WA Kofke’s patient presents for complex back surgery. The patient will be prone for many hours. She also has asthma. Vocal cord injury related to anesthetic management could derail her singing career. What can be done to minimize the risk vocal cord injury during general anesthesia? What symptoms require immediate post operative intervention? The patient asked that Dr. Kofke contact her voice doctor (Robert T. Sataloff, M.D., D.M.A., F.A.C.S; Professor and Chairman, Department of Otolaryngology - Head and Neck Surgery and Senior Associate Dean for Clinical Academic Specialties; Drexel University College of Medicine) who commented as follows: “Avoidance of vocal fold trauma in voice professionals is an important issue. Sadly, there are few evidence-based data to support clinical practice. Whenever possible, we try to use a 5 or 5.5 tracheal tube. However, in an asthmatic facing prolong surgery in the prone position, that might be difficult. A 6.0 tube would certainly be reasonable if it is necessary to manage her pulmonary condition. In addition to a neutral position of the head, the smaller tube and steroids, there are a few other suggestions that you might consider. First, documentation of the informed consent discussion should be meticulous. It is important for the record to reflect that she has been warned that voice damage can occur and could leave her speaking voice hoarse, and impair her ability to sing permanently. Although you and I both know that such problems are rare, this is just the kind of patient who could end up with an unexpected vocal fold trauma or cricoarytenoid joint injury. The keystone of virtually every case I have reviewed from a medical legal standpoint has been in the area of informed consent, since virtually all the untoward events I have been consulted on have been from recognized complications. Second, if possible, I would plan on deep extubation. Finishing emergence with spontaneous respiration by mask would prevent her from coughing on the tracheal tube or coughing during extubation. It is, of course, important for your resident or CRNA to be certain that the cuff is completely deflated during extubation (a common mechanism for posterior arytenoid dislocation). Third, it is helpful during emergence to untape the tube before your patient starts swallowing. This is especially important if you decide not to extubate her while she is deep. Coughing and swallowing against a fixed plastic obstruction causes sheering forces that are more traumatic to the vocal folds than direct contact alone which is what occurs after untaping (allows the tracheal tube to move with the larynx). A laryngeal mask airway instead of a regular mask during emergence is reasonable as long as the person you have placing it has a great deal of experience with laryngeal mask ventilation. I have seen three cases of arytenoid dislocation caused by LMAs, and the problems seem to occur with people who don't use them very often. Fourth, I would recommend making a definite effort to speak with the patient postoperatively. If she is hoarse following extubation, an otolaryngology consult should be obtained immediately. The second most common claim that I see following anesthesia (inadequate informed consent being first) is delay in diagnosis. This usually results in action against the anesthesiologist and the surgeon; the anesthesiologist usually is held accountable unless the surgery was performed as an outpatient. Even then, the issue has been problematic for anesthesiologists. If the patient stays in the hospital even one night and is not assessed with documentation by a written note about the voice, defense is difficult if problems arise. More importantly, immediate evaluation of post-extubation hoarseness by an otolaryngologist allows identification of problems that require immediate intervention. These may range from trauma along the vibratory margin that may require voice rest, to arytenoid subluxation which may respond to prompt reduction. Hopefully (and most likely), there will be no postoperative hoarseness. However, if there is, immediate otolaryngologic management of this recognized complication minimizes the likelihood of long-term dysphonia and complies with a state-of-the-art standard of care.”
I asked a vocal cord expert who I work with, Natasha Mirza, M.D., to review the above comments. She replied that “Dr. Sataloff has captured the gist of what is needed most in these professional voice users which is a detailed informed consent. For shorter cases an LMA may be better with less risk of vocal fold injuries. If intubation is necessary then the smaller the tube the better. Also post op it is always a good idea to ask the surgeon to write for a week of proton pump inhibitors to help prevent granulomas as we know that even a few hours of intubation can lead to VF irritation. I and my team will obviously be available to assist you all in any way we can if there are any issues in the post op period.”
DSS notes: There is very little in the anesthesia literature on the anesthetic management of the professional singer or other people such as actors or announcers whose voices are their source of income. Many years ago, I offered an opera singer a spinal anesthetic instead of a general anesthetic for her lumbar laminectomy. Her response was on the order of – I would rather not sing again than have a spinal. Clear communication is key to successful care of these patients.
A few references:
1. Torrey MJ, Wong JH, Finley-Detweiler R: The vocal athlete and endotracheal intubation: A management protocol. J Voice 1998;12:349
2. Bullough A, Craig R: Anesthesia for the professional singer (letter). Eur J Anaesthesiol 2001:18:414
3. Errando CL: Anaesthesia for the professional singer (letter). Eur J Anaesthesiol 2002;19:687
4. Anon: Post-intubation granuloma (editorial). BMJ 1973; November10:313
5. Loh KW, Irish JC: Traumatic complications of intubation and other airway management procedures. Anesthesiology Clin N Am 2002;20:953
6. Zimmert M et al: Effects on vocal cord function and incidence of laryngeal disorder when using a laryngeal mask airway in comparison with an endotracheal tube. Eur J Anaesthesiol 1999;16:511
7. Hamadan A-L et al: Immediate post-operative vocal cord changes in patients using laryngeal mask airways versus endotracheal tube. J Laryngol Otol 2008;121:879
Dr. Mirza is Associate Professor of Otorhinlaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania
David S. Smith, M.D., Ph.D.