Intubation Granuloma

Laryngeal Granulomatous Polyp after Short-term Intubation of a Child

It is well known that prolonged endotracheal intubation may result in formation of laryngeal granulomata. It is rare to find such lesions following short-term intubation. Furthermore, the virtual absence of such granulomata in children has been attributed to certain characteristics of the pediatric larynx. We report a 7-year-old child who developed a laryngeal granulomatous polyp following endotracheal intubation for less than 12 hours. A discussion of the incidence, pathogenesis, and treatment of this and other postintubation laryngeal lesions follows.

Anesthesia care for the professional singer

The professional singer comes to the day of surgery with a measure of anxiety about the effects of anesthesia or surgery on his or her voice. A detailed informed consent should be obtained to discuss and document risks, as well as set realistic expectations for recovery. The smallest endotracheal tube possible should be used to intubate in the least traumatic way. Movement of the tube should be minimized, both during anesthesia, as well as in emergence. Postoperative care may be coordinated with an otolaryngologist and speech language pathologist as the singer plans a return to performance.

Retrospective analysis of the clinical course for intubation vs. unspecified laryngeal granulomas

Intubation laryngeal granulomas (ILGs) are a well-known complication of endotracheal intubation. Cases other than ILGs can be categorized as unspecified laryngeal granulomas (ULGs) since their etiologies are often difficult to confirm. We intended to clarify clinical features of both ILGs and ULGs and that anticoagulant medication could cause the formation and delayed healing of ILGs in terms of wound-healing delay. We compared the results of our treatment of ILGs (n = 16) and ULGs (n = 47) treated between 1998 and 2009 to characterize these patients. The clinical course, treatment (medical vs. surgical), indications for surgical resection, treatment outcome, and use of anticoagulants for preexisting disease were reviewed and compared between these two groups. The resolution rate was significantly better in ILGs (p < .05). Five ILGs and seven ULGs were surgically resected. The main reason for resection was airway obstruction and the need for histological assessment, respectively. The use of anticoagulants was significantly higher in ILGs than ULGs (8/16 vs. 4/47, p < .01). The resolution period was significantly longer in the ILGs patients with anticoagulant medication compared to that in the ILGs patients without anticoagulant medication (152 ± 101 days vs. 76 ± 44 days, p < .05). ILGs may have different clinical course from ULGs, especially in terms of the resolution period. Moreover, administration of anticoagulants may deter healing of small injury due to intubation. Patients taking anticoagulants should be managed carefully during the perioperative period to prevent the occurrence of ILGs.

The roles of transforming growth factor-β₁ and vascular endothelial growth factor in the tracheal granulation formation

BACKGROUND

Acquired tracheal stenosis is common in patients with a long-term tracheostomy and granulation is one of the most commonly observed lesions in benign airway stenosis. The aim of this study was to investigate the mechanisms of tracheal granulation formation and find the potential therapeutic targets to prevent the granulation formation.

RESULTS

In granulation tissue obtained from patients during interventional bronchoscopy for the relief of airway obstruction, increased expression of transforming growth factor (TGF)-β₁ and vascular endothelial growth factor (VEGF), as well as increased numbers of fibroblasts, was found by immunohistochemical staining. TGF-β₁ expression was detected in both the epithelial and submucosal layers. The highest levels of VEGF and vimentin expression occurred in the submucosal layers. In comparison with the control, significantly increased numbers of small vessels were observed in the submucosal layers of the granulation tissue. In vitro, TGF-β₁ stimulated production of VEGF by cultured fibroblasts at both the mRNA and protein level. VEGF siRNA treatment resulted in a significant decrease of TGF-β₁-induced VEGF production. SIS3, a selective Smad3 inhibitor, and UO126 both inhibited p44/42 MAP kinase phosphorylation and attenuated subsequent VEGF production by fibroblasts. A low concentration of erythromycin (1 μg/ml), but not dexamethasone (100 μM), inhibited TGF-β₁-induced VEGF production.

CONCLUSION

This study provides important information that facilitates an understanding, at least in part, of the mechanisms of granulation formation. Targeting these mediators and cells may help to prevent the formation of granulation tissue in long-term tracheostomy or prolonged endotracheal intubation patients.

Short-term effects of endotracheal intubation on voice

The objective of this study was to examine the vocal symptoms and acoustic changes perceived in the short period after endotracheal intubation, and to find the association between these changes and the endotracheal tube parameters. A total of 35 subjects were included. They were examined preoperatively, and 2 and 24 hours postoperatively. The vocal symptoms of hoarseness, vocal fatigue, loss of voice, throat clearing, globus pharyngeus, throat pain, and the acoustic variables mainly average fundamental frequency, relative average perturbation, shimmer, noise to harmony ratio, voice turbulence index, habitual pitch, and maximum phonation time (MPT) were assessed as such and in relation to the following endotracheal tube parameters: duration of anesthesia, number of intubation attempts, size of the tube, cuff volume, cuff mean pressure, and the emergence. The association between anesthesia parameters with incidence of vocal complaints and changes in acoustic parameters were examined using logistic and linear regression. Vocal fatigue was associated significantly with the increase in cuff volume and the number of intubation attempts. Throat clearing was associated significantly with the increase in cuff mean pressure. Only the increase in habitual pitch was associated significantly with the increase in cuff volume. The acute short-term effect of endotracheal intubation on voice is significant. The most important endotracheal tube parameters that affect the vocal changes are the cuff mean pressure and volume. The laryngeal contribution to these vocal changes seems to be minimal. All vocal symptoms increased significantly except for globus pharyngeus at 2 hours postoperatively. The acoustic parameters did not change significantly except for a decrease in MPT. At 24 hours postoperatively, all vocal symptoms subsided with no significant difference to baseline value. The habitual pitch increased significantly, and the rest of the parameters remained comparable to baseline value.

Immediate post-operative vocal changes in patients using laryngeal mask airway versus endotracheal tube

Objective and hypothesis:

(1) To examine the vocal symptoms and acoustic changes perceived in the short period immediately after laryngeal mask airway, and (2) to compare these findings in patients using laryngeal mask airway and endotracheal tube.

Materials and methods:

A total of 27 patients were enrolled. They were evaluated pre-operatively and then at 2 and 24 hours post-operatively. Patients were divided into two subgroups, laryngeal mask airway and endotracheal tube. Patients were asked about the presence or absence of the following: hoarseness, vocal fatigue, loss of voice, throat-clearing sensation, globus pharyngeus and throat pain. Patients then underwent acoustic analysis of their voice, measuring the average fundamental frequency, relative average perturbation, shimmer, noise to harmony ratio, voice turbulence index, habitual pitch and maximum phonation time.

Results:

In the laryngeal mask airway group, there was an increase in the incidence of all vocal symptoms two hours post-operatively, except for globus pharyngeus. The increase was statistically significant for vocal fatigue, loss of voice and throat pain. All the symptoms had reverted back to a normal baseline level by 24 hours. There was a decrease in the maximum phonation time and habitual pitch, with an increase in all the perturbation parameters, two hours post-operatively. At 24 hours, an increase was still present for shimmer, noise to harmony ratio and voice turbulence index. The maximum phonation time and habitual pitch reverted back to normal values.

In the endotracheal tube group, there was a significant increase two hours post-operatively in the incidence of hoarseness, loss of voice and throat pain. At 24 hours, all the symptoms reverted to baseline, except for vocal fatigue and throat pain. Two hours post-operatively, there was a significant decrease in maximum phonation time and an increase in all other parameters (however, the latter was significant only for relative average perturbation and noise to harmony ratio). At 24 hours, there was a significant increase in the maximum phonation time and a persistent (but statistically insignificant) increase in the average fundamental frequency, habitual pitch, noise to harmony ratio and voice turbulence index.

At two hours, there was more loss of voice and vocal fatigue in the laryngeal mask airway group, compared with the endotracheal tube group. At 24 hours, these symptoms were comparable in both groups. Comparing changes in acoustic parameters to baseline values in both groups, there were no statistically significant changes.

Conclusion:

Shortly after reversal of anaesthesia, laryngeal symptoms following laryngeal mask airway are no less significant than those experienced following endotracheal tube anaesthesia. Both methods can be regarded as nontraumatic, in view of the lack of significant vocal symptoms and acoustic changes 24 hours after anaesthesia.

Long-term complications of artificial airways

In summary, long-term complications of artificial airways are rare but important sequelae of artificial airways. Many of the potential long-term complications of translaryngeal intubation and tracheotomy are similar and overlapping. Although most patients who undergo these procedures tend to tolerate them without difficulties, significant morbidity and mortality may occur. Identifying the exact cause of the complication may not be possible at times, due to the multiple risk factors involved in the pathogenesis. It is hoped that understanding these potential complications will lead to a more vigilant preventive measures during the institution of long-term artificial airways and a judicious early search for the underlying pathology when a complication is suspected.

Lesões crônicas da laringe pela intubação traqueal

Introdução: Várias complicações, muitas vezes graves, têm sido relacionadas com a intubação traqueal (IT), com incidência chegando a 18%. Objetivos: Analisar as alterações da laringe provocadas pela IT: o desenvolvimento de estenose e de granuloma na laringe e a evolução da voz. Pacientes e métodos: Foram estudados prospectivamente 73 pacientes internados na Unidade de Terapia Intensiva do Hospital Cajuru, da Pontifícia Universidade Católica do Paraná, na região Sul do Brasil, submetidos a IT por cinco dias consecutivos e com previsão de necessidade de IT por mais sete dias, que foram traqueostomizados no sexto dia de IT. Foi realizada fibrolaringotraqueobroncoscopia (FLTB) nos 6º, 14º, 21º, 28º, 60º, 90º e no 180º dias após a IT. Resultados: No 180º dia do estudo havia 30 pacientes sobreviventes: 18 apresentavam voz normal, nove não puderam ser avaliados e três apresentavam disfonia. Em oito pacientes foram observados granulomas na laringe, sendo que cinco foram curados espontaneamente, dois foram ressecados e um permaneceu no 180º dia do estudo. Apenas um paciente apresentou estenose de laringe. Conclusões: Devido ao menor tempo de exposição da laringe ao trauma da cânula orotraqueal, a realização da traqueostomia no 6º dia da IT parece causar poucas complicações.

Topical inhalant steroid (budesonide, Pulmicort nasal) therapy in intubation granuloma

Intubation granuloma of the larynx is an iatrogenic disease which is induced by endotracheal intubation. It has basically been managed by conservative medical treatment with observation. Surgical excision can be considered as a last resort due to the high recurrence rate which subjects the patients to repeated anaesthesia. The purpose of this study is to evaluate the therapeutic effect of topical steroid in intubation granuloma, comparing the results of conservative medical treatment with, or without, surgery (Group I, 14 patients) and inhalant therapy with topical budesonide (Group II, 20 patients). In Group I, complete disappearance of granuloma occurred in six cases within a year (42.8 per cent) with conservative therapy only. Microlaryngeal surgery was performed on the eight cases of persisting granuloma after conservative therapy for a year, resulting in two cases of recurrence. In Group II, the granuloma disappeared completely in 85 per cent within six months and in 95 per cent within 12 months without any remarkable side-effects. We concluded that intubation granuloma of the larynx could be treated with topical inhalant steroid as the first choice of therapy rather than other medical treatment or surgical intervention.

Laryngeal injuries after short- versus long-term intubation

Forty-five patients were seen over a 5-year period with laryngeal injuries following endotracheal intubation (ETI). The mean duration of ETI was 5.6 days (2 hours to 37 days). Patients intubated for less than 24 hours were most likely to present with a vocal fold immobility or an anterior glottic web. Long-term intubation was associated with the development of subglottic stenoses and granulomas. Patients with vocal fold immobility were seen more often after ETI for surgical reasons and had a significantly higher incidence of previous intubation and tobacco usage. Subglottic stenoses were seen in younger patients intubated for medical reasons and associated with nasogastric tubes and longer periods of intubation.

The vocal athlete and endotracheal intubation: a management protocol

Endotracheal intubation is associated with significant laryngeal sequelae that range in severity from mild hoarseness to life-threatening tracheal stenosis. Although the most severe trauma appears to be related to prolonged intubation, even short-term intubation (< 1 day) can adversely affect laryngeal and vocal function. Concern is warranted for all intubated patients, but particularly for the vocal athlete whose livelihood and identity depend on optimal vocal function. It is proposed that the vocal athlete faced with endotracheal intubation risk warrants careful multidisciplinary management. A number of intubation risk factors have been identified in the literature; however, clinical management of vocal athletes who undergo intubation has not been addressed. In medical settings where adverse intubation outcomes can lead to litigation, this clinical management protocol is expected to improve the probability of favorable voice outcome following endotracheal intubation.

Excision and low-dose radiotherapy for refractory laryngeal granuloma

Laryngeal granulomas are uncommon lesions of an inflammatory origin. They are conventionally managed by simple excision with the occasional use of adjuvant treatment depending on the aetiological factors. Unfortunately, recurrences can occur, requiring repeated excision. Some lesions are refractory to this approach and alternative management approaches include excision and immediate adjuvant radiotherapy. The use of radiotherapy in the management of benign disease can be limited by the risk of induction of late malignancy and informed consent of a patient must include an assessment of this risk. We describe a case of refractory laryngeal granuloma successfully treated by excision and immediate radiotherapy in a patient occupationally dependent upon his voice.

Postextubation laryngeal edema in adults. Risk factor evaluation and prevention by hydrocortisone

OBJECTIVE

To evaluate the risk factors for postextubation laryngeal stridor and its prevention by hydrocortisone in adult patients.

DESIGN

Prospective, randomized, double-blind, placebo controlled study.

SETTING

Medical and surgical ICU of a tertiary teaching hospital.

PATIENTS

77 consecutive patients of both sexes, who had undergone tracheal intubation for more than 24 h and fulfilled the weaning criteria, were eligible for the study. Patients were excluded if they were less than 15 years of age, had a disease or the surgery of the throat, or had been extubated during the current hospitalization.

INTERVENTION

The control group received placebo (normal saline 3 cc) and the experimental group received hydrocortisone 100 mg by intravenous infusion 60 min before extubation.

MAIN OUTCOME MEASURES

Patients were observed 24 h after extubation for symptoms or signs of laryngeal edema or stridor: prolonged inspiration with accessory usage of respiratory muscles or crowing sound with inspiration or reintubation.

RESULTS

The overall incidence of postextubation stridor was 22% (17/77). Only one patient (1%), who belonged to the control group, needed reintubation. 39% of female patients and 17% of male patients developed stridor. The relative risk of females developing this complication was 2.29. 7/39 of the hydrocortisone group and 10/38 of patients in the control group developed postextubation stridor.

CONCLUSIONS

Hydrocortisone did not significantly reduce the incidence of postextubation laryngeal edema or stridor. From the risk factors evaluated, we were unable to demonstrate a statistical correlation between postextubation stidor and the duration of the intubation, the patient's age, the internal diameter of the endotracheal tube, or the route of intubation. However, female patients were more likely to develop this complication.

Histopathologic fundamentals of acquired laryngeal stenosis

Acquired laryngeal stenosis is the most serious long-term complication of endotracheal intubation in children. Employing the whole-organ serial section technique, the sequence of histopathologic changes leading to stenosis was studied. Ulceration occurs when an endotracheal tube causes mechanical abrasion and/or induces pressure necrosis on the laryngeal mucosa. Secondary healing of ulceration produces granulation tissue and subsequent fibrous scar tissue. Most exuberant granulation tissue resolves without sequelae, but some becomes firm, almost avascular fibrous scar tissue. The accumulation of submucosal fibrous tissue may decrease the size of the glottic or subglottic lumen. Contraction of scar tissue causes a distortion of glottic and subglottic laryngeal complex, leaving a reduced and irregularly shaped glottic and subglottic lumen. Submucosal mucous gland hyperplasia directly reduces the inner diameter of the airway. Finally, compromise of the laryngeal lumen may occur when the duct of a mucous gland is obstructed by scarring resulting from intubation: mucus accumulates in the dilated duct, producing a ductal cyst.

Post intubation laryngeal sequelae in an intensive care unit

The incidence, severity and pattern of post-intubation laryngotracheal sequelae in a 12 bed multidisciplinary intensive care unit (ICU) were assessed in this prospective study. One-hundred and fifty consecutive patients requiring intubation for more than 24 hours for various indications were studied. Evaluation of the larynx and trachea was done using a fibreoptic bronchoscope introduced through the endotracheal tube prior to elective extubation. Rigid bronchoscopy and direct laryngoscopy were performed in very small children and adults requiring tracheostomy. One-hundred and thirty-one (87.6 per cent) patients had visible laryngeal pathology in the immediate post-extubation period. Thirteen (8.6 per cent) had long term sequelae. A high incidence of long term sequelae was noted in patients with seizures (25 per cent) followed by patients with head injury (19 per cent). Steroid therapy failed to offer any significant protection but resulted in doubling of pulmonary sepsis. A grading system was adopted to classify acute laryngotracheal injury and a significant correlation was found between the presence of slough in the immediate post-extubation period and subsequent development of long term sequelae. There was also a significant correlation between a deeper insertion of the endotracheal tube and development subsequently of long term sequelae. The significance of these findings is discussed.

Vocal process granulomata

The case records and histology of 34 patients with vocal process granulomata were reviewed. The five patients presenting most recently with idiopathic vocal process granulomata were investigated by axial computerized tomography (CT). Increased density of the arytenoid cartilage on the side of the lesion was found in all five cases. It is suggested that this indicates cartilage ossification, secondary to perichondritis. This perichondritis, playing either a primary or a secondary role in granuloma development, may explain the annoying tendency of vocal fold granulomata to recur after excision.

Intubation granuloma of the larynx: successful eradication with low-dose radiotherapy

Postintubation granuloma of the larynx is a well recognized entity, which has accompanied the increased use of endotracheal intubation for general anesthesia. Voice rest, corticosteroids, antibiotics, antacids, and surgical removal are generally accepted conventional therapies, although select cases are fraught with a high rate of recurrence. We recently evaluated a patient who had undergone 6 surgical excisions of a postintubation laryngeal granuloma during a 5-month interval. The larynx was treated with 1,200 cGy photon irradiation during a 4-day period, and there has been no granuloma recurrence in 36 months of follow-up. The rationale and selection criteria for patients who might benefit from low-dose radiotherapy for recurrent laryngeal granulomas are discussed.

Diagnosis of tracheal injury in mechanically ventilated premature infants by flexible bronchoscopy. A pilot study

Flexible bronchoscopy (FB) is uniquely suited for the study of large airway lesions in the ventilated premature infant. However, no standardized clinical scoring system of distal tracheal injury exists and the adverse consequences of FB in ventilated premature infants are not well described. Using a prototype Olympus fiberoptic ultrathin bronchoscope with a directable tip and an outer diameter of 2.2 mm, we serially scored distal tracheal injury in conventionally ventilated premature infants on the basis of mucosal and obstructive changes observed at bronchoscopy. In addition, we prospectively evaluated the incidence of adverse cardiovascular and pulmonary effects during, immediately after, and within 1 h of FB. We performed 21 FBs in eight conventionally ventilated premature infants with birth weight of 1,239 +/- 438 g and gestational age of 30 +/- 3 weeks. The carina and mainstem bronchi were easily visualized in all infants using the prototype bronchoscope. During the first several days of life, moderate-to-severe distal tracheal mucosal injury occurred frequently, while moderate-to-severe obstructive injury occurred infrequently. Distal mucosal injury appeared to improve during the fourth week of life. Mild distal obstructive injury began to appear during the second week of life. Adverse consequences of FB observed in our patient population included transient hypoxemia and bradycardia during FB, changes in systolic blood pressure immediately and within 1 h after FB, and emesis immediately after FB. Serious adverse cardiovascular or pulmonary effects were not observed. We conclude that FB can be performed safely with appropriate monitoring and is a useful tool in the clinical assessment and serial evaluation of distal tracheal injury in ventilated premature infants. We speculate that moderate-to-severe distal tracheal mucosal injury may be associated with the development of later obstructive injury. On the basis of this preliminary study, further prospective investigations of tracheal injury in ventilated premature infants appear to be warranted.

Acoustical effects of endotracheal intubation

Certain acoustical consequences of endotracheal intubation were examined in 13 male cardiovascular-surgery patients. Each subject recorded three tokens of a sustained vowel 1 day before intubation, 1 day after, upon discharge, and during a follow-up visit. Eight acoustical measures were obtained from the audio-recorded vowels: (a) mean fundamental frequency (Fo), (b) Fo standard deviation, (c) Fo perturbation quotient, (d) mean sound pressure level (SPL), (e) SPL standard deviation, (f) SPL perturbation quotient, (g) spectral flatness of the residue signal, and (h) coefficient of excess. Mean Fo, Fo standard deviation, mean SPL, SPL standard deviation, and coefficient of excess did not differ significantly across recording sessions, although certain predictable trends were apparent. Fo perturbation quotient, SPL perturbation quotient, and spectral flatness of the residue signal varied significantly across sessions, implying that these acoustical measures may be useful in the identification and monitoring of even minor intubation-related laryngeal trauma.

Bedside videolaryngoscopic assessment of intubation trauma

Telescopic laryngoscopic examination was performed at the bedside after extubation in 29 consecutive surgical intensive care unit patients who required endotracheal intubation for more than 16 hours. The examinations were documented with a portable video recording system. The majority of patients exhibited evidence of acute endolaryngeal trauma. Vocal fold ulceration and vocal fold motion abnormalities were the most common lesions. Patients with abnormal larynges were followed up after discharge from the intensive care unit. Most of the identified injuries resolved without intervention. However, silent aspiration was identified frequently in patients with vocal fold paresis and was thought to be a significant factor in postoperative pulmonary complications. Early identification of significant laryngeal trauma and/or vocal fold paresis in critically ill patients is important for both postoperative pulmonary care and voice rehabilitation. This pilot study demonstrated that documentation of the laryngeal examination is feasible in critically ill patients in an intensive care unit setting.

Postintubation granuloma of the anterior subglottic larynx

We present an unusual case of a granuloma in the subglottic laryngeal airway of a 6-week-old infant with a history of previous endotracheal intubation. Postintubation granuloma formation in this region has not been previously reported in infants.