Anesthetic Options
Not too long ago, a patient undergoing a surgical procedure had two options: local injection of the surgical area (similar to a dental procedure), or full general anesthesia with laryngeal intubation. This involves placing a plastic tube through the larynx between the vocal folds and positioning it with the end in the trachea, to allow the administration of oxygen and anaesthetic gases.
Today there are many anesthetic options available. Specifically, endolaryngeal (or endotracheal) intubation can be avoided. Most smaller procedures around the head and neck can be performed with a combination of local injection supplemented by intravenous sedation. The patient is rendered sleepy, and the surgical area is anesthetized with a medication that numbs the surgical site for several hours. During the procedure the patient’s awareness and comfort level is continuously monitored, and additional intravenous sedation is given if necessary. Most nasal and sinus procedures can be performed in this way. Operations on the middle ear, as well as cosmetic procedures on the face can also fall into this group. Conventional tonsillectomy is an important exception: here, the anesthetists must prevent any blood from entering the airway, and thus an endotracheal airway or laryngeal mask is used.
The combination of local or regional block with intravenous sedation is also generally used for smaller orthopedic procedures on the extremities (such as carpal tunnel, Dupuytren’s contracture of the hands, or podiatric procedures), and hernia surgery. If general inhalational anesthetic is deemed necessary, the anesthetists may still avoid intubation by use of a laryngeal mask.
The laryngeal mask is similar in principle to a facemask (“oxygen mask”). It is smaller in size and is placed in the back of the throat to fit over the top of the larynx. Once in position, it is inflated and seals off the airway from the rest of the pharynx. This prevents saliva or other fluids from entering the windpipe. For short procedures requiring general anesthesia, or for patients too anxious to tolerate local anesthesia with intravenous sedation, the laryngeal mask is a useful alternative. Specifically for the vocal artist, the laryngeal mask covers rather than invades the larynx and minimizes trauma to the vocal folds.
Minimally Traumatic Intubation Anesthesia
Thus far, we have discussed surgery and anesthesia as if we had a catalogue of options. Of course, surgery is not always optional, and there may be situations where a full general anesthesia with endotracheal intubation is necessary. Like the general population, singers may be involved in accidents, develop serious or life-threatening conditions or require prolonged surgical procedures. In these instances, the need to save a life, to remove potentially fatal disease, or to correct a debilitating condition takes precedence. Once the patient understands the severity of his disease and treatment options are limited, it is generally wise to defer clinical decisions to the physician.
There are several components to a minimally traumatic intubation anesthetic. If the patient has the opportunity, she should inform the anesthetists that she is a singer whose livelihood depends on her larynx. She should request, if possible, that should an intubation be necessary, it is performed by an experienced anesthetist. Particularly in teaching hospitals, the intubation should be done by a qualified specialist, not a student, resident, or a trainee.
The endotracheal tube used should be the smallest one that can adequately deliver anesthesia and protect the airway. The choice of tube size is made by the anesthetists, and this is an area where experience is important. Although tubes of “standard size” are generally used, for the vocalist a smaller size represents less trauma and is therefore desirable.
Anesthesia is usually accompanied by a paralytic agent. This relaxes the muscles and allows the anesthetists to control completely the patient’s breathing, an important part of managing respiration and oxygenation. The paralysis is reversed at the end of surgery, and spontaneous breathing resumes. The tube may be removed either just before or just after spontaneous breathing movements return. Since these movements are accompanied by movements of the vocal folds, it is our suggestion that, if possible, the tube be removed before the folds begin to move. This “deep extubation” removes the tube before the vocal folds start to come together and minimizes trauma to their vibrating surfaces.
During extubation there may be some retching with reflux of stomach acid. Some anesthesiologists routinely suction the stomach before awakening the patient in order to prevent this. Along with suctioning, postoperative antinausea medications can prevent damage to the vocal folds by stomach acid. The increasing recognition of perioperative acid reflux has led some laryngologists to recommend antacid medications prior to surgery. Certainly, if the vocalist patient is prone to reflux, their routine anti-reflux medications should be continued before surgery to just before they need to begin fasting (usually midnight the night before the procedure).
Once in the recovery room, the patient should be given a facial mask with humidified air or oxygen. Humidity is important, as is voice rest. Unnecessary talking, particularly in a noisy recovery room, can further traumatize the vocal folds.
Early Convalescence
Even the singer cognizant of possible vocal damage will feel the need, after surgery, to cough. This cough clears the airway of secretions and is part of the process of reinflating the lungs. If possible, coughing should be done with minimal trauma. A forceful clearing of the airway without approximating the vocal folds, or a single strong cough, is better than repeated paroxysms of coughing. If the lungs are not properly reinflating, physical therapy can help and should be offered. Postural drainage and clapping over the chest can loosen secretions and make the cough more productive.
Pain is a frequent part of convalescence. While excessive pain should not be tolerated, the singer needs also to be aware of the side effects of excessive analgesics. An over-sedated patient may not cough effectively, and recovery of lung function may be delayed. Some analgesics are drying, an undesirable state for the vocal performer. Medications containing codeine or codeine analogues are also constipating. Straining on the toilet involves forceful approximation of the vocal folds and should be minimized. Indeed, if the patient is constipated for any reason following surgery, he should request a mild laxative.
When can singing be resumed? After any surgical procedure requiring endotracheal intubation, the singer should not vocalize for at least 4 to 5 days. If at that time the voice is not clear, another 5 days of rest should be considered. If after 12 days the voice is not normal, the larynx should be examined by a laryngologist to make sure there is no evidence of hemorrhage or trauma. Once the singer has a clear bill of health, full vocal activity may be resumed. Mild residual edema may create difficulty at the top of the range, and this need not be a cause for concern. Prolonged vocal rest is to be avoided, since disuse of the larynx can create its own problems. After prolonged intubation (such as may be necessary for some after an accident), the larynx should be examined prior to any vocal exertion. Prolonged intubation can not only cause mucosal damage in the posterior part of the larynx but can also result in malpositioning of the vocal folds. These conditions may require medical treatment and voice therapy.
Reprinted with permission from Care of the Professional Voice: A Management Guide for Singers, Actors and Professional Voice Users, by D. Garfield Davies, Anthony F. Jahn. Currently available at Amazon.com, and Classical Singer magazine (see page 43 bottom).
DISCLAIMER: The suggestions given by Dr. Jahn in these columns are for general information only, and not to be construed as specific medical advice or advocating specific treatment, which should be obtained only following a visit and consultation with your own physician.
