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Korean J Anesthesiol 2013 December 65(6 Suppl): S147-S148 http://dx.doi.org/10.4097/kjae.2013.65.6S.S147 Endotracheal intubation-related vocal cord ulcer fol owing Choon-Kyu Cho1, Jae-Jung Kim1, Tae-Yun Sung1, Sung-Mee Jung2, and Po-Soon Kang1 Department of Anesthesiology and Pain Medicine, 1Konyang University Hospital, Konyang University Col ege of Medicine, Daejeon, 2Yeungnam University Medical Center, Yeungnam University Col ege of Medicine, Daegu, Korea Post-intubation throat pain is a common complaint that pain during the hospitalization period. However, the attending is caused by focal ischemia, damage to the laryngeal mucosa, physician and nurse overlooked his complaints because throat or edema. However, if the laryngeal symptoms persist after 72 pain was considered to be a normal side effect of intubation. h, vocal cord paralysis, the formation of granulation tissue, or He was therefore discharged 4 days after the operation without ulcers can occur [1]. Most vocal cord ulcers that are caused by any further examination. The day after discharge, the patient intubation are found after progression to granuloma. However, was concerned that his sore throat persisted, unlike his previous we recently observed a patient in whom the ulcer was detected experience with general anesthesia and intubation, and visited an before progression, and was successful y treated with conserva- otolaryngology outpatient clinic. Laryngeal endoscopic examina- tion showed an ulcer in the posterior of the vocal cord (Fig. 1A). A 39-year-old male (167 cm, 66 kg) was scheduled for elec- Prednisolone (5 mg, BID) and esomeprazole (40 mg, QD) were tive Guyon’s tunnel release surgery. The patient had no signifi- prescribed, and voice rest was recommended. His sore throat cant medical history, except for septoplasty surgery 6 years ago improved after 1 week, and laryngoscope examination revealed using general anesthesia with endotracheal intubation. Pre- partial cure of the vocal cord ulcer (Fig. 1B). After subsequent operatively, he exhibited no laryngopharyngeal symptoms such visits, the ulcer had completely healed without progressing to as sore throat, hoarseness, or stridor. Anesthesia was induced using 130 mg propofol, and endotracheal intubation was per- Vocal cord ulcers are non-neoplastic lesions of the posterior formed with 35 mg rocuronium. An endotracheal tube with an glottis, and represent an early stage in the progression of vocal internal diameter of 8.0 mm, and a high volume/low pressure cord granulomas [2]. General y, vocal cord ulcers occur due to cuff was used. Laryngoscopy was performed using a standard 3 mechanical or chemical damage, such as the overuse of voice, Macintosh metal blade, a stylet, and external laryngeal pressure, chronic coughing, throat clearing, or gastroesophageal reflux and was characterized as Cormack-Lehane laryngoscopy grade disease [3]. The common symptoms of vocal cord ulcers and III. There was slight friction when going through the vocal cord granulomas are throat pain, hoarseness, and coughing [4]. during intubation, but the process was otherwise successful. The The causes of vocal cord ulcers related to endotracheal intu- duration of intubation was 65 min, and anesthesia was com- bation are vocal cord mucosa damage during intubation and ex- pleted without any specific hemodynamic instability. Emergence tubation, clasping movements between the vocal cords and the was smooth, and extubation was completed without any cough- tube, continuous pressure of the tube during anesthesia, use of a tube that is too large, or infection. During endotracheal intuba- After surgery, the patient persistently complained of throat tion, inflammation can occur on the mucous membrane of the Corresponding author: Tae-Yun Sung, M.D., Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Konyang University College of Medicine, 685, Gasoowon-dong, Seo-gu, Daejeon 143-701, Korea. Tel: 82-42-600-9316, Fax: 82-42-545-2132, E-mail: unt1231@naver.com CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright ⓒ the Korean Society of Anesthesiologists, 2013 Fig. 1. (A) Five days after surgery, a vocal
Twelve days after surgery, the vocal cord ulcer had decreased in size after medical vocal process area of arytenoid cartilage, and its severity tends to the ulcer has progressed to granuloma, it may lead to aspiration increase with longer intubation times or increased pressure [5].
and respiratory distress, and so long-term treatment or even In the current case, the duration of intubation was short, and surgical excision may be required [1,4]. there was little or no movement of the head and neck during the To prevent post-intubation vocal cord ulcers from occurring, surgery or extubation. It is therefore likely that the vocal cord using an appropriately sized tube, adequate sedation and muscle ulcer was caused by friction with the tube during intubation, relaxation, performing smooth intubation, stabilization of the damaging the vocal cord mucosa. It is also possible that the en- tube, and extubation without laryngeal reflexes are recommend- dotracheal tube used was too large, or that the pressure exerted by the external cricoids led to backward and lateral tilt, making In conclusion, anesthesiologists should recognize that vocal the vocal process more prominent and vulnerable to injury [5]. cord ulcers could occur as a complication of intubation fol ow- Most vocal cord ulcers can be cured with conservative treat- ing endotracheal anesthesia. Persistent post-operative laryngo- ment such as voice therapy, or medical interventions including pharyngeal symptoms should not be overlooked, and appropri- steroids, antibiotics, proton pump inhibitors, or histamine-2 ate examinations wil help identify complications, such as ulcers, receptor blockers. However, if the cause of ulcer is iatrogenic or References
1. Hamdan AL, Sabra O, Rameh C, El-Khatib M. Persistent dysphonia fol owing endotracheal intubation. Middle East J Anesthesiol 2007; 19: 2. Hoffman HT, Overholt E, Karnel M, McCul och TM. Vocal process granuloma. Head Neck 2001; 23: 1061-74.
3. Cummings CW, Flint PW, Haughey BH, Lund VJ, Niparko JK, Richardson MA. Cummings Otolaryngology - Head and Neck Surgery. 5th ed. Philadelphia, Mosby-Elsevier. 2010, pp 874-6.
4. Emami AJ, Morrison M, Rammage L, Bosch D. Treatment of laryngeal contact ulcers and granuloma: a 12-year retrospective analysis. J 5. Elsamma YE, Mossal am I, Habeed AY, el-Khodary AF. Laryngeal intubation granuloma. J Laryngol Otol 1971; 85: 939-46.

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