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Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2016) 17, 75–79

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Egyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied


Sciences
www.ejentas.com

ORIGINAL ARTICLE

Effect of general anesthesia on voice


Balegh Hamdy a,*, Haytham Mamdouh b, Rasha Ahmed a, Sohair Adeeb c, Amna Ali d

a
ENT, Minia University, Egypt
b
Phoniatrics, Minia University, Egypt
c
Anesthesiology, Minia University, Egypt
d
Health Insurance, Egypt

Received 28 February 2016; accepted 18 May 2016


Available online 19 July 2016

KEYWORDS Abstract Background: Transient voice change after surgical operations under general anesthesia
Dysphonia; has generally been attributed to vocal fold trauma. The aim of this study was to examine the effect
General anesthesia; of general anesthesia on voice in order to aid the early detection and prevention of these changes.
Laryngoscopy Patients and methods: This study was carried out on 100 patients who were scheduled for a vari-
ety of elective surgical procedures under general anesthesia. They were 47 males, ranging in age
from 6 to 55 years, and 53 females with the same range of age. Evaluation of vocal functions
was carried out at three intervals, 1 day before operation, 1 day after operation and 2 weeks later.
All patients were subjected to analysis of their complaints (using Arabic Voice Handicap index,
VHI), auditory perceptual assessment of their voice (APA), and laryngeal assessment using
telescopic rigid orolaryngoscopy.
Results: Among 95 patients (using endotracheal tube), ten patients complained of postoperative
voice change, ranging in severity from mild in 8, moderate in 1, and severe in one patient. After
2 weeks, one patient was still complaining of severe voice change. There was postextubation mild
to moderate voice change in 10 patients. The pitch was decreased in three patients, strained and
leaky voice quality was perceived in one patient, strained voice was perceived in three patients,
whereas breathy quality was perceived in one patient. Irregular quality was perceived in five
patients; after 1 week, there was an improvement in all the perceived parameters; however,
persistent mild dysphonia was perceived in one patient. The telescopic rigid orolaryngoscopy,
performed 1 day after extubation, indicated evidence of traumatic laryngeal manifestations in 40
patients; erythema and congestion in 39 patients and in one patient intubation granuloma was
recorded. Using laryngeal mask airway in 5 patients had no effect on their voice postoperatively.
Conclusion: Traumatic manifestations of the laryngeal structures that occur during intubation
are the most common causes of postoperative dysphonia, with a tendency toward a regressive
course of the resulting dysphonia. As such, it is important to establish an early diagnosis and adopt
preventive measures.
Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

* Corresponding author.
Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
http://dx.doi.org/10.1016/j.ejenta.2016.05.008
2090-0740 Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
76 B. Hamdy et al.

1. Introduction (4) Auditory Perceptual Assessment of Voice (APA): The


subjective impression (perceptual judgment) of the
patient’s voice was assessed by three expert phoniatri-
Each year, millions of patients undergo instrumentation/ma-
cians using a modified GRBAS scale [11] [overall grade
nipulation of the airway as part of routine anesthetic care.
or severity (G), roughness of the voice (R), breathiness
Although both endotracheal intubation and the use of a laryn-
(B), asthenia (A), and strain (S)]. The degree of dyspho-
geal mask (LMA) are associated with postoperative laryngeal
nia was graded according to a 0–3 scale, where 0 is nor-
morbidity, the incidence of dysphonia and vocal fold injuries
mal, 1 indicates mild dysphonia, 2 indicate moderate
is not clear.8
dysphonia, and 3 indicate severe dysphonia.
Postoperative dysphonia, an important clinical sign of
(5) Full Laryngeal examination: All patients in the study
laryngeal injury or dysfunction, can be distressing to a
underwent Telescopic rigid fiber orolaryngoscopy in
patient.10 It may have a negative effect on the patients’ degree
the Phoniatric department at Minia University Hospital
of satisfaction, as well as on their level of activity after hospital
using rigid fiberoptic laryngoscope Henke-Sass Wolf
discharge.9 However, patients usually consult an Otorhino-
angle 90.
laryngologist only if postoperative dysphonia persists for a
longer time (eg, 6 weeks), since it is considered to be a typical
effect of general anesthesia and is expected to recover
spontaneously.6 3. Results

2. Patients and methods A correlation was done between smoking Index of patients and
VHI values (24 h & 2 weeks postoperative), APA grades (24 h
& 2 weeks postoperative) and laryngoscopy finding (24 h &
This study was carried out on 100 patients who were enrolled
2 weeks postoperative), which revealed that there was no
in this prospective randomized study. Patients were of either
correlation between smoking Index of patients and VHI,
sex, aged between 6 and 55 years, belonging to ASA physical
APA and laryngoscopy (2 weeks postoperative) and there is
status class I or II, scheduled for elective surgery (likely to last
significant positive correlation between smoking index and
between half an hour and three hours) under general anesthe-
laryngoscopy finding (24 h postoperative) (Table 1).
sia with orotracheal intubation or laryngeal mask airway.
A correlation was done between the duration of operation
Operations included Otologic and orthopedic surgeries.
and VHI values (24 h & 2 weeks postoperative), APA grades
Patients with a history of upper respiratory tract infection,
(24 h & 2 weeks postoperative) and laryngoscopy finding
patients undergoing surgeries of the oral, nasal cavity or
(24 h & 2 weeks postoperative), which revealed that there
pharynx, use of nasogastric tube, and patients with anticipated
was no correlation between duration of operation and VHI,
difficult airway (Mallampati grade >2) were excluded.
APA and laryngoscopy (2 weeks postoperative) and there is
A variety of anesthetic techniques were used and a variety
significant positive correlation between duration of operation
of endotracheal tube sizes and materials were used. The
and laryngoscopy finding (24 h postoperative) (Table 2).
anesthetist involved in each case was required to fill a form
A correlation was done between the ETT size and VHI val-
involving the premedication agents, anesthetic agents, the
ues (24 h & 2 weeks postoperative), APA grades (24 h &
degree of relaxation, duration of operation, and the size of
2 weeks postoperative) and laryngoscopy finding (24 h &
the endotracheal tube or laryngeal mask used.
2 weeks postoperative), which revealed that there was no cor-
Evaluation of vocal functions was carried out in the Unit of
relation between ETT size and VHI, APA and laryngoscopy
Phoniatrics, Minia University Hospital, at three intervals:
(2 weeks postoperative) and there is significant positive corre-
1 day before operation, 1 day after operation, and 2 weeks
lation between ETT size and laryngoscopy finding (24 h post-
later. The following assessment protocol was used to assess
operative) (Table 3).
the vocal functions:

(1) Full clinical history: Personal history and analysis of 3.1. Patients’ self-rating of severity (using VHI)
patient complaint.
(2) Phoniatric history: Phonasthenic symptoms (vocal Among 95 patients (using endotracheal tube), ten patients
fatigue). (10.5%) complained of postoperative voice change, ranging
(3) Arabic voice handicap index (VHI): In 1997, Jacobson in severity from mild in 8(8.4%), moderate in 1(1.1%), and
and Grywalsky3 proposed a measure of voice handicap
known as the voice handicap index (VHI). This
patient-based self-assessment tool consists of 30 items.
Table 1 Correlation between smoking index and VHI (24 h &
These items are equally distributed over three domains:
2 weeks), APA (24 h & 2 weeks) and laryngoscopy (24 h &
functional, physical, and emotional aspects of voice dis-
2 weeks) postoperatively.
orders.The functional domain includes statements that
describe the ‘‘impact of a person’s voice disorders on Smoking VHI APA Laryngoscopy
his or her daily activities.’’ The emotional domain indi- 24 h 2 weeks 24 h 2 weeks 24 h 2 weeks
cates the patient’s ‘‘affective responses to a voice disor- R 0.099 0.021 0.102 0.021 0.265 0.021
der.’’ Items comprising the physical domain are p-value 0.329 0.839 0.312 0.839 0.008* 0.839
statements representing self-perceptions of laryngeal dis- *
P < 0.05; significant correlation.
comfort and voice output characteristics.
Effect of general anesthesia on voice 77

Table 2 Correlation between duration of operation and VHI 4. Discussion


(24 h & 2 weeks), APA (24 h & 2 weeks) and laryngoscopy
(24 h & 2 weeks). Several studies have attempted to identify the causative factors
of postoperative dysphonia, results of the present study found
Duration VHI APA Laryngoscopy
of Op. that the size of the endotracheal tube and duration of intuba-
24 h 2 weeks 24 h 2 weeks 24 h 2 weeks tion were found to be correlated with the 24 h postoperative
R 0.143 0.089 0.14 0.089 0.559 0.089 findings of laryngoscopy. This is in agreement with finding
p-value 0.156 0.377 0.165 0.377 <0.001* 0.377 of the study of Jaensson et al.4 who mentioned that the use
*
P < 0.05; significant correlation. of ETT of smaller size (ETT size 6 instead of 7 in women
and 7 instead of 8 in men), reduced incidence of sore throat
as well as dysphonia in the early postoperative recovery
period.4 This may be explained by the fact that the longer
Table 3 Correlation between ETT size and VHI (24 h & the tube is kept in place, the greater the vocal fold affection,
2 weeks), APA (24 h & 2 weeks) and laryngoscopy (24 h & and the larger the size of the tube, the higher the deformation
2 weeks) postoperatively. pressure exerted on the mucosal covering of the vocal fold.
Also this is in agreement with the study of Hassan et al.1
ETT VHI APA Laryngoscopy
size
The present study found significant positive correlation
24 h 2 weeks 24 h 2 weeks 24 h 2 weeks between 24 h postoperative finding of laryngoscopy and smok-
R 0.069 0.048 0.074 0.048 0.219 0.048 ing index. Smokers are exposed to a higher risk of postopera-
p-value 0.509 0.644 0.479 0.644 0.033* 0.644 tive pulmonary complications than non-smokers in the form of
*
P < 0.05; significant correlation. bronchoconstriction, atelectasis and pulmonary infections as
well as Postoperative sore throat, cough and dysphonia.7
Regarding ETT group95 patients (95%), In terms of postop-
erative voice complaints, there is a large variation in its reported
incidence. It has generally been reported to occur in between
severe in 1 patient (1.1%) (Table 4). After 2 weeks, one patient
4%5 and 42%11 of patients. The incidence in the present study
was still complaining of severe voice change (1.1%).
was ten patients (10.5%) (Using VHI, 1 day postoperative)
mainly as being of mild degree in 8 patients (8.4%) to moderate
3.2. Auditory perceptual assessment in 1 patient (1.1%) and severe in 1 patient (1.1%) who was
reported having intubation granuloma postoperatively.
One day after operation, there was mild to moderate voice In terms of postoperative auditory perceptual assessment of
change in 10 patients (10.5%), strained and leaky voice quality the patient’s voice (APA), indicated presence of postoperative
was perceived in one patient (1.1%), strained voice was dysphonia. The results of the present study described the post-
perceived in three patients (3.1%), whereas breathy quality operative dysphonia (24 h postoperative) in 10 patients
was perceived in one patient (1.1%). Irregular quality was (10.5%) mainly as being of mild grade and irregular quality,
perceived in five patients (5.2%). The pitch was decreased in with lower pitch. Similarly, Beckford et al. (1990) reported a
three patients (3.1%) (Table 5); after 2 weeks, there was an mild degree of postoperative dysphonia and increased rough-
improvement in all perceived parameters; however, persistent ness or breathiness along with reduced loudness and minimal
mild dysphonia was perceived in one patient (1.1). pitch variation in a group of 10 patients undergoing short-
term outpatient surgical procedures under general anesthesia
3.3. Full Laryngeal examination and endotracheal intubation.
In terms of the nature of the postoperative vocal fold
Telescopic rigid orolaryngoscopy, performed 1 day after pathological manifestations (using Telescopic rigid orolaryn-
operation, there is indicated evidence of traumatic laryngeal goscopy), the present study found laryngeal affection in 40
manifestations in 40 patients (42.1%). The types of manifesta- patients (42.1%) in the form of vocal fold congestion identified
tions were vocal fold congestion in 39 patients (41%) ranging in 39 patients (41%) ranged in severity from mild degree in 26
from mild in 26 patients (27.3%) to moderate in 13 patients patients (27.3%) to moderate in 13 patients (13.7%) and intu-
(13.7%) (Table 6) and intubation granuloma was recorded in bation granuloma was also recorded in one patient (1.1%).
one patient (1.1%) (Fig. 1). Using laryngeal mask airway which is in agreement with the result of Hassan et al.1 and
had no effect on postoperative VHI, finding of laryngoscopy. Keshav et al. (2014).

Table 4 Comparison of VHI values preoperative and 24 h postoperative.


Normal Mild Moderate Severe Z p-value
Freq. % Freq. % Freq. % Freq. %
Pre 95 100 0 0 0 0 0 0 2.97 0.003*
24 h 85 89.4 8 8.4 1 1.1 1 1.1
*
P < 0.05; significant correlation.
78 B. Hamdy et al.

Table 5 Comparison of APA grades preoperative and 24 h postoperative.


No dysphonia Mild Moderate Severe Z p-value
Freq. % Freq. % Freq. % Freq. %
Pre 95 100 0 0 0 0 0 0 3.16 0.002*
24 h 85 89.5 10 10.5 0 0 0 0
*
P < 0.05; significant correlation.

Table 6 Comparison of laryngoscopy finding preoperative and 24 h postoperative.


Normal Mild Moderate Severe Other finding Z p-value
Congestion of vocal folds
Freq. % Freq. % Freq. % Freq. % Freq. %
Pre 95 100 0 0 0 0 0 0 0 0 5.728 <0.001*
24 h 55 57.9 26 27.3 13 13.7 0 0 1 1.1
*
P < 0.05; significant correlation.

5. Conclusion and recommendations

The results of the present study indicate that there is a need to


inform patients scheduled for general anesthesia by the
possible postoperative voice change that could last longer than
1 day. Furthermore, it is important to make an early diagnosis
by following the protocol of assessment of voice for patients
with dysphonia postoperatively; moreover, it would be
prudent to adopt preventive measures such as the use of intra-
operative steroids in cases of difficult intubation to minimize
vocal fold edema, and involve experts in cases of difficult intu-
bation, or the use of fiberoptic intubation to avoid rough
maneuvers such as the use of introducers (boojie), which might
injure the vocal folds. Using endotracheal tube of smaller size
(ETT size 6 instead of 7 in women and 7 instead of 8 in men),
reduced incidence of sore throat as well as dysphonia in the
early postoperative recovery period.4
Figure 1 A case of female patient 35 years old, presented by
dysphonia (intubation granuloma was recorded), after an ortho- References
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