(Acta Anaesth. Belg., 2008, 59, 103-105) A patient with haloperidol induced laryngeal dystonia Abstract : We discus the case of a forty-nine year old
Firstly, we considerd an atypical epileptical insult patient with haloperidol induced laryngeal dystonia or psychiatric problem. A CT-Cerebrum and EEG were performed and revealed no abnormalities. The Laryngeal dystonia is a life threatening, very rare patient was able to be discharged from the hospital medical condition which is difficult to diagnose. It can occur after a short treatment of a patient with atypical After three weeks the patient presented him- antipschycotics. LD can induce severe respiratory insuf- self again at the emergency department with acute ficiency leading to hypoxemia and death. Due to the lackof diagnosis, we performed an emergency tracheotomy confusion, restlessness while he hadn’t been able to because of severe respiratory distress syndrome. An sleep properly since two weeks. Physical examina- emergency tracheotomy can be a life-saving procedure in tion again revealed no abnormalities. Anti-viral medication (due to the suspicion of a viralencephalitis) and anti-psychotic medication Keywords : Laryngeal dystonia ; haloperidol ; tracheo-
(haloperidol) were started. Subsequently his neuro- logical status deteriorated rapidly from extremelyagitated to a state of apathy within three days.
Further medical investigations were performed : EEG, CT-Cerebrum, MRI/MRA-Cerebrum andcerebrospinal fluid sample which showed no abnor- Antipsychotics are frequently used in the field malities. After three days the patient acutely of anesthesia and psychiatry. They can be classified showed periods of severe respiratory distress with as typical (classical) antipsychotics and atypical extreme stridor and hypoxia for which initially we antipsychotics. Haloperidol is a typical antipsychot- did not have any explanation. These periods of res- ic and is used as a first-line medication in treating piratory distress lasted approximately three minutes psychotic symptoms such as delirium. It is available and terminated spontaneously. During the events in oral, intramuscular and intravenous formulations.
vital signs revealed tachycardia and hypoxia. The The disadvantage of typical antipsychotics is that events repeated themselves every 30 minutes and they have more side effects than atypical antipsy- subsequently increased in frequency within a few chotics such as extrapyramidal symptoms (EPS).
hours. Surprisingly between the periods of respira- We report the case of a patient who developed tory distress the patient had absolutely no signs of laryngeal dystonia after three days of treatment Therefore a tracheotomy was performed under local anesthesia. The ENT surgeon used lidocaine1% to a maximum dose of 5 mg/kg subcutaneously.
After thorough investigation of the patient’s med-ication we noticed that there had been an increase of the dosage of haloperidol within the last 72 hours referred to the outpatient clinic of the neurology after admittance (from initially 25 mg a day to department. Since three weeks he was complainingof a feeling of nausea, excessive sweating andacoustical hallucinations. Further medical historyrevealed mild asthma, bronchitis and atypical stom- ach complaints. There was no history of surgery, (*) Dept of Anesthesiology, University Hospital Maastricht, allergy, intoxication, drug abuse or psychiatric dis- PO box 8800, 6202 AZ, Maastricht, The Netherlands.
ease. Current medication consisted of salmeterol/ Corresponding author : D. F. P. M. Peek, Dept of Anesthesio-
flucitason, fexofenadine and temazepam. The logy, University Hospital Maastricht, PO box 8800,6202 patient was immediately admitted to the hospital.
Acta Anæsthesiologica Belgica, 2008, 59, n° 2 50 mg a day). This alerted us to the possible diag- because they weakly bind to D2 receptors and are nosis antipsychotic induced laryngeal dystonia easily displaced by endogenous dopamine in the After the tracheotomy procedure the patient Dopamine and anticholinergics have mutually initially had no respiratory problems but was admit- antagonistic function in the nigrostriatale system ted to the intensive care unit with an aspiration and therefore anticholinergica can be used for treat- During further course the patient was treated Haloperidol induced laryngeal dystonia is a for an ileus and urosepsis and was successfully very rare, life-threatening syndrome with a difficult decannulated after a few weeks and could be dis- diagnosis. The syndrome may be misdiagnosed as charged in good medical condition from the hospital tetanus, hysteria, catatonia or convulsions. There after four weeks. Concerning his neurological dis- have been several antipsychotic related fatal cases ease we finally diagnosed encephalitis lethargica.
in patients receiving haloperidol who developedLD (6, 7). The haloperidol dosage ranged in thesecases from 25 mg to 140 mg a day. Droperidol induced dystonic reactions are also very rare andhave been described in dosages as low as 1 mg Haloperidol, a butyrophenone , is used as a intravenously (4). More frequent side effects first-line medication in treating psychotic symp- encountered in anesthesia practice are hallucina- toms. But haloperidol has significant disadvantages tions, drowsiness, shivering or anxiety (8) LD can such as an increased incidence of extrapyrimidal be treated with diphenhydramine (9) (antihistamine symptoms including Parkinsonism, neuroleptic with a potent anticholinergic function), clozap- malignant syndrome, and a laryngeal dystonia.
ine (10) (atypical antipschycotic with anticholiner- Also, haloperidol (like droperidol) (3) can cause gic side effects) , tracheotomy (11) or anticholiner- prolongation of the QT-interval which can lead to gica (1). However, in this case we decided to per- torsade de pointes and ventricular fibrillation. Ten form a tracheotomy because we initially had no to thirty percent of patients treated with neurolep- diagnosis and the patient experienced increasing tics develop dystonias which differ in severity. Also droperidol ( also a butyrophenon), which is is fre- It is important to familiarize anesthesiologists quently used as a anti-emetic, can cause dystonic with this syndrome because haloperidol is frequent- reactions (4). Dystonia is a neurological movement ly used in the field of anesthesia. After ruling out disorder in which sustained muscle contractions allergic reactions or other causes of acute respirato- cause twisting and repetitive movements or abnor- ry obstruction, the diagnosis of LD in a patient mal postures. Dystonias can be focal, segmental or receiving haloperidol should be considered.
generalized. A dystonic reaction typically results inloss of control of onset and offset of muscle con-traction. In the larynx region the adductor muscles and abductor muscles are involved. Acute dystonia,which can develop hours to days after initiating the We report the case of a patient treated with medication, is the most life-threatening condition haloperidol for three days after which the patient because of the possibility of aspiration of food or developed life threatening laryngeal dystonia.
respiratory insufficiency resulting in a hypoxemic Antipsychotic induced laryngeal dystonia is a very condition. The risk factors involved in laryngeal rare medical condition. Characteristic symptoms, dystonia are particularly young males aged under particularly acute intermittent dyspnea, should be thirty years, hypersensitivity to antipsychotics, fam- familiar to every clinician prescribing this medica- ily history, cocaine abuse and head trauma. The tion. Performing an acute tracheostomy can be a pathophysiologic basis of the extrapyrimidal adverse reaction is found in an insufficient activityof nigrostriatal dopamine. Antipsychotics and espe-cially the typical antipschycotics cause EPS via the References
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(LD) (5). Atypical antipschycotics cause less EPS Acta Anæsthesiologica Belgica, 2008, 59, n° 2 2. Mellacheruvu S., Norton J. W., Schweinfurth J., Atypical 7. Modestin J., Krapf R., Boker W., A fatality during antipsychotic Drug-Induced Acute Laryngeal Dystonia, J.
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department : is it safe ?, J. EMERG. MED., 24, 441-7, 2003
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Dystonia Causing Stridor, A LESSON TO REMEMBER.
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Acta Anæsthesiologica Belgica, 2008, 59, n° 2

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