Unilateral vocal cord paralysis following arthroscopic rotator cuff repair in the beach chair position: a case series.

Introduction: Vocal cord paralysis (VCP) is a rare complication of endotracheal intubation. During shoulder surgery in the beach chair position, deliberate hypotension may compromise perfusion of laryngeal structures. This case series was conducted to describe the clinical characteristics of postoperative VCP in this setting and to explore the potential role of intraoperative hypotension as an underlying mechanism. Case presentations: This retrospective single-center case series included four consecutive female patients with hypertension who developed unilateral (left-sided) VCP after arthroscopic rotator cuff repair in the beach chair position under general anesthesia. Intraoperatively, mean blood pressure was maintained at low levels, with periods below 60 mmHg in all cases. Postoperatively, patients presented with hoarseness and aspiration. Laryngoscopic examination confirmed left-sided VCP in all cases, and laryngeal electromyography demonstrated recurrent laryngeal nerve neuropathy in two cases. All patients improved with conservative management, and no statistical analysis was performed given the descriptive nature of this case series. Discussion: Direct airway trauma, endotracheal tube malposition, and cuff overinflation were unlikely causes. Instead, reduced perfusion pressure related to head elevation and intraoperative hypotension may have contributed to ischemic injury of the recurrent laryngeal nerve. These findings suggest that postoperative VCP may involve factors beyond traditional mechanical airway-related mechanisms and warrant further investigation of perioperative hemodynamic influences. Conclusion: Shoulder surgery in the beach chair position combined with intraoperative hypotension may predispose patients to postoperative VCP. This case series extends previous observations by highlighting a potential association between intraoperative hemodynamic management and postoperative recurrent laryngeal nerve dysfunction. These findings underscore the potential importance of individualized intraoperative blood pressure management in reducing the risk of this complication. Further prospective studies are warranted to clarify the relationship between head elevation, regional perfusion, and laryngeal nerve injury during shoulder surgery.