Associate Professor of Voice, Shenandoah Conservatory Artistic Director of the CCM Vocal Pedagogy Institute
Today multiple news outlets announced that former Fleetwood Mac guitarist Lindsey Buckingham sustained damage to his vocal cords during an emergency open heart surgery. One of the ways injuries of this type can occur is through intubation.
Dr. Andrew Rosenberg, MD, an anesthesiologist at the University of Michigan Medical Center, sheds light on intubation considerations for singers in the Vocal Athlete by Dr. Wendy Leborgne, CCC-SLP and Marci Rosenberg, CCC-SLP. According to Dr. Rosenberg, intubation is performed using an endotracheal tube, commonly known as an ETT.
The ETT is necessary during anesthesia to both help the patient breathe and reduce the risk of the patient aspirating fluids from their mouth or stomach. The ETT is routed through the mouth, down the pharynx, and through the vocal folds. A soft balloon is then inflated below the vocal folds to protect the lungs from external fluids. It also helps the tube stay in place. (Leborgne & Rosenberg, p. 133-142)
According to Leda Scearce, CCC-SLP, author of the Manual of Singing Voice Rehabilitation and head of performance voice care at Duke Voice Care Center “acute complications of intubation, including laryngeal mucosal injury; vocal fold hematoma, laceration, or avulsion; and arytenoid dislocation, have been reported. Postoperative hoarseness following short term intubation less than four hours is reported to be as high as 69%. Complications following long-term intubation greater than 48 hours are reported in approximately 90% of patients and include erythema, edema, and ulceration of the laryngeal mucosa and vocal folds in the initial stages progressing to vocal fold granuloma, pressure necrosis of the posterior commissure, interarytenoid scaring, posterior glottic stenosis, subglottic stenosis, and neuropraxia of the laryngeal nerves” (Scearce, p.49) Even if you do not understand all of those conditions, this is clearly scary stuff!
One of the most serious of these conditions is arytenoid dislocation and subluxation. According to Scearce “arytenoid dislocation is defined as displacement of the arytenoid from the cricoarytenoid joint, whereas arytenoids subluxation is displacement of the arytenoid within the cricoarytenoid joint. Although they are distinct injuries, they have similar clinical appearance and are treated in the literature as a single clinical entity. The estimated incidence of arytenoid dislocation following endotracheal intubation is less than .1%. However, both arytenoid dislocation and subluxation lead to reduced mobility of the ipsilateral vocal fold and incomplete glottal closure, similar to what is seen with vocal fold paresis.”
The good news is a) this is extremely rare (<0.1%) and b) there are operations that can help repair the injury and are successful in 85% of patients according to research (Scearce, 49-50).
So what is a singer to do when they have to undergo an operation that requires anesthesia? First, ask if intubation is even necessary. Dr. Rosenberg says that in an instance where the doctor is not concerned about the risk of aspirating liquids, a laryngeal mask airway (LMA) may be used. In a study comparing ETT and LMA, researchers found a significant reduction in vocal fold lesions when using LMA. If intubation is necessary, Rosenberg says that singers should discuss the size of the ETT tube with the medical team. The medical team usually uses the “largest size tube that would fit easily in an airway instead of the smallest sized tube that would still allow for easy breathing mechanics.” Singers should also discuss balloon pressures with the anesthesiologist as “pressure on the mucosal lining of the trachea has been associated with temporary vocal fold weakness because of pressure on the recurrent laryngeal nerve.” (Leborgne & Rosenberg, p. 137)
Finally, when you wake up from the procedure, do not try to sing. Marci Rosenberg, CCC-SLP, co-author of the Vocal Athlete, SLP at the University of Michigan Vocal Health Center, and resident vocal health specialist at the CCM Vocal Pedagogy Institute says “Though risk of long term vocal injury is relatively low for most surgeries, any decline in voice that extends beyond 2 weeks after surgery, warrants laryngeal examination by a fellowship trained laryngologist. This is essential to determine the status of the vocal folds and surrounding structures. The laryngologist will refer to a speech-language pathologist who is also a clinical singing voice specialist for postoperative rehabilitation”
The most important thing is to communicate with your medical team. Let them know that you are a professional voice user and that sustaining a vocal injury could seriously impact your career. Request an experienced anesthesiologist to perform the procedure and insist that students and/or residents are not involved. Finally, always be kind. Having these discussions calmly and respectfully will get you the best results.
Matt Edwards is an Associate Professor of Voice/Director of Musical Theatre at Shenandoah Conservatory in Winchester, VA, and Artistic Director of the CCM Vocal Pedagogy Institute. He is the author of “So You Want to Sing Rock ‘N Roll” and dozens of articles and book chapters on functional voice training for non-classical styles. For more information visit EdwardsVoice.com
Disclaimers: This article discusses injuries that may occur from intubation. However, there are additional medical situations that could have lead to the voice loss that Mr. Buckingham is experiencing. Matt Edwards is not a medical professional. This article is written for informational purposes only and should not be used to make medical decisions. Always consult a licensed physician for medical concerns regarding your voice.