Laryngeal complications of COVID-19

Abstract

Objective: To describe and visually depict laryngeal complications in patients recovering from coronavirus disease 2019 (COVID-19) infection along with associated patient characteristics.

Study design: Prospective patient series.

Setting: Tertiary laryngology care centers.

Subjects and methods: Twenty consecutive patients aged 18 years or older presenting with laryngological complaints following recent COVID-19 infection were included. Patient demographics, comorbid medical conditions, COVID-19 diagnosis dates, symptoms, intubation, and tracheostomy status, along with subsequent laryngological symptoms related to voice, airway, and swallowing were collected. Findings on laryngoscopy and stroboscopy were included, if performed.

Results: Of the 20 patients enrolled, 65% had been intubated for an average duration of 21.8 days and 69.2% requiring prone-position mechanical ventilation. Voice-related complaints were the most common presenting symptom, followed by those related to swallowing and breathing. All patients who underwent flexible laryngoscopy demonstrated laryngeal abnormalities, most frequently in the glottis (93.8%), and those who underwent stroboscopy had abnormalities in mucosal wave (87.5%), periodicity (75%), closure (50%), and symmetry (50%). Unilateral vocal fold immobility was the most common diagnosis (40%), along with posterior glottic (15%) and subglottic (10%) stenoses. 45% of patients underwent further procedural intervention in the operating room or office. Many findings were suggestive of intubation-related injury.

Conclusion: Prolonged intubation with prone-positioning commonly employed in COVID-19 respiratory failure can lead to significant laryngeal complications with associated difficulties in voice, airway, and swallowing. The high percentage of glottic injuries underscores the importance of stroboscopic examination. Otolaryngologists must be prepared to manage these complications in patients recovering from COVID-19.

Level of evidence: IV.

Keywords: COVID‐19; intubation; laryngology; larynx; stenosis; voice.

FIGURE 1

Laryngeal complaints at presentation, from most to least frequent

FIGURE 2

63‐year‐old male with A, unilateral vocal fold immobility, with prolapse of the arytenoid tower (white arrow) over the posterior aspect of the glottis, with vocal fold bowing and foreshortening (gray arrow); and B, mild A‐frame deformity with oblong shape to tracheal cartilage, with small amount of granulation tissue on posterior wall (asterisk). The blood (black arrow) is from the transcricothyroid injection of lidocaine to anesthetize before tracheoscopy

FIGURE 3

69‐year‐old male intubated for 30 days, without tracheostomy, presenting with stridor. Office bronchoscopy demonstrated, A, mild tracheal granulation tissue (asterisk). Laryngoscopy demonstrated, B, bilateral vocal fold immobility with a narrow glottis opening which, on urgent exploration in the operating room, was shown to be (C) posterior glottis stenosis, with an obvious scar band (white arrow)

FIGURE 4

48‐year‐old male with dyspnea after 25 days of intubation. Granulation tissue (asterisk) and subglottic stenosis (black arrows) are demonstrated. There is loss of tissue in the posterior glottis (dotted lines), consistent with posterior glottis diastasis. The right cord tissue loss is not marked for comparison. This patients required two operations for stenosis within 2 months, as well as office steroid injections to keep his airway open