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Tapia Syndrome paralysis of vagus and hypoglossal nerves after intubation

last modified on: Thu, 02/29/2024 - 14:51

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Tapia syndrome is synchronous paresis or paralysis of the Vagus and Hypoglossal nerves (CN's X and XII) occurring after orotracheal intubation with the head maintained in a flexed position. Dysphonia, dysphagia and tongue deviation on awakening from anesthesia are the classic presentation.

Tapia syndrome has been confused with the onset of a stroke and has been reported to mimic 'partial Wallenberg syndrome' (Kerolus 2017).

CN damage is hypothesized to occur due to flexion of the neck after orototracheal intubation which results in stretching and compression of the lower CNs (Boisseau 2002 and Lykoudis 2012).

Kraus et al (2019) further described the proximity of the hypoglossal and recurrent laryngeal nerves in close proximity at the base of tongue/pyriform sinus as well as the anterior surface of transverse process of C1. Compression of the nerves between the endotracheal tube and stiff structures such as the cervical vertebrae or thyroid or hyoid cartilage has been proposed as a mechanism of nerve injury. Others have implicated use of a throat pack or overinflation of the cuff on the endotracheal tube as inducing trauma to the nerves. Stretch injury to the nerves has also been proposed as a mechanism. These investigators identified in their literature review that beach chair positioning (often for shoulder surgery) was a possible contributing factor. These authors conclude that beach chair positioning is a risk factor for Tapia syndrome and particular respect to the craniospinal axis is needed with verification of head position for neutrality on initial positioning and verify frequently during the procedure.

Initial report of Tapia's Syndrome (paralysis of recurrent laryngeal nerve and hypoglossal nerve) has been ascribed to the Spanish Otolaryngologist Antonia Garcia Tapia reporting paralysis of these cranial nerves from a bullfighter (Boğa 2010).

Evaluation suggested by Wei and De Jesus (Wei 2021) may include MRI as superior to CT to rule out central cause of Tapia Syndrome with the caveat that 'depending on the degree of suspicion, airway endoscopy may provide a safe and reliable diagnosis, thereby avoiding the unnecessary use of CT, MRI, barium swallow or electromyography" - with neurology consultation with EMG discussed as potential consultations but unlikely to alter the diagnosis or management. These investigators suggest the mainstay of treatment for Tapia syndrome is rehabilitation - with recovery that may take many months - focused on work with a speech pathologist to provide a structured swallowing rehabilitation.

As per Gevorgyan and Nedzelski (Gevorgyan 2013) report recovery from Tapia syndrome to be excellent in 30%; incomplete in 39%; and non in 26%. These investigators identify that lack of involvement of the spinal accessory nerve (CN XI) differentiates Tapia syndrome for jugular foramen syndromes (Vernet (CN IX, X, XI; Collet-Sicard (IC, X, XI, XII) and Villaret (Collet-sicard and Horner's Syndrome). Tapia Syndrome is identified as attributed to pressure neuropraxia or stretch injury to the nerve with the observation that 'glottic sensation is often intact'. These authors reviewed that of the 24 cases of Tapia Syndrome they identified in the literature, five were rhinoplasties or septorhinoplasties - identifying 'frequently require manipulation for he position of the patient's head". They identified treatment to be largely supportive with IV or oral steroids for 10 to 14 days as well as vitamins (B1, B6, B12) as options as well.


Kerolus MG1, Turel MK, O'Toole JE.An Unusual Presentation of Tapia Syndrome Mimicking a Partial Wallenberg Syndrome Following Anterior Cervical Spine Surgery.J Neurosurg Anesthesiol. 2017 Jun 30.

Boisseau N, Rabarijaona H, Grimaud D, et al. Tapia’s syndrome following shoulder surgery. Br J Anaesth. 2002;88:869–870. 5.

Lykoudis EG, Seretis K. Tapia’s syndrome: an unexpected but real complication of rhinoplasty: case report and literature review. Aesthetic Plast Surg. 2012;36: 557–559

Kraus MB, Cain RB, Rosenfeld DM, Caswell RE, Hinni ML, Molloy MJ, Trentman TL. Tongue Tied after Shoulder Surgery: A Case Series and Literature Review. Case Rep Anesthesiol. 2019 Oct 29;2019:5392847. doi: 10.1155/2019/5392847. PMID: 31781403; PMCID: PMC6855057.

Wei R, De Jesus O. Tapia Syndrome. 2021 Feb 9. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 33620824.

Boğa I, Aktas S. Treatment, classification, and review of Tapia syndrome. J Craniofac Surg. 2010 Jan;21(1):278-80

Gevorgyan A, Nedzelski JM. A late recognition of tapia syndrome: a case report and literature review. Laryngoscope. 2013 Oct;123(10):2423-7