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STUDENTS CORNER
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 32-33

Vocal cord granuloma and voice change following tracheal intubation in an actor


Department of Anaesthesia, Royal Free Hospital, London, United Kingdom

Date of Web Publication24-Sep-2013

Correspondence Address:
Ramanathan Kasivisvanathan
Department of Anaesthesia, Level 3, Royal Free Hospital, Pond Street, London NW3 2QG
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-9748.118731

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   Abstract 

This is a clinical report highlighting a vocal cord granuloma, a rare complication of short-term tracheal intubation, as a cause for persisting voice change and hoarseness in a 42-year male actor. The etiology and treatment for vocal cord granulomas are briefly discussed.

Keywords: Hoarseness, intubation, vocal cord granuloma, voice


How to cite this article:
Kasivisvanathan R, McGlennan A. Vocal cord granuloma and voice change following tracheal intubation in an actor. J Laryngol Voice 2013;3:32-3

How to cite this URL:
Kasivisvanathan R, McGlennan A. Vocal cord granuloma and voice change following tracheal intubation in an actor. J Laryngol Voice [serial online] 2013 [cited 2021 May 11];3:32-3. Available from: https://www.laryngologyandvoice.org/text.asp?2013/3/1/32/118731

A 42-year male actor, weight 82 kg, height 1.80 m, was referred to an otolaryngologist at our institution with a 3-month history of voice change. Over this period, his voice had become increasingly hoarse and progressively deeper to the point he was unable to audition for acting roles and thus sustain employment. The patient was a lifelong nonsmoker and during this period had no symptoms suggestive of upper respiratory tract infection, gastroesophageal reflux, or malignancy. He first noticed a change in his voice a few days after a general anesthetic for a laparoscopic cholecystectomy experiencing mild hoarseness. Review of the patient's anesthetic record revealed he had been a Cormack-Lehane grade 2 view and was intubated with an 8-mL internal diameter tracheal tube using a gum elastic bougie. A nasogastric tube was also inserted at the time of induction.

Examination of his glottis with a flexible fibreoptic laryngoscope revealed a 9 mm polypoid supraglottic granuloma of his right vocal fold [Figure 1]. In the absence of any other pathology, the otolaryngologist attributed the granuloma to be the cause of the change in his voice, postulating that trauma to his glottis during intubation was likely to have caused it.
Figure 1: Flexible fibreoptic laryngoscopy showing the vocal cord granuloma

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The patient opted to be treated conservatively and eliminated food that could cause gastroesophageal reflux, avoided caffeine, and worked with a speech therapist to improve vocal function. At repeat assessment after 2 months, the patient's voice had returned to what he perceived to be normal with no further symptoms of hoarseness, repeat fiberoptic examination showed almost complete resolution of the lesion.

Voice change following general anesthesia and tracheal intubation is common but usually resolves within 3 months. [1] Changes persisting for longer then this period should alert the physician to seek an alternate cause especially in those who rely on their voice for employment. There are only a few reports of vocal cord granulomas after short-term intubation and in these cases patients also had persisting voice change and hoarseness. [2] Vocal cord granulomas are benign lesions of the larynx usually occurring from irritation of laryngeal structures on the vocal process of the arytenoid cartilage, where the mucosal covering is a thin layer of stratified squamous epithelium. This thin layer of epithelium is susceptible to being crushed between any object (e.g., an tracheal tube or nasogastric tube) inserted into the glottis and the cartilage beneath it, leading to an inflammatory process and benign granuloma development. [3] They are more likely to occur if intubation has been difficult; with larger tracheal tubes, with the use of nitrous oxide, and when tracheal tube cuff pressures are raised. [4] In most instances, conservative treatment involving lifestyle changes, cessation of smoking, speech therapy, and proton pump inhibitor therapy resolves most symptoms with gradual disappearance of the granuloma in 3-6 months. [4] Sometimes, however, the granulomas can be slow to regress and symptoms persist; in these instances, more invasive management including botulinum toxin type A injections or surgery may be required.

This case highlights that although vocal cord granulomas are uncommon complications of tracheal intubation they should be considered as a cause of persisting voice change or hoarseness in those who have undergone even short-term intubation.



 
   References Top

1.Jones MW, Catling S, Evans E, Green DH, Green JR. Hoarseness after tracheal intubation. Anaesthesia 1992;47:213-6.  Back to cited text no. 1
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2.Kaneda N, Goto R, Ishijima S, Kawakami S, Park K, Shima Y. Laryngeal granuloma caused by short-term endotracheal intubation. Anesthesiology 1999;90:1482-3.  Back to cited text no. 2
[PUBMED]    
3.Devaney KO, Rinaldo A, Ferlito A. Vocal process granuloma of the larynx-recognition, differential diagnosis and treatment. Oral Oncol 2005;41:666-9.  Back to cited text no. 3
[PUBMED]    
4.Ward PH, Zwitman D, Hanson D, Berci G. Contact ulcers and granulomas of the larynx: New insights into their etiology as a basis for more rational treatment. Otolaryngol Head Neck Surg (1979) 1980;88:262-9.  Back to cited text no. 4
    


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