Transient Unilateral Recurrent Laryngeal Nerve Palsy Presenting as Post-extubation Stridor after Total Thyroidectomy for Non-toxic Multinodular Goiter: Anesthetic Implications and Airway Rescue

Muhammad Rezha Mansyur — 2026-06-01

Total thyroidectomy is among the most frequently performed endocrine procedures worldwide, yet it carries a defined risk of recurrent laryngeal nerve (RLN) injury that can precipitate post-extubation stridor and emergent airway compromise. Transient unilateral RLN palsy is estimated to occur in 2 to 10 percent of cases for benign disease and remains an important anesthetic consideration even in carefully planned surgery. We report the case of a 53-year-old woman with controlled hypertension and a longstanding bilateral non-toxic multinodular goiter of 8.5 by 10 centimeters who underwent intraoperative conversion from subtotal to total thyroidectomy under general anesthesia with endotracheal intubation. Intraoperative course was stable on a balanced regimen of midazolam, fentanyl, propofol, atracurium, and isoflurane. Ten minutes after a smooth extubation, she developed inspiratory stridor, suprasternal retractions, and desaturation. Awake reintubation with preserved spontaneous ventilation was performed using low-dose sedation, intravenous lidocaine, and direct laryngoscopy, which simultaneously secured the airway and demonstrated paresis of the left vocal cord while the right cord was mobile. The patient was transferred to the intensive care unit, received systemic methylprednisolone, and was extubated successfully within 24 hours with complete recovery of bilateral vocal cord mobility on follow-up laryngoscopy. In conclusion, awake reintubation with maintained spontaneous breathing is a powerful maneuver that secures the airway and confirms the laryngeal diagnosis at a single procedure. Early systemic corticosteroid, vigilant monitoring, and otolaryngology liaison support rapid neurapraxia recovery, with multidisciplinary cooperation as the cornerstone of a favorable outcome.

Medial Condyle Fracture of the Humerus Following an Arm-Wrestling Injury in an Adolescent: A Rare Kilfoyle Type II Injury with Transient Ulnar Neuropathy Managed by Open Reduction and Pinning

I Gede Mandra Adnyana — 2026-06-03

Fractures of the medial condyle of the humerus are uncommon injuries in the pediatric and adolescent population, accounting for fewer than two percent of elbow fractures, yet they are clinically important because the fracture line crosses both the articular surface and the distal humeral physis. Delayed or inadequate treatment may lead to nonunion, growth arrest, cubitus varus or valgus deformity, and elbow instability. We report a 15-year-old male who presented with one month of persistent left elbow pain after an arm-wrestling contest during which the elbow shifted and he fell onto the affected arm. He described intermittent paresthesia of the ring and little fingers and morning stiffness. Examination revealed medial elbow swelling, tenderness over the medial condyle, painfully limited motion, and paresthesia in the ulnar nerve distribution. Plain radiographs confirmed a left medial condyle fracture classified as Kilfoyle type II. Because of the intra-articular nature of the injury and the risk of displacement, open reduction and internal fixation with Kirschner-wire pinning was performed, followed by intravenous fluid support, ceftriaxone for prophylaxis, and intravenous paracetamol for analgesia. One week postoperatively the patient showed marked improvement, with resolution of stiffness, reduced pain, recovered range of motion, and improvement of the ulnar nerve symptoms, and no complications were observed. This report highlights arm wrestling as a rare mechanism of adolescent medial condyle fracture, its association with transient ulnar neuropathy, and the favorable early outcome achievable with prompt anatomical fixation and structured postoperative care.

Open Access Indonesian Journal of Medical Reviews

Transient Unilateral Recurrent Laryngeal Nerve Palsy Presenting as Post-extubation Stridor after Total Thyroidectomy for Non-toxic Multinodular Goiter: Anesthetic Implications and Airway Rescue

Medial Condyle Fracture of the Humerus Following an Arm-Wrestling Injury in an Adolescent: A Rare Kilfoyle Type II Injury with Transient Ulnar Neuropathy Managed by Open Reduction and Pinning