Early Tracheostomy and the Incidence of Posterior Vocal Cord Ulcers

Abstract

Background: Endotracheal intubation is a routinely performed procedure in the ICU that can result in laryngeal injury. Many injuries from intubations occur at the posterior vocal cords (PVC) and present as superficial ulcers that can progress to involve deeper mucosal layers. Posterior vocal cord ulcers (PVCU) can lead to the development of granulomas and vocal cord dysfunction, which can increase the risk of aspiration in ICU patients. There is currently no consensus in the literature on the incidence of PVCU. One method to determine the occurrence of PVCU is during a tracheostomy. This study investigated the length of time ICU patients can be on a ventilator before the development of PVCU by determining the presence of PVCU at the time of tracheostomy placement.

Methods: This was an IRB approved retrospective analysis of 1,355 patients from 2002–2018 who received a tracheostomy. Post tracheostomy operative notes were reviewed and considered only if proper visualization of the vocal cords was documented. Demographic data was ascertained. Primary outcome measures included the presence of PVCU, length of time on a ventilator until a tracheostomy, length of hospitalization, and mortality. Ulcers were stratified by severity (mild, moderate, and severe) and were analyzed using ANOVA with an alpha of 0.05. Data was reported as n (%) and median (IQR).

Results: 192 patients were included in the study and divided into two groups: patients who developed PVCU (n = 153) and patients who did not develop PVCU (n = 39). Comparisons were calculated between patients with and without PVCU. On average, PVCU subjects were significantly older [56 vs 44, P = 0.002] and had similar hospitalization stays [29 vs 34, P = 0.743]. PVCU patients were intubated for significantly longer [10 vs 6, P <0.001). There was no statistically significant difference between gender, BMI, and mortality between groups. Most notably, there was a statistically significant difference (P < 0.001) between the length of time on a ventilator before tracheostomy and the severity of the PVCU seen (Table 1).

Conclusions: Patients with PVCU were on average older and intubated for longer. Longer intubation before tracheostomy correlated with more severe ulceration of the PVC suggesting earlier conversion to tracheostomy may decrease the incidence of severe PVCU. Further development of improved endotracheal tube designs can aim to reduce pressure on the posterior vocal cord and improve outcomes.

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