Vocal Fold Hypomobility Secondary to Elective Endotracheal Intubation: A General Surgeon's Perspective

doi:10.1016/j.jvoice.2008.05.001

Journal of Voice

Volume 24, Issue 1, January 2010, Pages 110-112

https://doi.org/10.1016/j.jvoice.2008.05.001 Get rights and content

Summary

This study was performed retrospectively to evaluate the incidence of documented vocal fold injury as a result of elective endotracheal intubation during general surgical procedures. Medical record review was performed at a single institution and all surgical cases reviewed which required endotracheal intubation in the nonemergent setting between April 1, 2003 and August, 31, 2007. Cases with unexpected and documented vocal fold immobility postoperatively formed the study cohort, and data were gathered regarding diagnosis and procedures performed. Of 23 010 general surgery cases performed during the study period, only seven documented cases of vocal fold paralysis were discovered (0.03%). There were five women and two men in the group; all were adults. Only one patient had a primary diagnosis related to the head and neck. Comorbidities were recorded as well, but there were no statistically significant patterns discerned. Furthermore, during the study period, a total of 31 patients overall (both surgical and nonsurgical) were admitted who carried a primary diagnosis of vocal fold paralysis. Therefore, the study cohort therefore constituted 22.6% of this total. Finally, cohort patients spent a total of 150 days in hospital during the study period; this length of stay (an average of 16.7 hospital days per patient) was significantly longer than the average of 5.1 days, presumably at least in part related to the vocal paralysis.

Introduction

Vocal fold paralysis is a relatively rare but often devastating consequence of elective endotracheal intubation.1, 2, 3, 4, 5 The etiology of such damage is often multifactoral, and though the causes are still debated, the injury itself is usually a direct result of the head and neck procedure being performed.6, 7, 8, 9, 10, 11, 12, 13 Rarely, however, the vocal fold paralysis appears to be the direct result of the intubation itself, and such injuries often follow a prolonged and morbid course.14, 15, 16, 17, 18 Consequences can range from self-limited hoarseness8, 11, 15 to stridor and airway compromise10, 12, 14 and often take the general surgeon (operating for other reasons) by surprise, significantly increasing a patient's morbidity and hospital length of stay.10, 12 The current analysis was undertaken to investigate the incidence of this complication at a single institution and to increase the awareness of this potentially catastrophic injury among patients undergoing general surgery.

Section snippets

Methods

A retrospective medical record review was performed at a single institution in Philadelphia, PA, of all general surgery cases requiring general endotracheal intubation in the nonemergent setting between April 1, 2003 and August 31, 2007. The reviewer was blinded to patient demographic information. The procedures performed included a variety of general surgical procedures and were performed by a diverse group of general surgeons. The study cohort was comprised of all patients with unexpected and

Results

A total of 23 010 general surgical procedures requiring endotracheal intubation were performed during the 53-month study period. These nonemergent procedures had been performed for indications other than vocal fold pathology. There were seven cases of diagnosed postoperative vocal fold paralysis in this patient population; this constituted 0.03% of the total (Table 1). Unilateral vocal fold paralysis was diagnosed in six patients and bilateral cord paralysis in one.

Only one cohort patient had a

Discussion

Vocal fold paralysis as a direct result of elective endotracheal intubation is believed to be a rare occurrence; the incidence has been reported to be less than 0.1% of all elective intubations.¹⁶ The results of the current review (0.04%) correlate well with this published incidence. Admittedly, a number of vocal fold injuries may have been missed if the complication was not discovered immediately postoperatively and if the patient sought consultation for the problem outside of the hospital or

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Cited by (14)

Therapeutic and prophylactic effects of radiation therapy in the management of recurrent granulation tissue induced tracheal stenosis: a review on the role of Endobronchial brachytherapy and external beam radiation therapy
2023, Brachytherapy
Granulation tissue-induced tracheal stenosis (mainly secondary to intubation or lung transplantation) is one of the most common etiologies of benign airway obstructions. Recurrence rates after standard treatment options (surgical resection and/or endobronchial interventions) can inadvertently worsen the stricture through the stimulation of more granulation tissue generation (via increased fibroblast activity and roliferation). Low-dose radiotherapy could be a promising tool to prevent granulation tissue formation after surgery and/or endobronchial interventions regarding its established role in the treatment of keloids or hypertrophic scars, two benign diseases with similar a pathophysiology to tracheal stenosis. This study reviews case reports and small series that used endobronchial brachytherapy (EBBT) or external beam radiotherapy (EBRT) for the management of refractory granulation tissue-induced tracheal stenosis after surgery and/or endobronchial interventions.
Case reports and series (published up to October 2022) that reported outcomes of patients with recurrent granulation tissue-induced tracheal stenosis (after surgery and/or endobronchial interventions) treated by EBBT or EBRT (in definitive or prophylactic settings) were eligible.
Sixteen studies (EBBT: nine studies including 69 patients, EBRT: seven studies including 32 patients) were reviewed. The pooled success rate across all studies was 74% and 97% for EBBT and EBRT, respectively.
Radiation therapy appears to be effective in the management of selected patients with recurrent/refractory tracheal stenosis. Response to this treatment is usually good, but further studies with a larger number of patients and long-term followup are necessary to determine the optimal technique, dose, and timing of radiation therapy, late complications, the durability of response, and criteria for patient selection.
Voice and Vocal Fold Condition Following Short-Term General Anesthesia: A Prospective Study
2021, Journal of Voice
Citation Excerpt :
Although dysphonia is reported less frequently following a supraglottic airway (SGA), injuries, such as cricoarytenoid subluxation and recurrent laryngeal nerve palsy have been reported.1,4,5 Postoperative dysphonia affects social and professional performance.6–8 In the American Society of Anesthesiologists Closed Claims Project database 1990–2007, 7% of the 5230 claims were related to airway injury, of which 33% were of laryngeal nature.9,10
Dysphonia, with or without laryngeal changes, has been reported as a complication following prolonged intubation. In contrast, it is unknown if laryngeal changes also occur following short-term airway instrumentation. The objectives of this study were to determine the prevalence of laryngeal changes in patients undergoing short-term routine general anesthesia using an endotracheal tube (ETT) or supraglottic airway (SGA), and to identify predictors to these changes.
Standardized voice assessments were performed preoperatively, postoperatively, and at follow-up on adults undergoing general anesthesia for an elective procedure of less than three hours requiring an ETT or a SGA. The standardized voice assessment protocol comprised a rigid videolaryngostroboscopy, the Voice Handicap Index (VHI), and acoustic voice analysis. The effects of demographic and anesthetic characteristics and type of airway instrumentation on the videolaryngostroboscopic variables were studied using multilevel logistic regression. Multilevel linear regression was used to reveal preoperative versus postoperative changes in VHI and acoustic voice scores.
Overall, the prevalence of postoperative laryngeal changes was low. Significant postoperative laryngeal changes were found for the variables right-sided vocal fold redness in the ETT group (P = 0.048) and right-sided vocal fold blood vessels in both groups (ETT versus SGA). However, after adjustment for all demographic and anesthetic characteristics in the regression model, the effect of the type of airway instrumentation (ETT versus SGA) on the variable right-sided vocal fold redness was no longer significant.
ETT and SGA short-term airway instrumentation are vocal fold function sparing techniques with negligible laryngeal changes.
A closed claims analysis of vocal cord injuries related to endotracheal intubation between 2004 and 2015
2020, Journal of Clinical Anesthesia
Citation Excerpt :
Vocal cord paralysis most commonly occurs due to recurrent laryngeal nerve damage, although the exact mechanism remains unclear. One postulated mechanism is damage to the endolaryngeal segment of the recurrent laryngeal nerve by trauma from the ETT being inserted or by high pressures of the ETT cuff that exceed the capillary perfusion pressures of the internal thyroid lamina, thus decreasing perfusion and ultimately causing clinically significant damage to the recurrent laryngeal nerve [28–30]. The significance of this damage is evident in our analysis, where we found that 95% of cases had at least one alleged complication of vocal cord injury and paralysis in their claim (Fig. 1).
To provide a contemporary medicolegal analysis of claims brought against anesthesiologists for injuries related to endotracheal intubation.
A retrospective study of closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database between 2004 and 2015.
Closed claims that occurred in any surgical specialty in which the patient was undergoing general anesthesia and anesthesiology was named as the primary responsible service.
Twenty claims were identified for analysis in 7 surgical specialties. Patient ages ranged from 45 to 76. Data regarding patient comorbidities and case history were obtained when available.
None.
Data collected includes patient demographics such as age, outcome severity, alleged complication, plaintiff allegations, contributing factors to the injury, the surgical specialty in which the injury occurred, and the ultimate result of the claim (dismissed/denied/settled).
Out of 20 claims, settlement payments were made in 10% of claims with a mean payment amount of $7669. Mean patient age was 55.6 years. Within severity of injuries, 65% of claims were classified as “Permanent Minor.” The most common contributing factor in claims was “Technical Knowledge/Performance” and the most common plaintiff allegation was “Trauma from endotracheal tube placement.” Bilateral vocal cord paralysis, unilateral (left-sided) vocal cord paralysis, and laryngeal nerve injury were the top alleged complications. The surgical specialty in which claims most often resulted was orthopedic surgery.
Injuries related to endotracheal intubation remain an ongoing challenge to anesthesiologists. Their etiology is often multifactorial and was found in this study to stem most commonly from technical errors and patient co-morbidities. A detailed discussion of risks with patients during the consent process, careful documentation of such discussion, and prompt referral to specialists when needed are critical. Understanding the patterns related to injuries during intubation is essential in order to develop strategies for improved patient safety and outcomes.
Unilateral vocal fold adductor paralysis after tracheal intubation
2018, Auris Nasus Larynx
Citation Excerpt :
Vocal fold immobility is a relatively rare complication that can arise after tracheal intubation [1].
Vocal fold immobility is a relatively rare complication that can occur after tracheal intubation. Differential diagnoses include a rare clinical entity called unilateral vocal fold adductor paralysis in which only branches entering the thyroarytenoid and lateral cricoarytenoid muscles of the recurrent laryngeal nerve become paralyzed. Computed tomography and laryngeal electromyography are required to distinguish this condition from others such as cricoarytenoid dislocation/subluxation. Here, we describe two patients who developed vocal fold adductor paralysis after intubation. Patient 1 was a 56-year-old man who underwent living-donor liver transplantation and was extubated on day 7 after surgery. Patient 2 was a 52-year-old man who received life support measures including intubation due to ventricular fibrillation, and was extubated two days later. Both were hoarse soon after extubation. Endoscopic laryngeal examination revealed normal abduction and insufficient adduction of paralyzed vocal folds. Computed tomography ruled out cricoarytenoid dislocation/subluxation and laryngeal electromyography confirmed unilateral vocal fold adductor paralysis. Laryngologists should consider this rare pathogenesis.
Effect of general anesthesia on voice
2016, Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Citation Excerpt :
Although both endotracheal intubation and the use of a laryngeal mask (LMA) are associated with postoperative laryngeal morbidity, the incidence of dysphonia and vocal fold injuries is not clear.8 Postoperative dysphonia, an important clinical sign of laryngeal injury or dysfunction, can be distressing to a patient.10 It may have a negative effect on the patients’ degree of satisfaction, as well as on their level of activity after hospital discharge.9
Transient voice change after surgical operations under general anesthesia has generally been attributed to vocal fold trauma. The aim of this study was to examine the effect of general anesthesia on voice in order to aid the early detection and prevention of these changes.
This study was carried out on 100 patients who were scheduled for a variety of elective surgical procedures under general anesthesia. They were 47 males, ranging in age from 6 to 55 years, and 53 females with the same range of age. Evaluation of vocal functions was carried out at three intervals, 1 day before operation, 1 day after operation and 2 weeks later.
All patients were subjected to analysis of their complaints (using Arabic Voice Handicap index, VHI), auditory perceptual assessment of their voice (APA), and laryngeal assessment using telescopic rigid orolaryngoscopy.
Among 95 patients (using endotracheal tube), ten patients complained of postoperative voice change, ranging in severity from mild in 8, moderate in 1, and severe in one patient. After 2 weeks, one patient was still complaining of severe voice change. There was postextubation mild to moderate voice change in 10 patients. The pitch was decreased in three patients, strained and leaky voice quality was perceived in one patient, strained voice was perceived in three patients, whereas breathy quality was perceived in one patient. Irregular quality was perceived in five patients; after 1 week, there was an improvement in all the perceived parameters; however, persistent mild dysphonia was perceived in one patient. The telescopic rigid orolaryngoscopy, performed 1 day after extubation, indicated evidence of traumatic laryngeal manifestations in 40 patients; erythema and congestion in 39 patients and in one patient intubation granuloma was recorded. Using laryngeal mask airway in 5 patients had no effect on their voice postoperatively.
Traumatic manifestations of the laryngeal structures that occur during intubation are the most common causes of postoperative dysphonia, with a tendency toward a regressive course of the resulting dysphonia. As such, it is important to establish an early diagnosis and adopt preventive measures.
Neurogenic vocal fold motion impairment after routine intubation for tonsillectomy in a pediatric patient
2014, Journal of Voice
Vocal fold motion impairment is a rare complication of general anesthesia and is more common in older patients undergoing longer duration of anesthesia. We present a case of recurrent laryngeal nerve (RLN) axonotmesis in a 16-year-old patient undergoing general anesthesia for tonsillectomy.
Case report.
The patient was intubated with a 6-0 oral RAE tube for routine tonsillectomy and was dysphonic postoperatively. Right vocal fold motion impairment was discovered on flexible laryngoscopy, and serial examinations with videostroboscopy were performed. She underwent laryngeal electromyography 3 months postoperatively.
Initial videostroboscopy demonstrated findings consistent with right RLN injury. Laryngeal electromyography showed severe active denervation of the right thyroarytenoid muscle with signs of early reinnervation, consistent with axonotmesis. Complete recovery was achieved 4 months postoperatively.
This case demonstrates RLN axonotmesis after brief routine intubation. The presumed mechanism of injury is compression of the nerve between the thyroid cartilage and the arytenoid or cricoid cartilage. The use of an oral RAE endotracheal tube may have contributed to the injury owing to the short distance between the bend of the tube and the cuff, placing the cuff at a higher level within the airway.

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Vocal Fold Hypomobility Secondary to Elective Endotracheal Intubation: A General Surgeon's Perspective

Summary

Introduction

Section snippets

Methods

Results

Discussion

Otolaryngol Head Neck Surg

Otolaryngol Clin North Am

J Am Coll Surg

J Vasc Surg

J Clin Anesth

Br J Anaesth

True vocal cord paralysis following intubation

Laryngoscope

Recurrent laryngeal nerve palsy and endotracheal intubation

J Laryngol Otol

Rocuronium is not associated with more vocal cord injuries than succinylcholine after rapid-sequence intubation: a randomized, prospective, controlled trial

Anesth Analg