Tuesday, June 8, 2010

Why is My Voice Hoarse After Intubation?

When a breathing tube is placed into the airway for surgery or mechanical ventilation due to severe illness there is a chance of temporary or permanant damage to the vocal cords. Injury leading to vocal cord dysfunction can occur from a variety of mechanisms.

The first group of injuries occur during the intubation procedure. During intubation, a breathing tube (endotracheal tube) is passed through the mouth, throat, and vocal cords, into the windpipe. The tube can traumatize the vocal cords during placement, leading to bruising or ulceration of the vocal cord, dislocation of the arytenoid cartilage (part of the vocal cord), or a combination of injuries. Bruising of the vocal cord is referred to as a vocal hemorrhage. In particular, patients with difficult to expose larynges or those intubated emergently are at a higher risk.

The next group of injuries includes damage from a breathing tube sitting in place in the larynx and upper windpipe. The risk of injury correlates with the duration of the intubation. The inflated cuff on the breathing tube can create a pressure injury to the trachea or subglottis, leading to ulceration, inflammation, and scarring. When scarring occurs it can lead to a narrowing of the airway. If this occurs below the vocal cords it is called subglottic stenosis or tracheal stenosis. If the injury occurs at the level of the vocal cords it is referred to as glottic stenosis. And above the vocal cords it is called supraglottic stenosis.

More common than airway stenosis is the formation of a laryngeal granuloma. A laryngeal granuloma is also referred to as a pyogenic granuloma, contact ulceration, or intubation granuloma. Granulomas are inflammatory growths caused by injury to the covering of the arytenoids by the breathing tube. They normally resolve over time, although they can be difficult to eradicate often due to concurrent acid reflux or voice abuse.

Another group of injuries after intubation includes vocal cord paralysis and vocal cord paresis. A paralysis can occur from pressure exerted by the breathing tube on the recurrent laryngeal nerve. This can occur in conjunction with arytenoid dislocation. Paralysis can resolve on its own or persist. Permanent weakness can develop with varying degrees of recovery. A partially recovered paralysis is referred to as a vocal cord paresis. Treatment of the paralyzed vocal cord depends on the mechanism of injury, duration of vocal cord paralysis, and the symptoms experienced by the patient.

Treatment options include vocal cord injection (injection laryngoplasty), vocal cord medialization laryngoplasty (thyroplasty, Isshiki type I thyroplasty). Injection of the vocal cords is easily performed in the office setting in the unsedated patient. Materials used to inject or augment the vocal cords include Restylane, Radiesse Voice, Radiesse Voice Gel, Juvederm, Collagen, Cymetra, Fat, Gelfoam, etc. Injections can be temporary, semipermanent, or permanent, depending on the material used.

If your voice is hoarse after an intubation, you should seek the care of an otolaryngologist or laryngologist. Laryngeal examination will be performed and the cause of your hoarseness can be addressed.

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