title: Asystole During Direct Laryngoscopy for Vocal Fold Injection in a Healthy Patient.
abstract: OBJECTIVE
  This study aims (1) to present a case of asystole during direct laryngoscopy in an otherwise healthy patient at an outpatient surgery center and (2) to review literature on cardiac complications, specifically asystole and bradycardia, during direct laryngoscopy.
  
  
  METHODS
  A 67-year-old woman with no prior cardiac history underwent induction with succinylcholine and remifentanil for direct laryngoscopy and vocal fold augmentation. During suspension laryngoscopy, the patient became asystolic, and advanced care life support measures were started. The patient regained a cardiac rhythm after chest compressions and epinephrine and was transferred to a tertiary care hospital for further treatment. She remained intubated overnight, requiring pressors, and regained normal cardiac function over the next few days.
  
  
  RESULTS
  A structured literature review uncovered few reports of asystole during suspension laryngoscopy. Although bradycardia is common during suspension laryngoscopy, likely secondary to stimulation of afferent visceral sensory parasympathetic fibers of the vagus nerve, asystole is rare.
  
  
  CONCLUSIONS
  Cardiac complications are possible in otolaryngologic surgery, especially with activation of the oculocardiac or trigeminocardiac reflexes. Asystole during direct laryngoscopy, although rare, is not always predictable from medicine or cardiac risk indices. Awareness, rapid recognition, and early implementation of advanced care life support are crucial to avoid further complications.
authors.affiliation: NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, New York. Electronic address: zahrah.taufique@nyumc.org.
authors.forename: Zahrah
authors.initials: Z
authors.lastname: Taufique
authors.affiliation: NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, New York.
authors.forename: Gregory R
authors.initials: GR
authors.lastname: Dion
authors.affiliation: NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, New York.
authors.forename: Milan R
authors.initials: MR
authors.lastname: Amin
mesh_terms: D000368:Aged; D005260:Female; D006323:Heart Arrest / Q000209:etiology*; D006801:Humans; D007828:Laryngoscopy / Q000009:adverse effects*; D014832:Voice Disorders / Q000628:therapy
keywords: Asystole; Bradycardia; Direct laryngoscopy; Vagal stimulation; Vocal cord injection