More thoughts on intubation trauma

I'm writing to you in response to the editorial “Intubation trauma and the head and neck surgeon: issues with a shared airway” published in the Journal of the Royal Society of Medicine.

We felt that there were some points within the article that may have benefited from further discussion.

The article mentions that injury to the larynx following intubation occurs in one-third of patients. From our experience at the Royal United Hospital Bath, this figure seems excessively high. At Bath, just under 300 intubations for laryngeal surgery were performed last year and we do not recall any incidence of laryngeal injury. ² While laryngeal trauma can occur, it is uncommon with significant trauma being rare.

The article mentions a variety of alternative strategies that can be employed for difficult intubations. While videolaryngoscopy was mentioned, we felt that it deserved some elaboration as there are units where videolaryngoscopy (C-MAC Karl Storz Videolaryngscope) has become the standard technique for intubation. ³ It allows both the anaesthetist and the ENT surgeon to evaluate the airway in real time prior to intubation. We would also like to mention the usefulness of jet ventilation either through a ventilating laryngoscope or a narrow Hunsaker Mon-Jet catheter, with the later requiring no intubation.

There is also a review of recurrent laryngeal nerve injuries. The article suggests that recurrent laryngeal nerve monitoring is becoming the standard of care for thyroid surgery. In our experience, many surgeons do not use recurrent laryngeal nerve monitoring. Unlike facial nerve monitoring for parotid surgery, recurrent laryngeal nerve monitoring has not proved as useful in practice. As a result, we do not feel that recurrent laryngeal nerve monitoring is becoming the standard of care and one would not be criticised for not using a recurrent laryngeal nerve monitor in the medicolegal setting. ⁴