Overview
Dysphagia (difficulty swallowing) and vocal cord paralysis are increasingly recognized complications in patients who have undergone long-term endotracheal intubation, especially in critical care settings. As ICU stays become more common—particularly during pandemics and respiratory crises—post-extubation complications are rising, often leading to prolonged recovery, impaired communication, and nutritional challenges.
What Causes These Complications?
- Mechanical Trauma: Prolonged presence of an endotracheal tube can damage the larynx, vocal cords, or recurrent laryngeal nerve.
- Pressure Ischemia: Constant pressure from the tube on delicate airway tissues can lead to local tissue necrosis or nerve damage.
- Inflammation and Scarring: Long-term irritation and inflammation can cause fibrosis around the vocal cords.
- Sedation and Muscle Disuse: Weakening of swallowing and voice-related muscles during extended mechanical ventilation.
Dysphagia (Swallowing Difficulty)
- May appear after extubation as choking, coughing, or aspiration during meals
- Can lead to malnutrition, dehydration, and aspiration pneumonia
- Often underdiagnosed without specific swallowing assessments
- Severity ranges from mild discomfort to complete inability to swallow solids or liquids
Vocal Cord Paralysis
- May affect one (unilateral) or both (bilateral) vocal cords
- Results in hoarseness, breathy voice, vocal fatigue, or loss of voice
- In severe cases, bilateral paralysis can cause airway obstruction and require surgical intervention
Who Is Most at Risk?
- Patients intubated for more than 48–72 hours
- COVID-19 or ARDS survivors with prolonged ICU ventilation
- Elderly individuals with frail tissue and lower healing capacity
- Patients with multiple re-intubations or traumatic intubations
- Neurologically impaired patients or those with pre-existing dysphagia
Diagnostic Tools
- Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
- Videofluoroscopic Swallow Study (VFSS)
- Laryngoscopy to assess vocal cord movement and structural damage
- Clinical bedside swallow assessments for initial screening
Management and Treatment
For Dysphagia:
- Swallowing therapy with a speech-language pathologist
- Modified diet textures (pureed foods, thickened liquids)
- Postural techniques during eating (chin tuck, head turn)
- Feeding tubes in severe or prolonged cases
For Vocal Cord Paralysis:
- Voice therapy for mild unilateral paralysis
- Medialization procedures (e.g., vocal cord injection or thyroplasty)
- Tracheostomy in cases of bilateral paralysis with airway compromise
- Surgical nerve repair in rare cases
Long-Term Outcomes
- Many patients recover partial or full function with early intervention
- Persistent symptoms may require long-term rehabilitation and lifestyle adjustments
- Untreated cases can lead to recurrent aspiration pneumonia, social withdrawal, and poor quality of life
Prevention Strategies
- Minimize intubation duration and transition to tracheostomy when long-term support is needed
- Use of smaller, less traumatic tubes and careful insertion techniques
- Post-extubation screening protocols for early detection of swallowing or voice issues
- Early referral to speech and swallowing therapists