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Can intubation for surgery damage your vocal cords and change your voice?
Q: Can intubation for surgery damage your vocal cords and change your voice?
Krishna: Yes! There is much more to it. I have seen several research papers that describe the effects of intubation, if not done properly. But I will try to be brief here.
It's common to experience hoarseness after being intubated for a surgical procedure or for a severe respiratory illness such as the flu, pneumonia, or COVID-19.
Post-intubation throat pain is a common complaint that is caused by focal ischemia, damage to the laryngeal mucosa, or edema. However, if the laryngeal symptoms persist after 72 h, vocal cord paralysis, the formation of granulation tissue, or ulcers can occur(1).
The causes of vocal cord ulcers related to endotracheal intubation are vocal cord mucosa damage during intubation and extubation, clasping movements between the vocal cords and the tube, continuous pressure of the tube during anesthesia, use of a tube that is too large, or infection. During endotracheal intubation, inflammation can occur on the mucous membrane of the vocal process area of arytenoid cartilage, and its severity tends to increase with longer intubation times or increased pressure (2).
Vocal cord ulcer can be caused by friction with the tube during intubation, damaging the vocal cord mucosa. It is also possible that if the endotracheal tube used is too large, or that the pressure exerted by the external cricoids leads to backward and lateral tilt, making the vocal process more prominent and vulnerable to injury (2).
Most vocal cord ulcers can be cured with conservative treatment such as voice therapy, or medical interventions including steroids, antibiotics, proton pump inhibitors, or histamine-2 receptor blockers. However, if the cause of ulcer is iatrogenic or the ulcer has progressed to granuloma, it may lead to aspiration and respiratory distress, and so long-term treatment or even surgical excision may be required(1,3).
True vocal cord paralysis may follow endotracheal intubation and be the result of peripheral nerve damage. This damage can occur as the result of compressing the nerve between an inflated endotracheal tube cuff and the overlying thyroid cartilage. A series of anatomic dissections defined the likely site of injury to be at the junction of the vocal process of the arytenoid cartilage and the membranous true vocal cord approximately 6 to 10 mm below the level of the cord (4,5). Analysis of the real case results indicated that nitrous oxide diffuses into endotracheal tube cuffs causing a substantial increase in the intracuff pressure. Scientists have concluded that true vocal cord paralysis which follows endotracheal intubation is usually temporary.
To prevent post-intubation vocal cord ulcers from occurring, using an appropriately sized tube, adequate sedation and muscle relaxation, performing smooth intubation, stabilization of the tube, and extubation without laryngeal reflexes are recommended (2,3).
Footnotes:
1. Hamdan AL, Sabra O, Rameh C, El-Khatib M. Persistent dysphonia following endotracheal intubation. Middle East J Anesthesiol. 2007;19:5–13. [PubMed] [Google Scholar]
2. Elsamma YE, Mossallam I, Habeed AY, el-Khodary AF. Laryngeal intubation granuloma. J Laryngol Otol. 1971;85:939–946. [PubMed] [Google Scholar]
3. Emami AJ, Morrison M, Rammage L, Bosch D. Treatment of laryngeal contact ulcers and granuloma: a 12-year retrospective analysis. J Voice. 1999;13:612–617. [PubMed] [Google Scholar]
Hamdan AL, Moukarbel RV, Farhat F, Obeid M.Eur J Cardiothorac Surg. 2002 Apr;21(4):671-4. doi: 10.1016/s1010-7940(02)00019-2.PMID: 11932166
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