Complex regional pain syndrome in all four limbs.

supply to cranial nerves X and XII, and thus carotid dissection after minor trauma may lead to sudden cranial nerve X and XII palsies. For this reason, in the present case, MR angiography and carotid triplex scan took place but did not reveal any abnormality. Additionally, Tapia’s syndrome can be considered as a localized lesion at the crossing of the recurrent laryngeal and hypoglossal nerves. It has been suggested that pressure neuropathy occurs owing to hyperinflation or malposition of the cuff of the endotracheal tube within the larynx causing compression on both nerves at this crossing point [4]. In the present case, the cuff pressure was low and no nitrous oxide was administered. Interestingly, Tapia’s syndrome has been caused by central nervous system tumours. Kranianski and colleagues have reported an interesting case of hypoglossal and vagus nerve palsy in a patient with metastatic haemangiosarcoma [5]. To exclude a tumour, an MR scan of the brain was performed and did not show any lesion. In our case, we could find no clear mechanism inducing the bilateral hypoglossal and recurrent laryngeal nerve palsy. Inadvertent hyperextension and lateral flexion of the neck at some point during sternotomy phase, in conjunction with endotracheal tube malposition, might have led to compression at the crossing point of the vagal and hypoglossal nerves, but this is speculation. Another possibility is that originally described by Boiseau and colleagues, where Tapia’s syndrome developed after compression by the tracheal tube caused by displacement of the head during shoulder surgery in the sitting position [6]. We believe that this is a rare cause of failed extubation and that it has occurred in cardiovascular anaesthesia for the first time. Extreme care must be taken in the placement of the head during every procedure and in endotracheal tube position as this may result in bilateral hypoglossal and recurrent laryngeal nerve paralysis, which should be considered possible, whenever extubation fails owing to upper airway obstruction.