The anesthetic plan was balanced general anesthesia with standard monitoring EKG lead II, SpO 2 , NIBP, nasopharyngeal thermometer , plus Foley catheter, anti-embolism socks, intermittent pneumatic compression, warming blanket and a non-slip mattress. He was easily ventilated and intubated on the first attempt with a cuffed Endotracheal Tube ET size 8.
Sevoflurane was used for maintenance end-tidal concentration of 1. An orogastric tube was also inserted without incident. The patient remained stable during the entire procedure. Laparoscopic surgery lasted 5 hours and 30 minutes, mainly in the Trendelenburg position, without incidents. The patient was extubated after reversion of muscle relaxation with Sugammadex mg iv, and transferred to the recovery unit, where he stayed for minutes, and was then moved to his room with adequate pain management.
Otorhinolaryngologic assessment was requested, describing a weak and breathy voice without neck pain. Laryngeal videostroboscopy evidenced left vocal cord immobility in paramedian position, bowed free edge and overhanging ipsilateral arytenoid, determining an incomplete glottic closure.
The "jostle sign" was present the "jostle sign" describes a passive medial movement of the affected vocal cord during adduction due to absence of lateral tension from the denervated musculature, and helps discriminate between a vocal cord paralysis and an arytenoid subluxation.
The right vocal cord mobility was preserved in adduction and abduction, and there was no hematoma or trauma sign. Vocal speech therapy was indicated, and outpatient medical evaluation with a laryngeal videostroboscopy 8 days after surgery showed no change. Endotracheal intubation is a routine, safe procedure worldwide. Nevertheless, it can be a source of morbidity.
Airway damage is a widely known complication, mostly involving women and during elective surgery. The larynx is the most common site of airway injury during endotracheal intubation, representing a third of cases, including granuloma, hematoma, vocal cord paralysis, and arytenoid subluxation. Hoarseness is a symptom that can appear usually after endotracheal intubation, even in surgery not related with pathologies of head and neck.
There are a small number of documented cases in the literature where hoarseness is explained by vocal cord paralysis secondary to intubation process, thus being a rare complication. In general, the symptoms are evident within the first 24 hours after intubation; however, diagnosis of vocal cord paralysis is performed on average after two weeks. This could be explained by endotracheal tube fixation at the right angle of the mouth, with less chance of damage to the recurrent laryngeal nerve on that side.
Nasogastric tube positioning could compress the nerve too. Patients with unilateral vocal cord paralysis clinically manifest changes in voice quality, perceived as dysphonia. Other associated symptoms such as vocal fatigue, decreased range and intensity, can affect communication skills. In addition to changes in voice, vocal cord paralysis produces an inefficient cough mechanism, which can lead to aspiration with the consequent risk of pneumonia.
A group of patients show respiratory failure, stridor and obstructive symptoms. Thus, it can be a severe complication that requires immediate diagnosis and medical care. The suspected diagnosis begins with the subjective perception of changes in voice from the patient, following a surgery under general anesthesia. Physical examination of patients with unilateral vocal cord paralysis reveals a weak and breathy voice, with loss of projection, vocal fatigue and loss of vocal range especially upper end of register.
These features are explained by glottal insufficiency secondary to paresis or paralysis of the vocal cord. In the diagnostic evaluation it is necessary to examine the structure and function of the larynx.
Laryngeal videostroboscopy is a useful tool in the diagnosis of voice disorders. Voice outcome following acute unilateral vocal fold paralysis. Ann Otol Rhinol Laryngol. Patients who develop hoarseness secondary to vocal cord paralysis after endotracheal intubation, can be categorized in two groups: in certain cases, the intubation results in difficulty for anatomical reasons, and in the other, it is not possible to identify an obvious cause.
Several factors are associated with the development of this complication. Anaesthesia and tracheal intubation were achieved with the use of a Macintosh laryngoscope and a stylet limited to the tracheal tube by board-certified anaesthetists. Anaesthesia was achieved by standard methods, and details were left to the discretion of the attending board-certified anaesthetist.
General anaesthesia was maintained with sevoflurane in oxygen and nitrous oxide. For patients less than 20 yr of age, the size of the tracheal tube was determined according to the patient's age, 16 and was adjusted to the size of the trachea measured on a routinely obtained chest X-ray film. For females aged 20 or older, a tracheal tube of internal diameter 7.
Once the tracheal tube was seen to pass through the vocal cords, the position was checked by looking for equal chest movement, bilateral axillary auscultation, and expired carbon dioxide. The tracheal tube was fixed in the right angle of the patient's mouth. Tracheal intubation was performed after complete muscle relaxation approximately 3 min after administering vecuronium bromide.
After surgery, patients' trachea were extubated at the discretion of the anaesthetist in charge of the patient. Extubation criteria included: full reversal of neuromuscular block by administration of atropin 0. All patients included in the present study were extubated immediately after surgery. All patients underwent postoperative assessment for possible vocal cord paralysis by a board-certified anaesthetist on the day of surgery or the first postoperative day.
Subsequently, the physician in charge assessed all patients for postoperative symptoms in the ward and clinic. All patients with notable or persistent dysphonia within postoperative 30 days were evaluated by the hospital's otolaryngology service.
Vocal cord paralysis associated with tracheal intubation was defined as immobility of the vocal cords when other causes of immobility had been ruled out. Assessment and diagnosis of vocal cord paralysis by board-certified oto-rhino-laryngologists included postoperative interviews and flexible fibrescopy.
All study patients underwent preoperative assessment for pre-existing morbidities. Pre-existing morbidities included hypertension defined as systolic blood pressure of at least mm Hg, diastolic blood pressure of at least 90 mm Hg, or both , diabetes mellitus [defined as a blood glucose level of at least mg 6.
Pre-existing morbidities also included cardiovascular disease diagnosed by a board-certified cardiologists. Pre-existing morbidities also included cerebrovascular disease diagnosed by a board-certified neurologist. This included ischaemic stroke based on new neurologic deficits that persisted for more than 24 h, computed tomography scans or magnetic resonance images.
The computerized medical database file of each patient was obtained at the time of enrollment and secured in the Division of Medical Records and Information of our institutions. Incidences and risks of vocal cord paralysis were calculated. The characteristics of the patients who were associated or not with vocal cord paralysis after tracheal intubation were compared by one-way analysis of variance followed by Bonferroni multiple comparison test. Potential associations of the duration of tracheal intubation, size of the tracheal tube, patient age, sex, history of cardiac, and cerebral, vascular, or metabolic disease with the occurrence of vocal cord paralysis after the tracheal tube were analysed by the chi-square test and Fisher's exact test for trend.
Vocal cord paralysis after tracheal intubation was treated as the dependent categorical variable. All independent variables that were significant two-tailed nominal P -value of less than 0. Stepwise logistic regression was performed, and variables that were significant two-tailed nominal P -value of less than 0. Characteristics of patients are summarized in Table 1.
The age distribution and duration of intubation of these patients are shown in Figures 1 a and 2 a , respectively. The types of surgery were general The incidence of vocal cord paralysis increased with age.
Multivariate analysis showed the risk of vocal cord paralysis to be increased three-fold in patients aged 50 or above. Intubation duration-specific incidence of vocal cord paralysis. Characteristics of patients who underwent tracheal intubation including those who suffered vocal cord paralysis. Numbers or percentage of patients are shown unless otherwise indicated.
The incidence of vocal cord paralysis in patients who underwent tracheal intubation is summarized in Table 1. The age-specific incidence is shown in Figure 1 b , and the intubation duration-specific incidence is shown in Figure 2 b. A total of 24 patients 0. There was no incidence of difficult tracheal intubation in any of these patients.
Of the 24 patients who suffered vocal cord paralysis, eight 0. The occurrences of vocal cord paralysis in type of surgery were as follows: in three patients 0. In all 24 patients, dysphonia was notable with the earliest postoperative examination on the day of surgery or the first postoperative day.
There were certain periods from the notice of dysphonia to the diagnosis of vocal cord paralysis. The median period between surgery and the date of diagnosis of vocal cord paralysis was 14 days, with a range of 1—30 days males: 13 days, range: 1—25 days; females: 14 days, range: 1—30 days.
Nine of the 24 patients All of those 24 patients were treated with mecobalamin vitamin B 12 for treatment and mobility of the paralysed vocal cords was observed in all of these patients after 68 17 days 41—97 days, approximately within 2—3 months.
The results of multivariate logistic regression analysis of the risk factors for vocal cord paralysis in patients who underwent tracheal intubation are summarized in Table 2. The risk and incidence of vocal cord paralysis increased with age for every year: multivariate odds ratio, 1. The risk and incidence of vocal cord paralysis increased with the duration of intubation for every hour: multivariate odds ratio, 1.
Data obtained from this large observational study of consecutive surgery patients offer physicians important, clinically relevant information about the relation of patient's age, history of diabetes mellitus, and hypertension, and duration of tracheal intubation to the incidence, and risk of vocal cord paralysis. This study basically supports the theory that vocal cord paralysis after intubation is likely to be due to nerve damage caused by microcirculatory compromise affecting laryngeal nerves.
Age, diabetes mellitus, hypertension, and prolonged intubation would all potentially increase the risk of vocal cord paralysis. The left vocal cord was shown to be two times more vulnerable to vocal cord paralysis than the right vocal cord. This may be due to rightward insertion and fixation of the tracheal tube in the right angle of mouth.
The mobility of the paralysed vocal cords was observed in all of these patients after approximately 2—3 months. Placement of the tracheal tube is thought to immobilize the vocal cords and muscles and paralyse the peripheral nerves. The details of the included studies are described in Table 4. Of the 13 included articles, 3 were considered to meet the criteria of level A2, 18 - 20 4 of level B, 21 - 24 and 6 of level C 15 , 25 - 29 Table 4.
Two studies 22 , 24 examined vocal cord injuries as well as hoarseness. Six studies 18 , 19 , 23 , 25 , 26 , 29 examined vocal cord injuries, of which 2 26 , 29 investigated only vocal cord paralysis.
Five studies 15 , 20 , 21 , 27 , 28 examined postoperative hoarseness. The mean duration of intubation ranged from 65 to The number of patients in the studies ranged from 6 to All investigations from to used descriptive statistics and several used statistical analysis to evaluate their results.
All studies used various measurement tools and outcome assessments Table 4. For the measurement of vocal cord injury, laryngoscopy or videolaryngostroboscopy was used. For the measurement of hoarseness, various instruments were applied, including several subjective interviews, acoustic analysis, and audioperceptual analysis in voice recordings.
The timing of postoperative follow-up measurements varied from once immediately after the operation to 6 months postoperatively. Postoperative vocal cord injuries and hoarseness were common in most studies using the ET. Vocal cord injuries ranged from none of 6 participants to 69 of participants. Hoarseness ranged from 4 of 10 participants immediately after the operation to 54 of patients within the first postoperative week.
In one study 22 using the LM, 1 participant of 21 was diagnosed as having vocal cord injury and 1 participant of 28 reported hoarseness. In the study of Hamdan et al, 21 hoarseness after use of the LM was also reported. In all investigations, the number of participants having hoarseness or vocal cord injuries decreased after the first postoperative measurement. Not all studies described a follow-up until total resolution of hoarseness or vocal cord injuries had occurred. In the studies of Friedrich et al 26 and Mencke et al, 18 both using an ET, persistent vocal cord injuries were described as varying from 1 week to 6 months.
Jones et al 28 reported on 5 participants with persistent hoarseness up to 99 days following the use of an ET. With use of laryngoscopy, vocal cord injuries were diagnosed in these patients. In Table 5 and Table 6 , The included studies are summarized regarding available data on the occurrence and time of evaluation of vocal cord injuries and hoarseness.
Seven studies 18 , 19 , 22 , 24 - 26 , 29 described the type of vocal cord injuries. The most frequent types of injuries were hematoma and thickening of the mucosa with edema, equally located bilaterally and unilaterally left more than right. In 5 patients, granulomas were seen Table 5. The present systematic review aimed to evaluate the occurrence and type of vocal cord injury as well as the occurrence of hoarseness after short-term general anesthesia using an ET or an LM in adults.
Preoperative and postoperative assessments are necessary to measure the effects of ET or LM on vocal cord function and morphology.
It may be concluded that vocal cord injuries as well as hoarseness were common after short-term general anesthesia using an ET in most studies Tables 5 and 6. Even vocal cord injuries following LM insertion were reported, 22 although the LM does not traverse the vocal cords.
Furthermore, 5 patients from different studies were reported to have granulomas. In addition, persistent hoarseness was reported in several studies up to 6 months after routine short-term anesthetic care.
However, the results of the included studies vary widely. Because of heterogeneous designs, such as different measurement tools, outcome variables, and postoperative measurement times, the included studies can hardly be compared with each other.
Other methodologic shortcomings include, for example, the absence of a control group to identify confounders, 15 , 21 - 23 , 25 - 27 , 29 selection bias, 15 , 21 - 23 , 27 and loss to follow-up 21 - 24 , 27 ; these limitations result in weak overall conclusions.
If more time elapses between the end of anesthesia and the first measurement, more factors will interfere and affect the results. Six studies 18 - 22 , 27 used standardized times of postoperative measurement. Eight studies 18 - 22 , 24 , 27 , 29 performed the first postoperative measurement within 1 day. One author 24 did not report any information or included incomplete information on the time of postoperative measurement. A wide range of times of postoperative measurement, for example, within 1 to 5 days, 25 4 to 9 days, 26 and within 1 week 28 was observed in several studies, resulting in less-standardized study conditions.
Laryngoscopy is a routine procedure to examine the vocal cords. It is able to reveal a number of abnormalities. However, the definition of vocal cord injury was not uniform 22 - 24 and the classification of the type of injury varied. Furthermore, several studies reported whether lesions were present 22 , 24 , 29 or used classifications varying in detail concerning the type and location of the lesions. A classification can be made according to the impairment of the vibratory movement of the vocal cord and movement disorders of the vocal cords as suggested by the Phonosurgery Committee of the European Laryngological Society.
To evaluate hoarseness, several measurements are available. Audioperceptual evaluation involves problems such as the unstable internal standards for comparing speech stimuli and the lack of universally accepted definitions for perceptual concepts. Furthermore, despite the fact that instrumental analysis is considered to be more objective, it also has limitations, including imperfection in acoustic analysis eg, errors in pitch tracking, the inability to perform acoustic analysis in very aperiodic vocal vibrations, and the analysis of nonphysiologic speech samples, such as sustained vowels.
This self-administered questionnaire consists of 30 questions; the patient responds according to the appropriateness of each item 0, never; to 4, always. The Voice Handicap Index is scored from 0 to , with the latter representing the maximum perceived disability due to voice difficulties based on the patient's response. Acoustic analysis is performed by selecting a particular segment from a voice sample and analyzing it using defined acoustic algorithms: the percentage of jitter, shimmer, and noise to harmonic ratio.
It represents the relative period-to-period variability. The percentage of shimmer gives an indication of the period-to-period variability of the peak-to-peak amplitude. An important condition to obtain sufficiently reliable study results is blinding of the raters combined with consensus training and independent scoring of the visuoperceptual or audioperceptual outcome variables for vocal cord injuries and hoarseness.
Only 3 studies noted the presence of an expert rater. Blinding of the raters and reliability analysis of their results are necessary to generate reliable conclusions. Laryngeal injury caused by an ET may occur during induction of anesthesia as direct intubation trauma, an operation, or tracheal extubation. These include ET size, cuff design, cuff pressure, type of tube, use of an introducer, use of a gastric tube, muscle relaxation, use of propofol, duration of the operation, intubation conditions, and movement of the tube, as well as demographic factors such as sex, weight, history of smoking and gastroesophageal reflux, or even the type of operation.
More than 20 case reports of recurrent laryngeal nerve injuries have been published. For future research, it is important to use a standardized anesthesia protocol and report potential contributing factors to vocal cord injuries. The clinical objective examined by the present systematic review was to evaluate the occurrence and the type of vocal cord injury as well as the occurrence of hoarseness following short-term general anesthesia using an ET or LM in adults.
All 13 of the included studies applied preoperative and postoperative measurements. Hoarseness and vocal cord injuries were common findings following the use of an ET applied for short-term anesthesia in most studies.
In addition, several investigations reported persistent hoarseness and injury for up to 6 months. However, because of heterogeneous study designs, such as different assessment tools, different outcome variables, and a wide range of postoperative measurement moments, the included studies could hardly be compared. Nevertheless, hoarseness and vocal cord injuries seem to be clinically relevant complications related to use of an ET or LM during short-term general anesthesia.
For future research, more well-designed prospective studies with both preoperative and postoperative examinations, validated measurement tools, and reliable outcome assessments are necessary to generate reliable data as well as develop techniques to reduce adverse laryngeal effects. Furthermore, a preoperative and postoperative standardized measurement protocol using acoustic analysis and the Voice Handicap Index is advised.
We recommend that vocal cord lesions due to general anesthesia be categorized. Correspondence: Jan W. Submitted for Publication: August 4, ; final revision received September 29, ; accepted November 9, Author Contributions: Drs Mendels and Brunings contributed equally to this study. Dr Brunings is independent of any commercial funder, had full access to all the data in the study, and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design : Mendels, Brunings, Hamaekers, and Stokroos. Acquisition of data : Mendels, Brunings, and Baijens. Drafting of the manuscript : Mendels, Brunings, Stokroos, and Baijens. Critical revision of the manuscript for important intellectual content : Mendels, Brunings, Hamaekers, Stokroos, Kremer, and Baijens. Statistical analysis : Mendels and Brunings.
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