and choking were noticed along with deviation of the tongue to the right on protrusion. An indirect laryngoscopy revealed paramedian position of the right cord.

The larynx is innervated by the Xth nerve through the superior and recurrent laryngeal branches. The recurrent laryngeal nerve (RLN) traverses in the tracheoesophageal groove and enters the larynx at the cricothyroid joint. The XIIth nerve exits the hypoglossal canal and passes over the transverse process of the first cervical (C1) vertebra. Here, it is crossed by the Xth nerve. Also, the Xth and XIIth nerves lie adjacently in the lower oropharynx and the upper hypopharynx.

Traumatic intubation and prolonged ventilation can cause dislocation of the cricoarytenoid and cricothyroid joints. The nerves may also get compressed during laryngoscopy with the head in an extended position at the lateral root of the tongue and at the C1 vertebrae. The ET tube cuff high up in the larynx compresses the RLN branches against the thyroid cartilage and stretches the hypoglossal nerve against the hyoid bone.[1] The high-cuff pressure also increases the risk for nerve injury. The risk of nerve palsy increases with advanced age, diabetes, hypertension, and prolonged ventilation.[2]

The nerves can get compressed at the laryngeal inlet during difficult insertion of the TEE probe.[3] The throat pack used during rhinoplasty surgery pushes the ETT against the pharyngeal wall increasing the incidence of Tapia's syndrome.[4] Similarly, the presence of the TEE probe along with the ETT can cause compression of the Xth and XIIth nerves [Figure 1].
Figure 1: Illustration of the mechanism of hypoglossal and the vagus nerve injury resulting in Tapiaæs syndrome in the presence of endotracheal tube, transesophageal echo probe, and direct laryngoscope during intubation

Click here to view

The placement of shoulder roll for optimizing surgical position stretches the nerves over the C1 vertebra and causes cephalad migration of the ETT.[5]

In our patient, the Tapia's syndrome resulted from a hyperextension of the neck. The additional causative factors might be advanced age, comorbidities, presence of the TEE probe along with the endotracheal tube, and prolonged ventilation. The assistance from the swallow and speech therapy team helped him to regain the vocal cord function within 6 months.

A preoperative workup can identify patients at risk of this syndrome. The hyperextension of the neck and high-cuff pressures should be avoided. The endotracheal tube cuff should be placed well below the vocal cords. Although the Tapia's syndrome is rare after cardiac surgery, a delay in its diagnosis can cause serious complications increasing morbidity and mortality.


We would like to express our gratitude to Mr Mithun Chakravarthy for helping us with the image for publication.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Varedi P, Shirani G, Karimi A, Varedi P, Khiabani K, Bohluli B. Tapia syndrome after repairing a fractured zygomatic complex: A case report and review of the literature. J Oral Maxillofac Surg 2013;71:1665-9.  Back to cited text no. 1
Raut MS, Maheshwari A, Joshi R, Joshi R, Dubey S, Shivnani G, et al. Vocal cord paralysis after cardiac surgery and interventions: A review of possible etiologies. J Cardiothorac Vasc Anesth 2016;30:1661-7.  Back to cited text no. 2
Zwetsch G, Filipovic M, Skarvan K, Todorov A, Seeberger MD. Transient recurrent laryngeal nerve palsy after failed placement of a transesophageal echocardiographic probe in an anesthetized patient. Anesth Analg 2001;92:1422-3.  Back to cited text no. 3
Lykoudis EG, Seretis K. Tapia's syndrome: An unexpected but real complication of rhinoplasty: Case report and literature review. Aesthetic Plast Surg 2012;36:557-9.  Back to cited text no. 4
Nalladaru Z, Wessels A, DuPreez L. Tapia's syndrome - A rare complication following cardiac surgery. Interact Cardiovasc Thorac Surg 2011;14:131-2.  Back to cited text no. 5

Correspondence Address:
G Gopan
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi - 682 041, Kerala
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.ACA_200_20

Rights and Permissions


  [Figure 1]