European Archives of Oto-Rhino-Laryngology

, Volume 271, Issue 2, pp 345–352 | Cite as

Laryngeal injuries following endotracheal intubation in ENT surgery: predictive value of anatomical scores

  • Arne Böttcher
  • Thomas Mencke
  • Amelie Zitzmann
  • Rainald Knecht
  • Nathan Jowett
  • Gabriele Nöldge-Schomburg
  • Hans Wilhelm Pau
  • Steffen Dommerich


Endotracheal intubation has been associated with a threefold higher incidence of laryngopharyngeal complaints following anesthesia in comparison to laryngeal mask airway. Such complaints, including hoarseness and sore throat, have been reported in up to 90 % of patients within 24 h of extubation. The purpose of this study was to determine which preoperatively documented clinical and anatomic parameters are predictive of laryngo-pharyngeal trauma resulting from elective endotracheal intubation. Fifty-three patients undergoing ENT procedures requiring general anesthesia with endotracheal intubation were recruited. Pre and postoperative laryngostroboscopic examination was performed and findings correlated to preoperative clinical and anatomic parameters. Readily assessed anatomic parameters including height (>180 cm) and weight (>80 kg) correlated significantly to the Eckerbom grade of intubation-associated acute laryngeal injury (rs = 0.374; p = 0.006 and rs = 0.278; p = 0.044, respectively). The mandibular protrusion test also correlated significantly to the Eckerbom grade (rs = 0.462, p = 0.001) while the upper-lip-bite test showed significant correlation to impaired vocal fold oscillation (rs = 0.288, p = 0.036), with injury prediction sensitivities of 37.5 and 39.4 %, respectively. No parameters correlated to subjective complaints (n = 5, 9.2 %). This study provides suggestions on how to improve the classification of intubation-associated laryngeal injuries as well as providing the basis for larger clinical trials in other surgical subspecialties.


Vocal fold sequelae Endotracheal intubation Laryngeal trauma Mandibular protrusion test Anatomical scores 


Conflict of interest

R. Knecht is a member of the Advisory Boards of Merck Serono, Sanofi Aventis, Boehringer Ingelheim and Bayer Healthcare, Leverkusen. The other authors report no conflict of interest.


  1. 1.
    Brandt L (1997) Illustrierte Geschichte der Anästhesie. Wissenschaftliche Verlagsgesellschaft Stuttgart, StuttgartGoogle Scholar
  2. 2.
    Yamanaka H, Hayashi Y, Watanabe Y, Uematu H, Mashimo T (2009) Prolonged hoarseness and arytenoid cartilage dislocation after tracheal intubation. Br J Anaesth 103:452–455PubMedCrossRefGoogle Scholar
  3. 3.
    Echternach M, Mencke T, Richter B, Reber A (2011) Laryngeal alterations following endotracheal intubation and use of larynx masks. HNO 59:485–498PubMedCrossRefGoogle Scholar
  4. 4.
    Higgins PP, Chung F, Mezei G (2002) Postoperative sore throat after ambulatory surgery. Br J Anaesth 88:582–584PubMedCrossRefGoogle Scholar
  5. 5.
    Kambic V, Radsel Z (1978) Intubation lesions of the larynx. Br J Anaesth 50:587–590PubMedCrossRefGoogle Scholar
  6. 6.
    Mencke T, Echternach M, Kleinschmidt S et al (2003) Laryngeal morbidity and quality of tracheal intubation: a randomized controlled trial. Anesthesiology 98:1049–1056PubMedCrossRefGoogle Scholar
  7. 7.
    Wilson ME, Spiegelhalter D, Robertson JA, Lesser P (1988) Predicting difficult intubation. Br J Anaesth 61:211–216PubMedCrossRefGoogle Scholar
  8. 8.
    Karkouti K, Rose DK, Wigglesworth D, Cohen MM (2000) Predicting difficult intubation: a multivariable analysis. Can J Anaesth 47:730–739PubMedCrossRefGoogle Scholar
  9. 9.
    Yildiz TS, Korkmaz F, Solak M et al (2007) Prediction of difficult tracheal intubation in Turkish patients: a multi-center methodological study. Eur J Anaesthesiol 24:1034–1040PubMedCrossRefGoogle Scholar
  10. 10.
    Mallampati SR, Gatt SP, Gugino LD et al (1985) A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 32:429–434PubMedCrossRefGoogle Scholar
  11. 11.
    Samsoon GL, Young JR (1987) Difficult tracheal intubation: a retrospective study. Anaesthesia 42:487–490PubMedCrossRefGoogle Scholar
  12. 12.
    Karkouti K, Rose DK, Ferris LE, Wigglesworth DF, Meisami-Fard T, Lee H (1996) Inter-observer reliability of ten tests used for predicting difficult tracheal intubation. Can J Anaesth 43:554–559PubMedCrossRefGoogle Scholar
  13. 13.
    Bindra A, Prabhakar H, Singh GP, Ali Z, Singhal V (2010) Is the modified Mallampati test performed in supine position a reliable predictor of difficult tracheal intubation? J Anesth 24:482–485PubMedCrossRefGoogle Scholar
  14. 14.
    Mak PH, Campbell RC, Irwin MG (2002) The ASA physical status classification: inter-observer consistency. American society of anesthesiologists. Anaesth Intensive Care 30:633–640PubMedGoogle Scholar
  15. 15.
    Fleischer S, Hess M (2003) Systematic investigation technique in videolaryngoscopy and stroboscopy. HNO 51:160–167PubMedCrossRefGoogle Scholar
  16. 16.
    Hanschmann H, Berger R (2009) Quantification of videostroboscopic vocal cord findings. Laryngorhinootologie 88:6–8PubMedGoogle Scholar
  17. 17.
    Cormack RS, Lehane J (1984) Difficult tracheal intubation in obstetrics. Anaesthesia 39:1105–1111PubMedCrossRefGoogle Scholar
  18. 18.
    Calder I (1992) Predicting difficult intubation. Anaesthesia 47:528–530PubMedCrossRefGoogle Scholar
  19. 19.
    Friedman M, Ibrahim H, Bass L (2002) Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 127:13–21PubMedCrossRefGoogle Scholar
  20. 20.
    Rombaux P, Bertrand B, Boudewyns A et al (2002) Standard ENT clinical evaluation of the sleep-disordered breathing patient; a consensus report. Acta Otorhinolaryngol Belg 56:127–137PubMedGoogle Scholar
  21. 21.
    Fischer Y, Neagos A, Gronau S, Rettinger G (2006) Examiner variability of clinical findings in patients with sleep related breathing disorders. Laryngorhinootologie 85:338–343PubMedCrossRefGoogle Scholar
  22. 22.
    Khan ZH, Kashfi A, Ebrahimkhani E (2003) A comparison of the upper lip bite test (a simple new technique) with modified Mallampati classification in predicting difficulty in endotracheal intubation: a prospective blinded study. Anesth Analg 96:595–599PubMedGoogle Scholar
  23. 23.
    Frerk CM (1991) Predicting difficult intubation. Anaesthesia 46:1005–1008PubMedCrossRefGoogle Scholar
  24. 24.
    Friedman PG, Rosenberg MK, Lebenbom-Mansour M (1997) A comparison of light wand and suspension laryngoscopic intubation techniques in outpatients. Anesth Analg 85:578–582PubMedGoogle Scholar
  25. 25.
    Nawka T, Anders LC, Wendler J (1994) Die auditive Beurteilung heiserer Stimmen nach dem RBH-System. Sprache Stimme Gehör 18:130–133Google Scholar
  26. 26.
    Eckerbom B, Lindholm CE, Alexopoulos C (1986) Airway lesions caused by prolonged intubation with standard and with anatomically shaped tracheal tubes. A post-mortem study. Acta Anaesthesiol Scand 30:366–373PubMedCrossRefGoogle Scholar
  27. 27.
    Mendels EJ, Brunings JW, Hamaekers AE, Stokroos RJ, Kremer B, Baijens LW (2012) Adverse laryngeal effects following short-term general anesthesia: a systematic review. Arch Otolaryngol Head Neck Surg 138:257–264PubMedCrossRefGoogle Scholar
  28. 28.
    Friedrich G, Remacle M, Birchall M, Marie JP, Arens C (2007) Defining phonosurgery: a proposal for classification and nomenclature by the phonosurgery committee of the European laryngological society (ELS). Eur Arch Otorhinolaryngol 264:1191–1200PubMedCrossRefGoogle Scholar
  29. 29.
    Bastian RW, Richardson BE (2001) Postintubation phonatory insufficiency: an elusive diagnosis. Otolaryngol Head Neck Surg 124:625–633PubMedCrossRefGoogle Scholar
  30. 30.
    Gould SJ, Howard S (1985) The histopathology of the larynx in the neonate following endotracheal intubation. J Pathol 146:301–311PubMedCrossRefGoogle Scholar
  31. 31.
    Weymuller EA Jr, Bishop MJ, Fink BR, Hibbard AW, Spelman FA (1983) Quantification of intralaryngeal pressure exerted by endotracheal tubes. Ann Otol Rhinol Laryngol 92:444–447PubMedGoogle Scholar
  32. 32.
    Gaynor EB, Greenberg SB (1985) Untoward sequelae of prolonged intubation. Laryngoscope 95:1461–1467PubMedCrossRefGoogle Scholar
  33. 33.
    Whited RE (1983) Posterior commissure stenosis post long-term intubation. Laryngoscope 93:1314–1318PubMedGoogle Scholar
  34. 34.
    Adnet F, Borron SW, Racine SX et al (1997) The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology 87:1290–1297PubMedCrossRefGoogle Scholar
  35. 35.
    Reed MJ, Dunn MJ, McKeown DW (2005) Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J 22:99–102PubMedCrossRefGoogle Scholar
  36. 36.
    el-Ganzouri AR, McCarthy RJ, Tuman KJ, Tanck EN, Ivankovich AD (1996) Preoperative airway assessment: predictive value of a multivariate risk index. Anesth Analg 82:1197–1204PubMedGoogle Scholar
  37. 37.
    Kheterpal S, Han R, Tremper KK et al (2006) Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology 105:885–891PubMedCrossRefGoogle Scholar
  38. 38.
    Defalque RJ, Wright AJ (2003) Who invented the “jaw thrust”? Anesthesiology 99:1463–1464PubMedCrossRefGoogle Scholar
  39. 39.
    Arviso LC, Klein AM, Johns MM 3rd (2012) The management of postintubation phonatory insufficiency. J Voice 26:530–533PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Arne Böttcher
    • 1
  • Thomas Mencke
    • 2
  • Amelie Zitzmann
    • 2
  • Rainald Knecht
    • 1
  • Nathan Jowett
    • 1
    • 3
  • Gabriele Nöldge-Schomburg
    • 2
  • Hans Wilhelm Pau
    • 4
  • Steffen Dommerich
    • 5
  1. 1.Department of Otorhinolaryngology, Head and Neck SurgeryUniversity Medical Center Hamburg-EppendorfHamburgGermany
  2. 2.Department of Anaesthesia and Intensive Care MedicineUniversity of RostockRostockGermany
  3. 3.Department of Otolaryngology, Head and Neck SurgeryMcGill UniversityMontrealCanada
  4. 4.Department of Otorhinolaryngology, Head and Neck SurgeryUniversity of RostockRostockGermany
  5. 5.Department of Otorhinolaryngology, Head and Neck SurgeryCharité, Universitätsmedizin Campus MitteBerlinGermany

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