The Management and Treatment of Recurrent Postoperative Laryngospasm

To the Editor: I read the case report by Mevorach with interest [1]. I believe the title is overstated, as it suggests that a series of cases and/or a comprehensive review of the relevant literature are reported. The most likely diagnosis, hysterical or psychogenic stridor, is not mentioned in the discussion. This entity was first reported by Patterson et al. in 1974 [2], and there is a growing body of medical literature on the subject in both anesthesia [3-6] and nonanesthesia journals [7-11]. This condition is most often seen in anxious adolescents and young adults and presents as sudden paroxysms of stridor or wheezing (which may be so severe as to appear life-threatening) in response to exercise or emotional stress. It is often misdiagnosed as asthma. Between episodes, the patient is well and has a completely normal physical and endoscopic examination. When examined during an acute episode, laryngoscopy has revealed laryngospasm with fully adducted vocal cords, hypopharyngeal spasm, or paradoxical vocal cord motion. Flow-volume loops have demonstrated paroxysmal extrathoracic airway obstruction. The differential diagnosis of the patient with acute postoperative stridor with emphasis on management of the patient with psychogenic stridor was reviewed recently by Sukhani et al. [6]. Perhaps Dr. Mevorach's patient would have benefited from reassurance and midazolam on emergence as much as he may have from bilateral superior laryngeal nerve blocks. Samuel E.