Peri-extubation airway complications such as coughing, laryngospasm and oxygen desaturation remain common during emergence from general anaesthesia and may contribute to postoperative morbidity. Lidocaine is widely used to reduce airway reactivity during extubation; however, evidence comparing intravenous and topical administration routes in adults remains limited. In particular, little evidence exists regarding topical lidocaine gel applied at the time of endotracheal intubation. This trial aims to compare intravenous lidocaine with topical lidocaine gel for prevention of peri-extubation airway complications in adults undergoing elective orthopaedic surgery.

Interscalene brachial plexus block (ISB) is commonly used for shoulder surgery and is associated with predictable complications such as phrenic nerve palsy due to its proximity to adjacent neural structures. While the spread of local anesthetic may involve the recurrent laryngeal nerve, resulting in vocal cord dysfunction, which is uncommon, progression to bilateral vocal cord paralysis, causing acute airway obstruction, is exceedingly rare. A 74-year-old obese female underwent elective outpatient right shoulder arthroscopy under ultrasound-guided interscalene block with bupivacaine. Within hours postoperatively, she developed progressive respiratory distress. Despite high-flow oxygen and bag-valve-mask ventilation, oxygen saturation declined into the 60s with marked resistance to ventilation. Emergent intubation resulted in immediate improvement. Point-of-care ultrasound demonstrated diffuse B-lines without right heart strain, and imaging confirmed pulmonary edema. Workup did not reveal a primary pulmonary or obstructive cardiac etiology; however, troponin elevation consistent with type 2 myocardial infarction was identified. The patient improved rapidly with ventilatory support and diuresis, was extubated within 48 hours, and was discharged without recurrence. This case demonstrates a rare complication of ISB involving sequential spread of local anesthetic, potentially facilitated by arthroscopic fluid extravasation, leading to phrenic nerve involvement and bilateral recurrent laryngeal nerve dysfunction. Resultant airway obstruction caused negative pressure pulmonary edema and secondary demand ischemia. Resistance to ventilation and refractory hypoxemia after ISB should raise concern for upper airway obstruction. Early airway management is critical to improve outcomes.

Anaplastic thyroid carcinoma (ATC) is one of the most aggressive malignancies and is associated with an extremely poor prognosis. Multimodal therapy, combining surgery, radiation therapy, and chemotherapy, is recommended. Although paclitaxel and lenvatinib have been used as drug treatments, combination therapy with dabrafenib and trametinib has recently been reported to be effective. This combination therapy is generally associated with few serious adverse events, although rare cases of cardiac dysfunction have been reported. Here, we report the case of an 84-year-old woman with BRAF V600E mutation-positive ATC who developed cardiac dysfunction during combination therapy with dabrafenib and trametinib. The patient had no significant medical history and was referred to our department with left vocal cord paralysis and a thyroid mass. Histological examination of the right thyroid lobe tumor revealed components of undifferentiated carcinoma. Imaging studies showed invasion of the larynx and trachea, leading to total thyroidectomy, total laryngectomy, and paratracheal lymph node dissection. Postoperative pathological examination confirmed ATC (pT4aN0). Postoperative imaging revealed no distant metastases, and adjuvant radiotherapy was administered. Four months after the completion of radiotherapy, a cervical lymph node recurrence and right lung metastases were observed. As the tumor tested positive for BRAF V600E mutation using the MEBGEN™ BRAF kit, combination therapy with dabrafenib and trametinib was initiated. At week five of treatment, pitting edema developed in both lower limbs, and a decrease in the left ventricular ejection fraction (LVEF) was noted, prompting the discontinuation of therapy. By week six, the LVEF recovered, and dabrafenib was restarted at the same dose, whereas trametinib was resumed at a one-step reduced dose. Follow-up CT at week six demonstrated a partial response (PR). Treatment was continued at these doses; however, tumor enlargement was observed at week 26, leading to treatment discontinuation and a transition to palliative care. ATC remains extremely challenging to treat because of its rapid progression and low sensitivity to drug therapies. Furthermore, lenvatinib, a molecularly targeted agent, shows limited efficacy against ATC and is associated with frequent adverse events. In contrast, combination therapy with dabrafenib and trametinib is considered an effective therapeutic option for patients with BRAF V600E mutation-positive ATC, when appropriate management and monitoring are implemented.