What has happened to her voice?” I remember thinking as Sammi and I began her first post-hospitalization voice lesson. Physically, she was almost completely recovered from her near-fatal highway accident three months earlier, and she was anxious to start singing again. Working slowly, we reviewed breathing and support—but although Sammi knew what to do, her voice wasn’t responding like someone who’d simply taken a break from singing. Stranger still, I hardly recognized her voice, and we’d worked together for a year. Eventually, I concluded that Sammi’s voice had been fundamentally altered by the longer-term intubation she underwent in intensive care. Although her voice still functioned just fine, it was like she had a completely different larynx. This new voice was higher and slightly thinner. In many respects, she would have to start over.
Unfortunately, effects on the voice (ranging from a sore throat to major damage) are a commonly-reported complication of intubation. Most singers and teachers aren’t fully aware of the risks or alternatives. This has led to some very unfortunate situations. In a recent Classical Singer e-mail survey, many readers reported negative intubation experiences, either first-hand or second-hand. In the worst cases, a routine medical procedure resulted in irreparable damage, and the instantaneous end to a successful career.
What Is Intubation?
There is more than one intubation procedure, but the most common is called endotracheal (or endolaryngeal) intubation. In this procedure, a PVC tube is passed down the throat, through the vocal folds, and into the trachea. (Please see Dr. Jahn’s article for complete information about this procedure.) Intubation is frequently used either with general anesthesia or after a traumatic injury. In emergency situations and some surgeries, it is crucial to saving the patient’s life. In cases where intubation can be avoided, however, singers should carefully consider their options. Intubation can have residual (sometimes permanent) negative effects on the voice.
How Common Are Complications?
A British Journal of Anesthesia study of intubation injuries found that the incidence of significant injury after short-term intubation was 6.2 percent. Of the 1,000 patients studied (after normal intubations during general anesthesia/surgery), 52 had evidence of hematoma (bruising), of which 45 were vocal cord hematomas. Eight had vocal cord lacerations, one had vocal muscle laceration, and one had arytenoid subluxation.1 A subsequent study from The Annals of Otology, Rhinology, and Laryngology found that 6.3 percent of 475 patients had traumatic lesions of the larynx or hypopharynx (30 patients). Twenty-two of these were hematomas of the vocal cord, two of the epiglottis, and one of the false cord; three had lacerations of the larynx or hypopharynx; and two had vocal cord paralysis.2 In an eastern European study, the rate of post-intubation injury was even higher, around 13 percent.3 (We share this statistic for the many singers performing around the world.) Altogether, the rate of significant injury from short-term intubation is around six percent
.
In cases where long-term intubation is required (like Sammi’s), the incidence of permanent injury is much higher. Studies have found a proportionate link between the duration of intubation and the severity of vocal injury. The link is strong enough that a tracheotomy is now recommended over long-term intubation.
How many of these injuries are “cured”? In a study of malpractice claims against anesthesiologists, half of the voice-related claims were for one of three injuries: vocal cord paralysis, granuloma (bumps), and arytenoid dislocation.4 Statistically, after a normal intubation, the chance of unresolved, permanent damage to the voice is around one in 100. 5
What Do These Injuries Mean
to the Singing Voice?
While a moderate risk of vocal cord injury may be acceptable to a non-singer, the risk level is uncomfortably high for singers. But how exactly does a “vocal cord hematoma” affect the singing voice?
I was unable to find any studies linking a specific injury to a specific vocal change. Anecdotally, however, intubation-caused vocal changes run the gamut from loss of singing ability to extended hoarseness, and everything in between. Patients are typically told that if everything goes well, they should expect a sore throat and hoarseness for 1-2 weeks after a non-eventful intubation. After an intubation in which something goes wrong, the effects can be much worse.
Loss of Singing/Speaking Ability
The worst-case scenario for a singer is permanent loss of the ability to sing and/or speak. Six CS subscribers reported family members or friends who completely lost their voice due to intubation injuries.
“Intubation damage happened about 30 years ago to my father, who was earning money as a hypnotist and a lecturer on hypnosis. His well-modulated and expressive speaking voice was one of his tools. His lovely (untrained) lyric baritone singing voice was just an added pleasure.
“He underwent plastic surgery on a badly broken finger. They stuck a tube down his throat— and that was the end of his voice. After the surgery, he would lose his voice after only a few minutes of talking. Eventually he saw a laryngologist, who told him that his vocal cords had been scratched by the tube and that there was really nothing to be done to put him vocally back to where he had been before the injury.
“Over and over my father has told me, with tears in his eyes, that if I ever need an operation which calls for anesthesia I must request that intubation not occur. If for some reason intubation must occur, warn the anesthesiologist that you are a singer, that your vocal cords must not be damaged, and threaten to sue if they are!”
—Marion Leeds Carroll,
soprano and stage director
Long-term Loss of Singing Ability
Another devastating effect is losing the ability to sing for a long period of time. Often, these injuries do resolve somewhat, but the singing voice never returns to normal.
“My sister was a fine soprano and sang all of her life. When she had quadruple bypass surgery, they intubated her for the duration of the operation. She told me that one of the most frightening things about her surgery was that this tube was down her throat when she woke up and she was gagging. She was told to blow out air while they took it out. What a terrible thing for a singer. Our throats are so sensitive that this alone was a trauma for her. After the surgery, she had quite a bit of pain and a sore throat for some time. She was not able to sing at all for three years, and although she can sing somewhat now, her voice is significantly weaker.”
—Carol Bayard,
NY City Opera soprano,
voice teacher and author
Loss of Some Vocal Ability
Another possible complication is the loss of some previously-held vocal function (e.g. the ability to blend the voice). In some cases, the actual physiological change is difficult to pinpoint. However, the singer is very aware of a change in function.
“I was a pretty good singer. I had a manager, was getting good work singing new music, and was still getting auditions for regional opera companies. I have a BM in voice from Eastman and had studied with a very prominent NYC voice teacher. After I gave birth, I had vocal hemorrhages and eventually had to have laser surgery on them. A few days after the surgery, the MD saw a swelling on the back of the cords and told me that the anesthesiologist nicked the cords while removing the tube. I was given a cortisone shot and my post-surgical regimen was changed to one week of vocal rest to six weeks of only head-voice humming.
“When it came time to sing out, I could barely phonate in the middle. Nothing I tried worked. There was just a huge hole in the voice. Chest voice worked, head voice worked, high notes were OK, but there was nothing doing in between. It would crack or be barely a whisper of sound, if anything at all. A sustained tone would crack with each oscillation of vibrato.
“I was then sent to a vocal therapist, who I saw for many months in tandem with my teacher, who came to some of the sessions. They trained me to sing solely in head voice from top to bottom, so that I could sing something again, but with little thought to a professional sound. I hated it! This was not my voice; this was half my voice. The vocal therapist told me that no amount of technical work could bring back my old voice. I credit this whole experience (intubation injury, then cortisone shot, then extended inactivity, then misguided voice therapy) with ending my career, such as it was.”
—East Coast soprano
Change in Vocal Function
Some singers report an overall change in the timbre of their voice after intubation.
“I was intubated for about a week following a serious highway accident two years ago. When I first sang afterwards, I felt like the notes were coming out of someone else. I was singing, but it didn’t sound like me. And, the notes that I thought were going to come out didn’t— everything came out higher. In particular when I sang lower, I didn’t know where to put those notes in my voice anymore. It was like I had a different, higher voice. My low voice has also changed; I feel like I have dirt in my voice when I sing low notes, no matter how much support I use.”
—Sammi Winniski,
Seattle student of voice
Temporary Loss of Vocal Function
The most common complication of intubation is temporary loss of normal singing and/or speaking ability.
“I came down with a terrible illness on Thanksgiving Day last year. At the hospital they informed me I would require not one but TWO separate surgical procedures. Normally, they do both at the same time, but I was so ill that they were hesitant to do both at once.
“I had a great anesthesiologist during the first procedure, who gave me “twilight” anesthesia instead of general anesthesia with intubation. After five days, I had the second procedure, which was to be done in the conventional manner with full anesthesia and multiple incisions.
“Unfortunately, I couldn’t get the same anesthetist for the second procedure. I wound up with someone who had no care about my concerns for vocal health. (I personally think he was more interested in doing his job and going home than in his patients.) I lost my voice completely for two weeks after the second surgery, and I could barely sing for four months. I came home on December 1st and didn’t get back to full voice until April.”
—Kristin Behrens, emerging concert soprano
What Can Singers Do?
It seems simple: just tell your doctors that you don’t want intubation, right? Unfortunately, it’s more complicated than that. For one, some procedures and medical conditions absolutely require intubation, and singers would be risking their lives and health to request something different. And, sometimes the situation is beyond the singer’s control. Examples include emergency procedures, or this situation, when the procedure was not explained fully to the patient:
“Many years ago, before my career was full time, I had general anesthesia while having several wisdom teeth extracted. It was just before I had to sing the High Holidays, and I was shocked when I awoke and found that I had a sore throat. No one told me that they were going to intubate me, and I was furious.”
—Josepha Gayer, Met Opera mezzo-soprano
It may take extraordinary effort to avoid intubation. In this situation, the medical professionals weren’t willing to change their routine:
“The first thing I did was to find the best surgeon, and then say repeatedly and loudly that I was a professional singer. Then I discussed with him the procedure. Apparently, for a ruptured disk in my neck, they had to go straight through from the front of my neck past the Adam’s apple. Since operating on one side of my trachea risked the laryngeal nerve (hence never being able to sing again), I asked for an approach from the other side. They were somewhat resistant to any change in their procedure, but I insisted. I asked to meet with the anesthesiologist. He was NOT receptive. Discussions with my anesthesiologist brother had informed me that they could use a SMALLER tube for intubation, thus reducing the risk of bruising and tearing. Although I believe you should try to gain the sympathy of your medical professionals, I also had to be a bit chuffy with the anesthesiologist to get him to pay attention. Altogether, the team was very resistant to any irregularity. Fortunately, the surgery was quite successful, and I’m fully recovered now.” — Douglas Biggs, dramatic tenor, Kentucky
And finally, communication between the surgeon and the anesthesiologist is sometimes lacking:
“Because I have a bad reaction to spinal blocks (leaky spinal cord), I requested another type of anesthesia for a lower-body procedure. My only other choice, they said, was general anesthesia and intubation. I balked, fearing for my cords, and asked if there was any other way. Reluctantly, the surgeon said they could do the procedure with an epidural and intravenous sedation, but that I’d need to speak to the head of the anesthesia department. I did, and he was happy to accommodate me.
“When I showed up for my procedure the next day, though, he wasn’t there, and the new anesthesiologist was all prepared to intubate me. I was pretty scared and upset, already in my gown and in some pain. Apparently, neither the surgeon nor the head of anesthesia had communicated my wishes to him. Fortunately, the new anesthesiologist was very kind and agreed to the epidural with sedation.”
— Seattle Opera chorus member
Positive Experiences
Happily, many CS readers also had empowering stories to share. Many had some prior knowledge about intubation risks (or at least a strong aversion to a tube passing through their larynx!) and had good experiences with their procedures. Below are stories of caring medical professionals who adjusted their routines to accommodate singers.
“I had had numerous family members with surgeries and wondered why they had rough throats for some time afterwards. At the tip-off of a voice teacher, I frantically contacted my doctor the night before my tonsillectomy (I was 21 at the time) about the procedure. He agreed to supervise the anesthesiologists during the intubation process, and also to have them use an adolescent-sized intubation tube. My medical staff were very kind about it, and I’m singing years later with no problems.”
—Gary Ruschman, San Francisco tenor
“I’ve had three surgeries requiring complete anesthesia in the past six years. The first two were in Germany (appendectomy & foot surgery—a work-related injury in the opera house there). Each time, after explaining that I was an opera singer, the anesthesiologist used the finest, most flexible tube possible. Apparently, awareness is a key factor. After each of these surgeries, I had the normal dryness associated with anesthesia, but absolutely no vocal problems. The last surgery I had was in August of this year. When the anesthesiologist learned that I was an opera singer, he administered anesthesia with a new technique that requires no intubation. The administering device remains in the mouth, well above the vocal folds. The anesthesiologists who treated me were very cooperative.”
—Repatriated (and working) American opera singer
“When I was a sophomore at Boston Conservatory, I was scheduled to get my tonsils out because my tonsils were HUGE and I had been getting too many colds and other unpleasant occurrences. I explained to the doctor that I was an opera singer and my cords were, at that point, my whole life. I expressed how nervous I was about someone putting a tube down my throat to “put me out” because I wanted to have a singing career. I asked to speak with the anesthesiologist in person and requested that a smaller tube be inserted with much care. I’ll never forget it; the anesthesiologist came to my hospital bedside and put my fears at ease. She heard and responded to my earnest concern. She said that she would take great care in the intubation process and that in using a smaller tube, she would get the same results she needed. Though I was insistent, it was worth it. My voice grew in size and color after removing the golf balls from the back of my throat and I’m happy to say I’m maintaining lovely, white, healthy cords as I sing daily … many thanks to the hospital and the attentive anesthesiologist who listened and heard me.”
—Donna Olson, Opera San Jose resident artist
Assertiveness Training!
Any surgery has risks, which is something that everyone (especially singers, whose bodies are their instruments) should consider—particularly before undergoing elective surgery. If you must have surgery, please carefully review Dr. Jahn’s article on anesthesia options. Choose your surgeon and hospital carefully. (Hospitals where ENT surgery is frequent may be more likely to accommodate singers’ needs). Then, discuss the procedure with your surgeon, and be prepared to possibly discuss it again with your anesthesiologist.
CS readers had some suggestions for getting that “extra special” treatment. One singer suggested stating that if your vocal cords are damaged, you will sue. Another suggested taping the word “SINGER” on your forehead before surgery! My favorite suggestion was to give a copy of your CD/demo to the staff, and request they play it during surgery.
ALERT! Singer on Board!
What about unplanned surgeries, or life-threatening injuries? Not much chance to do research or talk with medical staff in those situations! A few singers shared that they carry “singer alert” cards, similar to “medic alert” cards that inform emergency teams of your medications and conditions. The singers’ cards request that emergency teams take extra care with the vocal cords.
We’ve created a sample card, which you can cut out and keep in your wallet. This card may help prevent emergency intubation injuries or long-term intubation (such as happened to Sammi). If you have any additional medical information that emergency teams should know (allergies or medications you take regularly), you might want to make your own card and add that information to the back. If you have a serious medical condition or travel alone often, you might consider buying a “medic alert” necklace, bracelet, watchband, dog tag or pendant, which can be engraved with both your medical information and the “singer alert” information.
By being assertive, and by sharing this information with fellow singers, we may see an end to stories like those shared. Since only some voice programs educate their students about intubation and vocal surgery, it is my hope that this information becomes a standard part of voice program curriculum. Ultimately, though, it is up to singers to advocate for our voices. As the positive stories show, armed with a little information, it is possible to have a good surgical experience with little or no effect on your singing voice.
