Anesthesia and the Professional Voice
John Santiago, MD and Michael E. Mahla, MD
Department of Anesthesiology, University of Florida, Gainesville, Florida
ABSTRACT
A 52 year-old morbidly obese female professional opera singer presented for
an elective laparoscopic umbilical hernia repair. She strongly wished to
avoid endotracheal intubation for fear of losing vocal function transiently
or permanently. Her medical history indicated very poor exercise tolerance
secondary to osteoarthritis and dyspnea on exertion. She had no history of
heart disease or hypertension. She had no symptoms of reflux. She neither
smoked nor consumed alcohol. Physical examination revealed an anxious,
massively obese female. She was 66 inches tall and weighed 168 kg giving a
BMI of 57.3. Airway exam revealed moderately poor dentition with > 3 FB
mouth opening, good neck extension and a normal thyromental distance. Lungs
were clear to auscultation. Examination of the heart revealed distant heart
sounds and otherwise normal findings. The remainder of the physical
examination was unremarkable except for her obesity. Laboratory and all
diagnostic testing including a 2-D echocardiogram were normal. After
prolonged preoxygenation, anesthesia was induced with propofol and a
remifentanil infusion. A #5 ProSeal LMA (LMA-PS) was placed uneventfully and
gentle manual positive pressure ventilation was instituted. A leak was
detected at 35 cm H2O inflation pressure. Returned tidal volume at that
pressure was ~850 cc. Vecuronium, 8 mg was administered for muscle
relaxation, and mechanical ventilation was instituted using the pressure
control mode set at 35 cm water. A gastric tube was easily passed and the
patient's stomach contents suctioned. The tube was left open to vent any
gastric gas to the atmosphere. Anesthesia was maintained with oxygen, air,
propofol, remifentanil, and vecuronium. Ketorolac, 30 mg, was administered
prior to incision for preemptive analgesia. After insufflating the
peritoneal cavity and inserting the laparoscope, no evidence of gastric
distension or inflation was seen at any time during surgery. There were no
episodes of decreased oxygen saturation, and end-tidal CO2 values were
easily maintained at < 40 mm Hg. Surgery proceeded uneventfully. At the
conclusion of surgery with LMA-PS removal, there was no evidence of
aspiration and no staining of the LMA by gastric contents. Postoperative
pain was managed successfully with incremental doses of morphine. The
perceived tonal quality of her voice was unchanged from her preoperative
baseline.
Use of the LMA with positive pressure ventilation and in morbidly obese
patients will be reviewed. Changes in vocal apparatus function associated
with surgery and the probable role of endotracheal intubation will be
reviewed.
References:
1. Zimmert M et al. Effects on vocal function and incidence of laryngeal
disorder when using a laryngeal mask airway in comparison with an
endotracheal tube. Eur J Anaesthesiol 1999; 16: 511-5.
2. Lu PP et al. ProSeal versus the Classic laryngeal mask airway for
positive pressure ventilation during laparoscopic cholecystectomy. Br J
Anaesth. 2002 Jun;88(6):824-7.
