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Iatrogenic Upper Airway Trauma

SONIA J. VAIDA, MD
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Professor of Anesthesiology & Perioperative Medicine

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and Obstetrics and Gynecology

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Vice Chair for Research

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Director, Obstetric Anesthesia

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Department of Anesthesiology
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and Perioperative Medicine

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Penn State Hershey Medical Center

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Hershey, Pa.
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Dr. Vaida reported no relevant financial disclosures.

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pper airway trauma of varied
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severity can occur during both

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elective and difficult airway

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intubation, and can be caused by a

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diversity of airway devices.

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Traumatic upper airway injuries caused by airway airway intubation, and can be caused by a diversity of
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instrumentation are common and typically self-lim- airway devices. This article discusses iatrogenic upper
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iting complications. However, rare serious events can airway trauma caused by supraglottic airway devices
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occur, leading to significant morbidity and liability for (SADs), laryngoscopy and endotracheal intubation in
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anesthesiologists. Airway injuries account for 7% of all
adverse events, as reported by the Anesthesia Closed
Claims Database.1
Cook et al examined litigation related to airway and
respiratory complications in England between 1995 and
2007, and found that airway trauma accounted for one-
third of airway claims, with most cases occurring during
endotracheal intubation.2 Upper airway trauma of var-
ied severity can occur during both elective and difficult
adult patients undergoing general anesthesia.
Supraglottic Airway Devices
Since its introduction in 1988, the Laryngeal Mask
Airway (LMA, Teleflex) has provided a safe and effec-
tive alternative to endotracheal intubation in appropri-
ately selected patients. Following the success of the
LMA, a diverse armamentarium of SADs is now avail-
able for elective and emergency airway management.

A N E S T H E S I O L O G Y N E W S A I R WAY M A N A G E M E N T 2 0 2 0 83
Pharyngolaryngeal Complications
The most common postoperative pharyngolaryngeal
complications are sore throat (Table 1), dysphonia and
dysphagia. Even though these complications are fre-
quently considered to be minor events, they may cause
significant discomfort and patient dissatisfaction.
The majority of SADs, such as the LMA and the
King LTS-D Laryngeal Tube (Ambu), for example,
are equipped with a cuff to seal the oropharynx. The
pharynx, a fibromuscular cavity, can accommodate a
large, expandable SAD. However, prolonged excessive
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using SADs with an integrated pressure indicator, such
as single-use silicone cuff LM airways (e.g., LMA Protec-
tor with Cuff Pilot and LMA Unique with Cuff Pilot, both
by Teleflex).12 The integrated pressure indicator is color-
coded with four intracuff pressure zones.
There are many very well-established techniques for
inserting an SAD, with controversial outcomes regard-
ing pharyngolaryngeal complications. It seems that
inserting an LM airway fully inflated decreases the inci-
dence of postoperative sore throat.13
Regarding the incidence and severity of pharyngo-

intracuff pressure that exceeds the pharyngeal mucosa laryngeal complications, there are controversial
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capillary perfusion pressure can lead to impairment of reports about the benefits of one specific SAD over
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mucosal perfusion with consequent tissue ischemia and the others. The i-gel (Intersurgical), an anatomically
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postoperative sore throat and dysphagia.3,4 preshaped SAD with a soft, gel-like noninflating cuff,
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Most manufacturers recommend that SAD cuff pres- was found by Chang et al to cause less oropharyn-
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sure not exceed 60 cm H2O.5 Animal studies have shown geal mucosal injury than the LMA Protector; however,
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that intracuff pressures as low as 60 cm H2O maintained the incidence of postoperative sore throat remained
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for prolonged periods of time can cause epithelial and the same. The authors identified oropharyngeal muco-
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subepithelial mucosal damage.4,6 Intracuff pressure may sal injury by checking for presence of blood on the
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further increase with use of nitrous oxide, which dif- SAD’s surface after its removal.12 The LMA Unique, LMA
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fuses more rapidly into the cuff than nitrogen diffuses Supreme and i-gel were reported to cause similar inci-
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out of the cuff.7 dences of sore throat one day postoperatively after
The reported incidence of postoperative sore throat general anesthesia lasting less than two hours.14
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after general anesthesia with use of an SAD for airway Rare, severe pharyngolaryngeal complications
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management varies widely, but is lower than that fol- caused by SADs have been reported. Atalay et al
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lowing endotracheal intubation.8 The frequency and reported a case of pharyngolaryngeal rupture with
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severity of the sore throat, dysphagia and dysphonia resulting pneumomediastinum after an apparently
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vary significantly depending on the duration of the atraumatic standard index finger–facilitated insertion
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anesthetic, intracuff pressure throughout the proce- of an LM airway in a 72-year-old patient.15

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dure, insertion technique, number of insertion attempts,

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Nerve Injuries
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type of postoperative analgesia, and the choice of size

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and type of SAD.9-11 In addition to causing postoperative pharyngolaryn-

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Seet at al showed that using intraoperative manome- geal complications, increased intracuff pressure may
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try to measure and adjust the intracuff pressure to less cause nerve injuries (pressure neuropraxia) by com-
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than 44 mm Hg (60 cm H2O) in spontaneously breath- pressing part of the pharynx against rigid structures,
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ing patients reduced the incidence of postoperative such as the hyoid bone or cervical vertebrae. Other
pharyngolaryngeal adverse events by 70%.3 Continuous identified contributing factors to nerve injury after
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assessment of intracuff pressure can be achieved by SAD use include inappropriate SAD size, malposition
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of the SAD and long duration of surgery. Multiple types

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of nerve injuries, such as lingual, recurrent laryngeal,

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hypoglossal, glossopharyngeal, inferior alveolar and

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Table 1. Factors Affecting infraorbital, have been reported following SAD use. In
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Postoperative Sore Throat

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addition, multiple concomitant cranial nerve injuries

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After SAD Use have been reported (Table 2).16

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Choice of SAD Recurrent Laryngeal Nerve Injury

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Transient, permanent, unilateral and bilateral recur-

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Increased intracuff pressure

rent laryngeal nerve (RLN) injuries have been reported
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Malposition of the SAD after the use of different SADs (both LM airways and
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non–LM airways) and attributed to demyelinating

Multiple insertion attempts neuropraxia caused by mechanical compression or dif-
Size of SAD fusion of the lidocaine jelly applied before insertion.16-19
Unilateral RLN injury can cause hoarseness, dyspho-
Traumatic insertion nia and dysphagia, with symptoms typically present-
Type of postoperative analgesia ing within 48 hours after surgery.16 Bilateral RLN is a
very rare, severe complication that presents with inspi-
SAD, supraglottic airway device ratory stridor, dyspnea and airway obstruction, and
requires reintubation or tracheostomy.19

84 A N E ST H E S I O LO GY N E WS .CO M
Lingual Nerve Injury
Lingual nerve injury is the most common nerve
injury following use of SADs.16,20 The lingual nerve is
a branch of the mandibular division of the trigemi-
nal nerve that supplies sensory innervation and taste
perception to the anterior two-thirds of the tongue. It
enters the mouth at the level of the third molar. Inju-
ries to the lingual nerve can be unilateral or bilateral,
manifested by tongue numbness and taste alterations,
and last from a few hours after removal of the SAD to
six months.20
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a manometer to monitor and maintain intracuff pres-
sure less than 60 cm H2O throughout the procedure.
They also suggested that preexisting neuropathic dis-
ease could increase the risk for a nerve injury caused
by SADs.16
Other possible traumatic injuries following the use
of SADs include bilateral vocal fold immobility,23 ary-
tenoid cartilage dislocation,24 edematous uvula25 and
tongue swelling,26 among others.
Laryngoscopy and Endotracheal intubation

Sore Throat
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Hypoglossal Nerve Injury Postoperative sore throat caused by airway instru-

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Hypoglossal nerve injury is typically self-limiting, mentation is a symptom of pharyngitis, laryngitis or

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lasting up to six months and manifesting by ipsilat- tracheitis. Endotracheal intubation causes a signif-
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eral tongue deviation, speech disturbances and swal- icantly higher rate of postoperative sore throat than
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lowing difficulties. Proximity of the hypoglossal nerve SAD use, with an incidence as high as 50% for the for-
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to the hyoid bone in a patient with a malpositioned mer (Table 3).8 In a prospective study of 5,264 patients
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SAD or excessive cuff inflation can account for the undergoing general anesthesia for ambulatory surgery,
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injury.21 Stewart and Lindsay reported a case of bilat- Higgins et al found a significantly higher incidence of
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eral hypoglossal nerve injury following the use of the postoperative sore throat after endotracheal intubation
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LMA Classic. The injury caused an inability to move the (45.5%) than use of an LM airway (17.5%).27
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tongue and difficulty swallowing, and resolved after six The reported incidence of postoperative sore throat
weeks.22 varies largely depending on the techniques used for
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Thiruvenkatarajan et al reviewed case reports and intubation, method of questioning, skills of the anes-
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case series of cranial nerve injuries following the use thesiologist and the duration of anesthesia, among
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of SADs. To avoid such injuries, the authors recom- other factors.8 Risk factors for developing postopera-
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mended individualizing SAD size selection and using tive sore throat include female sex, history of smoking
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or lung disease, larger sized endotracheal tube (ETT),

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head and neck position during surgery (neutral, flexed,

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rotated), not using neuromuscular agents to facilitate

Table 2. Possible Nerve Injuries
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endotracheal intubation, greater intracuff pressure, and

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Following SAD Use

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gastric tube insertion.8,9,28,29

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Limiting the ETT intracuff pressure to 25 cm H2O sig-

Nerve injury Symptoms
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nificantly decreases both the incidence and severity of

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postoperative sore throat.9 Postoperative sore throat is

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Recurrent Unilateral nerve injury:

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laryngeal • hoarseness self-limiting in most cases, with an average duration of

• dysphonia/aphonia 16 hours.29 It may be accompanied by hoarseness and/
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• dysphagia or dysphagia, thereby significantly affecting postoper-

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Bilateral nerve injury: ative comfort and patient satisfaction.

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• inspiratory stridor
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• dyspnea
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• airway obstruction
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Table 3. Factors Affecting

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Lingual nerve Tongue numbness

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Altered taste perception (dysgeusia) Postoperative Sore Throat After

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Speech disturbances
Endotracheal Intubation
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Hypoglossal Ipsilateral tongue deviation

nerve Speech disturbances Duration of anesthesia
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Swallowing difficulties
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Female sex
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Inferior Numbness and scabbing of the

alveolar nerve lower lip Moving the head and neck

Infraorbital Sensory loss of the upper lip Muscle relaxants to facilitate intubation
nerve
Size of endotracheal tube
Greater Hard palate numbness
palatine nerve Type of postoperative analgesia

Type of surgery
SAD, supraglottic airway device

A N E S T H E S I O L O G Y N E W S A I R WAY M A N A G E M E N T 2 0 2 0 85
Soft Tissue Trauma
Both direct and video laryngoscopy are associated
with significant soft tissue injury after both routine and
difficult intubations. Soft tissue trauma during laryn-
goscopy occurs frequently, and ranges from mucosal
lacerations or hematomas to soft tissue defects requir-
ing surgical repair. Mourão et al reviewed 573 patients
intubated with direct laryngoscopy using a size 3 or
4 Macintosh blade. Soft tissue trauma was identified
postoperatively in 52% of patients, with tongue injury
being the most frequent event, followed by lower and
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upper lip injury and oral mucosa injury.30
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A systematic review of video laryngoscopy versus
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direct laryngoscopy that included 64 studies (involv-
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ing 7,044 adult patients for elective and emergency
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surgery with both easy and difficult airways) showed
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no difference in postoperative sore throat between
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the two techniques. However, video laryngoscopy was
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associated with less upper airway trauma and postop-
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erative hoarseness.31 Pieters et al found a significantly
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increased incidence of mucosal trauma using direct
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laryngoscopy compared with video laryngoscopy in
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patients with known difficult airways who were intu-
bated by experienced anesthesiologists (odds ratio
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[OR], 0.16; 95% CI, 0.04-0.75; P=0.02).32
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However, as video laryngoscopy has gained in pop-
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ularity, there have been increasing numbers of pub-
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lications reporting upper airway trauma caused by
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different types of video laryngoscopes.33-38 Video
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laryngoscopes with acutely angulated blades, such
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as the GlideScope (Verathon), require the use of a
or
curved stylet to facilitate advancement of the ETT into
the laryngeal inlet.39 Use of rigid stylets, such as the
GlideRite (Verathon), may significantly increase the
risk for upper airway injury.
Replacing rigid stylets with malleable stylets to
correctly shape the ETT can potentially decrease the
incidence of traumatic injuries. A standard malleable
stylet (shaped with a 90-degree angle formed 8 cm
from the distal end of the ETT) was reported to be
as efficient as a rigid stylet for GlideScope-facilitated
endotracheal intubations, when used by experienced
anesthesiologists.40 Alternatively, the S-Guide intubat-
ing stylet (VBM Medizintechnik, Germany), a new mal-
leable intubating stylet with a soft, preformed, hockey
stick–shaped distal tip, can be used instead of a rigid
stylet.41
Prompted by an increased number of pharyngeal
wall injuries observed by the otolaryngology service,
Greer et al retrospectively compared rates of pha-
ryngeal trauma caused by video laryngoscopy and
direct laryngoscopy. The authors reviewed the lit-
erature, which included 20 cases of oropharyngeal
trauma. They found a significantly higher incidence
of palate and oropharynx injury with video laryngos-
copy (0.234%) compared with direct laryngoscopy
(0.015%). The most common locations of the trau-
matic injuries were the tonsillar pillars and soft palate,
and the most common type of injury was soft tissue
86 A N E ST H E S I O LO GY N E WS .CO M
through-and-through perforation.38 The tonsillar pillars
are particularly susceptible to perforation by a styleted
ETT, when stretched with excessive force to enable
visualization of the laryngeal inlet.42
Pham et al reported nine cases of soft palate injury
after video laryngoscopy, with six cases presenting
with lacerations to the right palatoglossal arch. Three
patients required surgical repair of the soft palate
injury, with no further complications occurring postop-
eratively. Right-sided palatal injuries are more frequent
because most ETTs are inserted with the right hand.
The authors suggested surgical repair for through-
and-through perforations or large flaps, and adminis-
tering prophylactic antibiotics for lesions greater than
1 to 2 cm or those requiring surgical sutures.43 Most
cases presented in the literature had good outcomes
with either conservative treatment or surgical suture.
Focusing one’s visual attention on the video laryn-
goscope monitoring screen instead of the oral cavity
when advancing the ETT creates a blind spot in the
oropharynx. Because the ETT is not visualized when
reaching the blind spot, oropharyngeal soft tissues can
be highly susceptible to traumatic injury. To avoid cre-
ating this blind spot, it is recommended to insert the
video laryngoscope and the ETT under direct visu-
alization before focusing attention on the monitor-
ing screen. Van Zundert recommended switching to
the monitor view after the ETT is located beyond the
uvula.42
Use of a four-step technique for GlideScope-guided
endotracheal intubation is encouraged to avoid trau-
matic airway manipulation:
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1. Insert the GlideScope blade midline in the oral
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cavity under direct visualization.
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2. Switch visualization to the monitor to identify
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the epiglottis and glottis opening.
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3. Insert the ETT in the oral cavity under direct
visualization.
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4. Switch visualization to the monitor to com-
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plete the intubation.44,45
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Another approach is to introduce the ETT in the oral
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cavity first before inserting the GlideScope blade.45
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Laryngeal Injury
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Laryngeal trauma caused by endotracheal intuba-
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tion occurs frequently. It can happen after an elective
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uncomplicated intubation, a difficult intubation, an
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extubation or during surgery. Numerous factors can
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affect the incidence of laryngeal trauma, such as:
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• number of attempts at intubation,
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• traumatic insertion,
• degree of airway difficulty,
• skill of the practitioner,
• movement of the ETT during the procedure, and
• use of a stylet.
Large or overinflated ETTs, especially if used for a
prolonged time, can cause edema and ulceration of
the laryngeal mucosa. Using neuromuscular relax-
ants to facilitate endotracheal intubation improves the
quality of intubation and is associated with a lower
incidence of postoperative hoarseness and vocal cord
sequelae.46
An indicator of laryngeal injury, postoperative
hoarseness is caused mainly by edema of the vocal
cords. Yamanaka et al prospectively studied the dura-
tion of postoperative hoarseness after endotracheal
intubation. After a mean duration of intubation of 283
minutes, the authors reported hoarseness in 49% of
patients on the first postoperative day and 0.8% seven
days after surgery, as well as an incidence of 0.097%
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injuries can be caused by oro/nasogastric tube inser-
tion, Yankauer suction tips and transesophageal echo-
cardiography probes.45
Conclusion
• Postoperative sore throat and hoarseness caused
by airway instrumentation are very frequent com-
plications. Even minor iatrogenic upper airway
trauma can affect the patient’s postoperative
comfort and daily activities.
• Patients should be informed about the high inci-

for arytenoid cartilage dislocation.47 dence of minor postoperative events caused by

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A recent closed claims analysis of vocal cord inju- airway instrumentation.

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ries caused by endotracheal intubation, by Homsi et al, • Although the safety profile of SADs shows an
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identified and analyzed 20 cases between 2004 and excellent track record, serious traumatic compli-
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2015. The injuries included bilateral vocal cord paral- cations can occur.
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ysis, unilateral vocal cord paralysis, laryngeal nerve • High intracuff pressures for ETTs and SADs
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injury, vocal cord injury or dysfunction, and arytenoid are unfortunately a frequent finding in clinical
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subluxation. The authors recommended discussing the settings.

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potential risks of intubation, including laryngeal injury, • Monitoring and adjusting intracuff pressures
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with patients during the informed consent process.48 below 60 cm H2O for SADs and 25 cm H2O for
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Unilateral vocal cord paralysis caused by endotra- ETTs can significantly help decrease the incidence
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cheal intubation is very rare, with a reported incidence of upper airway trauma.
of 0.077%, most likely due to laryngeal nerve dam- • For SADs, the lowest cuff-filling volumes that
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age caused by prolonged impairment of mucosa cap- maintain an adequate oropharyngeal seal should
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illary perfusion or compression neuropraxia.49 Clinical be used.

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signs of vocal cord paralysis include hoarseness, vocal • When performing video laryngoscopy, direct visu-
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fatigue, dysphonia and dysphagia.49,50 alization of the ETT before it is displayed on the
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Late complications of prolonged endotracheal intu- monitoring screen of the video laryngoscope is
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bation include laryngotracheal stenosis, vocal cord recommended.

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hematomas and granulomas.50 In addition to airway

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instrumentation, iatrogenic upper airway traumatic The author wishes to thank Daniel Vaida for editorial assistance.
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