Intubation Injury

Injury, typically to the posterior part of both vocal cords, caused by an endotracheal tube1. An endotracheal tube may be used briefly during general anesthesia for surgery, but may be in place for much longer in persons suffering respiratory failure or neurological injury. When severe, the hallmark vocal phenomenology of intubation injury is breathy-pressed phonation.


Intubation injury audio with photos:

Voice sample of a patient with a cricoartyenoid joint intubation injury (see this patient’s photos just below):

 

Photos:

“Tattoo” of blood after detachment of intubation granuloma

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intubation granuloma on vocal cords

Intubation granuloma (1 of 5)

This woman was intubated for 5 days due to severe illness. Afterwards, she had no voice for several weeks. It has recovered nearly fully, but she was told elsewhere that there was a “growth” that needed to be removed.
granuloma becoming pedunculate

Intubation granuloma (2 of 5)

In this closer view with forced inspiration, one can see that this is a granuloma, with point of attachment at arrows becoming pedunculated. Since granulomas typically mature, pedunculate (become attached by a progressively thinner stalk), and fall off on their own, she was advised to return in 4 months, at which point it would likely be gone.
granuloma has detached

Granuloma is gone (3 of 5)

4 months later: In this distant view, it appears that the granuloma has indeed detached. (Typically patients do not know when this happened; rarely, they cough out a pink piece of tissue and a bit of blood at the time of detachement.)
Blood tattoo left from granduloma

Blood tattoo (4 of 5)

In this mid-range view, a “blood tattoo” is seen where the pedicle detached from the granuloma (arrow). This “blood spot” often persists for months or years.
Blood tattoo on vocal cord

Blood Tattoo (5 of 5)

A closer view of the “blood tattoo.”












Subglottic granulation and curving airstream

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Proud flesh within cricoid ring

Intubation injury (1 of 4)

After a 9-day intubation for serious illness, the patient has difficulty breathing due to this “proud flesh” response to injury within the cricoid ring, posteriorly. Breathing has improved in the past week, leading to a decision to await further maturation, rather than proceeding to microlaryngoscopic removal.
lobules of granulation tissue

Lobules (2 of 4)

Close-up view of the lobules of granulation tissue. Air can easily pass around the obstruction as indicated by the arrows.
subglottic scar band

2 months later (3 of 4)

As predicted, breathing continued to improve to the point of seeming normal to the patient, and 2 months later, the granulation tissue has matured and detached, leaving behind a subglottic scar band (parallel lines).
anterior border of the scar band

Scar band (4 of 4)

Here is a close-up of the scar band. A solid line denotes the anterior border of the scar band for reference in all 4 photos, but compare especially to photo 2.








  1. Bastian RW, Richardson BE. Postintubation phonatory insufficiency: an elusive diagnosis. Otolaryngol Head and Neck Surg. 2001; 124(6): 625-33.