Vocal Cord Injury After Intubation

Vocal cord injury after intubation includes haematoma, laceration, granuloma, ulceration, cord paralysis, and arytenoid injury. It presents as hoarseness, voice change, pain or airway symptoms.

Epidemiology. Hoarseness occurs in 10% to 50% of intubated patients, mostly mild. Structural injury is found on laryngoscopy in 5% to 10%. Vocal cord paralysis is rare (about 1 in 1,000 or less). Female sex, long intubation, large tubes and difficult intubation raise the risk.

Mechanisms. Direct trauma from laryngoscope blade or tube, cuff pressure on the posterior cord, traction on the recurrent laryngeal nerve branch, and ulceration from prolonged intubation.

Pathophysiology.

Pressure and shear injure the mucosa and underlying muscle. Posterior glottic ulcers form granulomas. Paralysis follows cuff compression of the anterior branch of the recurrent laryngeal nerve against the thyroid cartilage.

Hoarseness, weak or breathy voice, pain on phonation, throat pain, cough, aspiration with swallowing, stridor (bilateral paralysis) and dysphagia.

Red flags.

• Stridor.
• Aspiration.
• Hoarseness lasting over 2 weeks.
• Haemoptysis.

Flexible nasendoscopy or videolaryngoscopy assesses cord movement, haematoma, ulcer, granuloma and arytenoid position. Stroboscopy for mucosal wave. Laryngeal electromyography at 4 to 6 weeks if paralysis persists. CT neck if mass or fracture is suspected.

Differential diagnosis.

• Arytenoid dislocation.
• Laryngeal oedema.
• Recurrent laryngeal nerve injury from surgery.
• Pre-existing cord lesion.
• Reflux laryngitis.
• Tumour.

Most injuries recover. Offer voice rest for 1 to 2 weeks, hydration, and avoidance of throat clearing and smoking. Speech therapy supports recovery.

• Omeprazole: 20 to 40 mg orally once daily for 4 to 8 weeks when reflux contributes; maximum 40 mg daily; monitor symptoms; reduce in severe hepatic impairment.
• Prednisolone: 30 to 40 mg orally once daily for 5 to 7 days for acute haematoma or oedema with voice loss; maximum 60 mg daily; monitor glucose and blood pressure; avoid in uncontrolled infection.

Surgical options by ENT: microlaryngoscopy for haematoma drainage or granuloma excision, injection laryngoplasty (temporary filler) for unilateral paralysis with aspiration or poor voice, and medialisation thyroplasty or tracheostomy for bilateral paralysis with stridor.

Monitoring. Voice and swallow assessment at 2 weeks and 6 weeks.

Referral and escalation. ENT review within 2 weeks for persisting hoarseness, urgently for stridor, aspiration or suspected paralysis. Document the injury and inform the patient.

Special groups. Professional voice users need early laryngology review.