Breathing snd TEE Tubes Warning

[tobagotwo]

A recent visit to the ENT verified something I had determined on my own some time ago. My voice doesn't last as long after the surgery, going hoarse on me in longer sentences.

In the process of having a breathing tube and a TEE scope down my throat during the surgery, they "thinned" the left side of my vocal chords. As it's been almost four years now, my voice is as healed as it will get.

This is usually not done by your surgeron in a teaching hospital. It's done by the anesthesiologist and a surgeon in training. The problem is, the surgeon-in-training is interested in getting good pictures for the surgeon, and in what the TEE will show, and not so much in whether he had to push too hard to get it past your vocal chords. And, of course, you're in no position to complain.

You might just want to mention to your surgeon that you're a little concerned about damage form the throat tubes, because a friend of yours had this happen to him in open heart surgery. It might make him take notice of the procedure, and help assure a gentler hand than I got.

Also, ask if they normally use a lip clip for the breathing tube. If so, ask them if they would use tape instead. The lip clip will leave you with a fat lip that will last for a day or more afterwards. And it's entirely unnecessary.

Best wishes,

 

[Nancy]

Joe had permanent vocal cord damage. Don't know what caused it, but I watched the scope in the ENTs office. His vocal folds did not meet which meant that he tried to make stronger sounds by forcing his voice which only resulted in a higher pitched voice. His voice was soft and sometimes hard to hear. The ENT wanted to do surgery on him to bring the folds closer together which would have helped the problem, but Joe's health was too fragile to do any unnecessary procedures.

It could have been caused by his many intubations, TEEs, etc. BUT Pulmonary Hypertension can also cause pressure on the recurrent laryngeal nerve, and that can cause the same symptoms.

So they gave him a course of voice strengthening appts. with the speech pathologist. It was working a little, but he didn't have the strength to go on with them.

BTW, it also caused him to have choking problems from time to time too, and when they tried to insert a feeding tube in the hospital, it caused LOTS of problems with that insertion. Of course, I wasn't there when they tried the intubation, or I would have told the doctor and nurses about the folds not meeting and possibly causing the tube to get stuck in his throat.

It is not a problem that should be ignored.

I understand your disappointment with the situation.

 

[surfsparky]

Thanks Bob, I'll certainly be keeping a note of this one.

Yolanda

 

[Susan BAV]

Thanks for the information Bob. Fortunately your writing hasn't suffered .

To all: I've posted another warning here a few times in connection to an experience my younger son had when he was on a ventilator in his early teens (for a few days) because he developed an un/misdiagnosed, but large, growth on a nerve in his windpipe from it, called a granuloma. He also developed a smaller growth on a vocal chord. The larger growth was missed by special ENT testing and manifested itself in a life-threatening emergency, cutting off his airway, a few months after the ventilator experience. It was successfully removed in an emergent surgery. Another ENT told us that the same nerve is sometimes damaged by vents but this was the first growth he'd seen from that same nerve. My son's voice was extremely "gravely" from the time the vent was removed but was immediately resolved following removal of the growth.

Interestingly perhaps, my son was vented in a dire emergency and was at an awkward age for the adult-sized vent and they pushed it too far into his "right mainstem bronchus"--or something like that as I recall from the records--and following a quick CT scan, they had to pull it back. Perhaps that circumstance contributed to my son's difficulty.

 

[tobagotwo]

Just to clarify, for those yet uncleaved (uncloven?): - uh, who haven't had their surgeries yet...

I didn't have any trouble with the tube when it was in. I did wake up with it, but I had put it in my mind that it would be breathing for me for hours, so when it was still there upon awakening, I wasn't afraid of it. It didn't hurt. It didn't gag me, even when they took it out (and I have a terrific gag reaction). The response to the breathing tube is a mental/emotional one in the vast majority of cases, and it can usually be reduced into no big deal by visualizing it ahead of time.

The tube is my friend...the tube is my friend...the tube is my friend...

It's not something to be afraid of. This is just to assure that they take the best care possible in insertion and when using the TEE probe, in an activity that they often think of as merely secondary to the main theme.

Best wishes,

 

[MikeHeim]

Bob-
Huge question, but perhaps a stupid one and I'm missing something obvious. Why would a TEE affect your vocal chords? Last I checked, your vocal chords aren't in your esophagus. I imagine that you could have problems with the breathing tube, but not the TEE.

Mike

 

[tobagotwo]

Thanks for the reality check, Mike. I had thought the vocal chords were in the shared part of the throat, and that the interplay was a factor. I went diagram-hunting, and now I don't see how it could be. I should have looked first. I stand corrected.

The fault then lies with the anesthesiologist or his/her in-training minion, who put the breathing tube in with excessive vigor.

My apologies to surgeons-in-training at large for the earlier, inappropriate rebuff.

Many hospitals arrange for patients to meet their anesthesiologists for questions before the surgery. Perhaps mentioning your concern at that time might be appropriate.

Best wishes,

 

[Mary]

I asked Bob, my husband this question, since he frequently intubates patients.

When a patient is intubated, the endotracheal tube goes right between the vocal chords.
If the tube is in there for very long, it can rub against the vocal chords and cause some necrosis.
Or, if there's edema, there will be swelling that causes irritation.

Rarely is it anyone's fault when this occurs, and he said that a patient that is sedated for surgery is not going to have an endotracheal tube inserted roughly. That's not necessarily true for a patient who is awake and combative, but for surgery patients, it is.

And as Mike said, a TEE goes down the esophagus and doesn't touch the vocal chords.

 

[tobagotwo]

Okay. I can see that as reasonable. So, let's follow that premise. If the causation is rubbing, then the original concept still stands. The surgeon wannabees are not off the hook, and the anesthesiologist hopefuls may inherit that apology I had offered up, instead of the surgeons-in-training.

Remember, this is not an uncommon issue, and all OHS patients are sedated. It comes from somewhere. If nothing caused it, it wouldn't happen. I've pointed a finger here or there, but in the end, it's not about blame. It's about what could be causing it, and how might we stop it from happening, or at least limit how often it happens.

The TEE transducer probe does share the throat all the way to a point very close to where the breathing tube is in contact with the vocal chords. Manipulation of that instrument in the throat will push and rattle against the breathing tube and can easily cause the tube to rub against the vocal chords slightly farther down. Realize that the trachea is a rigid tube, and the only yielding tissues in it are the vocal chords. Moreover, based on the patient's positioning and the alignment of the throat, the movement of the TEE probe within the esophagus can also transmit its bouncing around to the breathing tube as it bumps the flexible esophagus against the stiff trachea.

Note my "thinning" was all on the left chord, which would be consistent with the breathing tube having been repeatedly pushed against from one side - perhaps the side the TEE probe was being manipulated from. Consider the regular echoes you've received, the serious pressure often applied, and the continuous movement to try to get a clearer or differently angled picture.

As we're not actively breathing (rhythmic, gross movement of the chest), it's difficult to say that it's repetitive internally-generated movement that would cause friction enough to do that damage. Even the heart is stopped for part of the procedure.

Was the problem there before the surgery? No. What changed? There were multiple tubes down the throat, with people manipulating one of them to get a picture of the valve. Focus was on the picture, not on the movement in the throat. To discount the tubes and the manual activity would lack logic.

Thus, I resubmit that concern for the vocal chords should be discussed with the surgeon. If mentioned to the anesthesiologist as well, they might help by being watchful, as they wouldn't want the patient to think that they contributed to any vocal problems that did show up.

Best wishes,

 

[aussigal]

I have similar issues Bob... it all started after my surgery too. My voice sounds a little different and will go hoarse very easily, it happens instantly if I try to yell . I also have this dry-throat thing that started at the same time. Unlike most people I had difficulties with the vent and was put back on it a few times during my extended stay in ICU...I assumed that something there could have caused my troubles, just never remembered to ask about it.

 

[harleygirl528]

Bob,

I was truly amazed to read your post because I am just a month post-op and really thought that the "hoarseness" I was experiencing right after surgery would have subsided by now. To be clear, it has diminished immensely but I still experiencing this crackling, sort of raspiness quality to my voice, especially when I am on a long-winded ramble (which I often am!). My husband has noticed it as well and has even commented on it and I really was quite certain that it was related to the ventilator tube since it was NOT present prior to my surgery. I had a totally non-traumatic experience with the ventilator and do not remember gagging on it or having a problem with it at all. I have only snippets of memory before the breathing tube was removed but I did not fight it in the least. My family was present when the tube was removed and they will verify that it was a totally calm, uneventful time on the ventilator and the removal as well. This is a topic worth pursuing as it would be great for future OHS patients to be able to avoid this.
Since I am only a month out...maybe mine will subside? One can hope...
Thanks, as always, Bob for your thought provoking posts!

 

[tobagotwo]

My own experience with this is that it got better over time - up to a point. I've seen similar statements from others in posts as well.

Again, the point is not to fix the blame on a person, but to find the part of the procedure that causes this issue. We've pointed out that OHS patients are not capable of being combative during insertion. If it's rubbing, then rubbing from what? After all, in the case of OHS, the patient is basically inert. If we accept that it simply happens sometimes, then we can't improve the process.

I'm going to have a procedure that requires intubation in a couple of weeks. The surgeon, an expert in the ENT area (including the larynx), is the one who looked at my larynx. He said that, "they thinned the left side a little." His comment was that he's going to have the anesthesiologist use a smaller gauge breathing tube when I'm put out to realign my sinuses.

There are thousands of people out there in the world who either occasionally or frequently intubate people. To assume that they're all gentle and align everything perfectly each time would be not only silly, but would deny their humanity, the sometimes combative nature of their patients, and even the diversity of the throat configurations of their patients. I didn't ask the ENT who "they" were. It wasn't the point.

What is important is whether there is something that might be done slightly differently that would reduce this incidence. Should the standard tube be just a smidge smaller diameter? Should other implements in the throat at the same time be under restriction for movement?

Best wishes,