Description

We report a case of postoperative expressive aphasia (EA) and our diagnostic journey to understanding this rare complication. A 20-year-old lady was scheduled for an elective Functional Endoscopic Sinus Surgery (FESS) with a background history of asthma and high BMI (Class II). She continued oral contraceptives up to anaesthesia and uses an electronic smoking device. The remainder of her pre-anaesthetic workup was unremarkable.

At induction, she received 100 micrograms of fentanyl, 300 milligrams of propofol and 50 milligrams of Rocuronium. She was intubated via video-assisted laryngoscopy with a size 7 RAE endotracheal tube. Immediately after intubation, her blood pressure rose to 190 mmHg systolic from 110 mmHg. This was believed to be secondary to a delay in starting the inhalational agent at induction.

Due to the possibility of awareness during anaesthesia, she received 3 milligrams of midazolam to achieve amnesia. She was hemodynamically stable throughout the 2-hour surgery.

Postoperatively, her observations were within normal parameters. Her neurological examination was unremarkable. She did understand and follow commands, but she was unable to speak, which raised the suspicion of EA or vocal cord injury. A fibreoptic bronchoscopy was unremarkable except for an oedematous uvula. CT brain showed no evidence of cerebrovascular insult.

Discussion

Given her use of oral contraceptives, high BMI and hypertension at induction, the suspicion of a CVA was the first differential considered and ruled out. The other differential could be her oedematous uvula, for which she was started on dexamethasone. Interestingly, there is a paucity of literature that shows a

0.19% link between midazolam and transient expressive aphasia post general anaesthesia [1]. It has also been documented in literature that excould also be functional in origin [2].