Objective: Dysfunction in speech, respiration, and swallowing can severely compromise the well-being of Parkinson’s disease (PD) patients. Here, we present a rare case of acute vocal cord dysfunction leading to failed extubation following STN-DBS surgery.

Background: We report a 65-year-old woman with Parkinson’s disease who initially presented with right-hand tremor and bradykinesia in 2009. She developed motor fluctuations since 2014. Around 2020, her disease progressed significantly, presenting severe motor fluctuations, marked drooling, frequent choking, and falls. Bilateral STN-DBS was proposed in 2019, the procedure was deferred due to financial constraints and the COVID-19 pandemic. In 2024 (at age 63), she was admitted for bilateral STN-DBS surgery.

Method: Our patient underwent staged STN-DBS. Stage 1 (bilateral electrode placement) on June 21, 2024, under general anesthesia. The initial post-operative course was uneventful, and she was extubated on June 22. However, drooling and impaired swallowing became apparent shortly after extubation, leading to the placement of a nasogastric tube.

On June 28, she underwent Stage 2 surgery for implantable pulse generator (IPG) placement. Post-extubation, she acutely developed marked stridor, necessitating immediate re-intubation. Despite rigorous pharmacological optimization, a second extubation attempt on July 8 failed due to recurrent inspiratory stridor, even with the patient being alert and cooperative. Bedside video laryngoscopy revealed bilateral vocal cord palsy in the paramedian position.

Results: On July 10, DBS was activated ahead of the standard one-month observation window as a rescue intervention starting with a low intensity (Left STN C+1-  0.6mA , 60 uS, 120Hz ; Right STN C+9- 0.5mA, 60 uS, 120Hz). The patient was successfully extubated on July 16 but remained with significant hypophonia and dysarthria. A subsequent adjustment to low-frequency DBS (85Hz) and higher intensity significantly improved vocal cord vibration during phonation, as confirmed by video laryngoscopy and clinical articulation assessment. Following this latest optimization ,the patient’s speech improved further, and the nasogastric tube was successfully removed one week later.

Conclusion: Our case demonstrates that low-frequency STN-DBS (85 Hz) may optimize vocal cord mobility and enhance articulatory performance in patients with post-operative airway compromise.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/a-case-of-difficulty-extubating-after-general-anesthesia-deep-brain-stimulation-dbs-surgery/