Patient safety incident review: A preventable, rare complication of Tapia’s syndrome following breast surgery

The following information and recommendations are being shared to assist facilities in their continuous quality improvement.

The Non-Hospital Medical and Surgical Facilities Accreditation Program Patient Safety Incident Review Panel recently reviewed an incident involving a patient who developed numbness and perceived swelling of the tongue while in the PACU. It was assumed to be from the lidocaine gel used prior to intubation. The numbness persisted and the patient presented at the ER the next day and was worked up for a possible stroke. The medical team made the diagnosis of Tapia’s syndrome, which although noted in the scant literature associated with anesthesia and intubation, was thought to be secondary to neck flexion resulting in stretching of cranial nerves X and XII as they pass through the pharynx and neck.

The patient made a quick recovery, although some patients with Tapia’s syndrome need careful follow-up and swallowing therapy as symptoms can persist for months.

The following contributory factors were considered by the panel:

  • The lidocaine gel used around intubation may have contributed, assuming it was used on the cuffed area of the ETT. This practice is not commonly used as lidocaine gel is associated with increased sore throat. It is not a large amount of gel, and it is hard to see how it could anesthetize both cranial nerves X and XII, but theoretically is possible with some gel sitting in the posterior pharynx and some on the ETT cuff.
  • Head position during breast surgery.
  • Prolonged sitting position during surgery, more than typical for this type of surgery.

In considering these contributory factors, the panel made the following recommendations: 

  • The panel noted that this was an unusual complication, and consideration should be given to the routine use of head supports during breast surgery to ensure neutral head position is maintained during sitting/supine maneuvers. A gel head donut is helpful and soft rolls on the sides of the neck may also be beneficial.
  • This case should be reviewed at M&M rounds at the facility to share learnings with the clinical team.

It was also recommended that this incident be shared more widely to remind facilities of possible rare and unusual complications, and recommend discussion with clinical teams to ensure recognition of this complication and that prevention measures are in place.