Severe hoarseness associated with the streamlined liner of the pharyngeal airway (SLIPATM)

Incidence and Risk Factors of Arytenoid Dislocation Following Endotracheal Intubation: A Systematic Review and Meta-Analysis

Endotracheal intubation carries risks, including arytenoid dislocation (AD), a rare but severe complication. Due to small sample sizes, the incidence of AD varies considerably among studies. Proposed risk factors for AD include difficult intubation, prolonged intubation, certain surgeries, patient positioning, female sex, and BMI. This review aims to investigate the incidence of AD and explore the various predisposing risk factors. We retrieved relevant studies up to April 2024 from PubMed, Scopus, Web of Science, and the Cochrane Library. Using OpenMeta v5.26.14 software (Institute for Clinical Research and Health Policy Studies at Tufts Medical Center, Boston, USA), we pooled AD incidence rates from individual studies. Other outcomes, reported in fewer studies and thus not suitable for meta-analysis, were synthesized manually. Study selection yielded 16 eligible articles. A random-effects model analysis of nine studies found a significant AD incidence rate of 0.093% (confidence interval (CI): 0.045% to 0.14%), but the results were highly heterogeneous (I2 = 91%). Older age was associated with prolonged hoarseness, while younger age and female sex increased the risk of AD. Additionally, AD risk factors included taller stature, higher BMI, specific surgeries, esophageal instrumentation, prolonged procedure durations, head-neck movement, and inexperienced intubators. However, intubation with a stylet reduced the AD risk. AD post-endotracheal intubation is rare (incidence: 0.09%), with potential underdiagnosis in larger datasets. Many risk factors may contribute to the condition, but the small number of studies per risk factor limits the ability to draw robust conclusions. Subjective diagnoses and retrospective studies further restrict comprehensive understanding. Further research is needed to explore AD risk factors effectively.

[Clinical outcomes of vocal fold immobility after tracheal intubation]

OBJECTIVE

To assess the incidence of postoperative vocal cord immobility in patients following endotracheal intubation underwent general anesthesia.

METHODS

We retrospectively enrolled patients who underwent surgical procedures with endotracheal intubation under general anesthesia from January 2014 to December 2018 in Peking University First Hospital. Demographic and treatment data were obtained for patients with hoarseness and vocal cord fixation. The incidence of postoperative hoarseness and vocal cord fixation were presented and clinical outcomes were further analyzed.

RESULTS

A total of 85 998 patients following tracheal intubation and general anesthesia were enrolled in this study. Hoarseness was observed in 222 (0.26%) patients postoperatively. Sixteen patients (73%) were accomplished with symptoms of choking on water, dysphonia and sore throat. Twenty-nine patients with persistent hoarseness on the third postoperative day needed further treatment by otolaryngologists. Among them, seven patients had pharyngolaryngitis and twenty-two patients (0.026%) were demonstrated postoperative vocal cord immobility. There were seventeen patients (77%) with left-side vocal cord fixation and five patients (23%) with right-side vocal cord fixation. Nine patients were identified with arytenoid dislocation. Seven patients had left vocal cord fixation and two patients had right-side vocal cord fixation. Seven patients were intubated under the guidance of visual laryngoscope. One patient was confirmed difficult airway and intubated with light wand. One patient was inserted with laryngeal mask airway. One patient was suspected to have hoarseness caused by gastric tube before anesthesia. One patient showed simultaneously left recurrent laryngeal nerve abnormality on laryngeal electromyography result. The symptom of hoarseness ranged between 6 and 31 days. Three patients underwent closed reduction under local anesthesia and one patient demonstrated spontaneous recovery. Among the remaining thirteen patients with vocal cord immobility, two patients were demonstrated vocal cord paralysis. Eleven patients underwent neck surgery, thyroid surgery and cardiothoracic surgery and further examinations including laryn-geal electromyography and computed tomography help to determine the diagnosis were not performed. All patients were treated with inhaled corticosteroid conservatively. Five patients had significant improvement of symptom and almost regained normal voice. One patient had slight improvement and sixteen patients were not relieved before discharge.

CONCLUSION

Patients with hoarseness and vocal fold immobility after endotracheal intubation should be treated properly and immediately.

Complications Associated with the Use of Supraglottic Airway Devices in Perioperative Medicine

Supraglottic airway devices are routinely used for airway maintenance in elective surgical procedures where aspiration is not a significant risk and also as rescue devices in difficult airway management. Some devices now have features mitigating risk of aspiration, such as drain tubes or compartments to manage regurgitated content. Despite this, the use of these device may be associated with various complications including aspiration. This review highlights the types and incidence of these complications. They include regurgitation and aspiration of gastric contents, compression of vascular structures, trauma, and nerve injury. The incidence of such complications is quite low, but as some carry with them a significant degree of morbidity the need to follow manufacturers' advice is underlined. The incidence of gastric content aspiration associated with the devices is estimated to be as low as 0.02% with perioperative regurgitation being significantly higher but underreported. Other serious, but extremely rare, complications include pharyngeal rupture, pneumomediastinum, mediastinitis, or arytenoid dislocation. Mild short-lasting adverse effects of the devices have significantly higher incidence than serious complications and involve postoperative sore throat, dysphagia, pain on swallowing, or hoarseness. Devices may have deleterious effect on cervical mucosa or vasculature depending on their cuff volume and pressure.