OUT OF COMMITTEE: Voice | Upper Aerodigestive Tract Manifestations of COVID-19: Voice, Airway, and Swallowing
COVID-19, like other upper respiratory tract infections that cause widespread airway inflammation and possible neurotropism of the vagus nerve, can affect the voice.
Sandra L. Ettema, MD, PhD, CCC-SLP, Diana N. Kirke, MD, and Karla F. O’Dell, MD
What We Know
COVID-19, like other upper respiratory tract infections that cause widespread airway inflammation and possible neurotropism of the vagus nerve, can affect the voice. The rate of dysphonia is widely variable, quoted at 25% of patients with mild-to-moderate disease to 75% of those with severe disease requiring intubation.1 Increasing age appears to be a significant factor in the development of dysphonia.2 Finally, duration has been reported as greater than two weeks in 47.1% but greater than a month in only 15.7%.3
What We Are Seeing
Dysphonia from COVID-19 can be related directly to the sequelae from intubation or can also occur in those who were not intubated. It generally manifests as voice fatigue, with one reported rate of 26.8%, and less rarely dyspnea.3 Dysphonia in those previously intubated is more likely related to structural and anatomic inflammatory changes of the glottis, such as arytenoid ankylosis and posterior glottic stenosis.4 In those who have not been intubated, the underlying cause of dysphonia appears to be related to a neurogenic etiology, such as vocal fold paralysis, paresis, and compensatory muscle tension dysphonia.4,5
What to Look for
If a patient has persistent dysphonia following infection with COVID-19, they should be promptly assessed by an otolaryngologist and speech language pathologist (SLP). Subjective and objective acoustic measures should be obtained at baseline, where possible. If dysphonia is persistent, the patient should be assessed via videostroboscopic assessment. Interventions are targeted toward the underlying cause and include voice therapy, in-office procedures, such as injection augmentation, and operative procedures aimed at addressing glottic stenosis.
What We Don’t Know
Intubation-related dysphonia is no doubt related to the inflammatory sequelae of pressure ischemia; however, whether this is worse in the COVID-19-affected patient has still yet to be elucidated. In those with non-intubation dysphonia, multiple hypotheses have been proposed and are largely centered on post-viral vagal neuropathy (PVVN). It is now well known that COVID-19 enters cells of the respiratory tract by attaching to angiotensin converting enzyme 2 (ACE-2) transmembrane protease serine 2 (TMPRSS2) proteins. Being that these receptors are found throughout the upper respiratory tract, including the vocal cords, is an indication to causality of the neurological dysfunction but is an area for further investigation.4
What We Know
COVID-19 can cause detrimental involvement of the lower respiratory tract with interstitial pneumonia requiring prolonged endotracheal intubation and mechanical ventilation with high positive end-expiratory pressure through an endotracheal tube (ETT) and often in prone positioning. Prior to COVID-19, use of smaller ETTs, shorter intubation periods, and a close monitoring of cuff pressures were advocated. Clinical practice with COVID-19 patients was to postpone tracheostomy until the patient no longer needed prone positioning as the fear of accidental decannulation and chance cross infection of healthcare professionals was concerning.6,7 The degree of laryngeal airway injury depends on size of ETT, duration of intubation, and any comorbidities, including cardiovascular issues, diabetes, obesity, shock, or other ischemic conditions or concomitant infections.
What We Are Seeing
Patients who had COVID-19 and required intubation and/or tracheostomy and possibly prone ventilation, high-dose steroids, feeding tube, and/or impaired wound healing from radiation/diabetes and other comorbidities are now often seen weeks to months after extubation or decannulation for acute dyspnea. They complain of shortness of breath with exertion and even rest, stridor, dysphagia, dry cough, globus, and hoarseness. These patients are at highest risk for these symptoms and development of laryngotracheal stenosis and other airway complications.6,8,9
What to Look for
As otolaryngologists, we need to maintain a high level of suspicion for the patients with a history of COVID-19 who were mechanically ventilated with or without tracheostomy post-hospitalization for laryngeal/airway injury and symptoms. There is often a delay in being evaluated by an airway specialist as many are being evaluated by primary care, pulmonology, cardiology, internists, ER physicians, and various allied health professionals first. Our European colleagues predicted an increased number of patients with COVID-19 to have symptoms of airway stenosis and provided direction for automatic follow-up with an otolaryngologist.6 Early endoscopic evaluation and treatment (e.g., debride necrotic tissue, inhaled steroids, antibiotics with anti-inflammatory properties, early dilation) improve the outcome of post-intubation airway stenosis.10-14 Multidisciplinary communication is imperative to heighten awareness of laryngotracheal airway issues and lower the threshold for consultation to an otolaryngologist for an airway evaluation.
What We Don’t Know
It is difficult to know if the airway symptoms in patients with COVID-19 are due to entities we are currently aware of in our knowledge of airway complaints. For example, we are aware increasing cuff pressures and size of ETT can lead to ischemia and airway stenosis, but is it worse if the patient is prone and has COVID-19?6 It has also been pointed out that COVID-19 laryngitis and laryngeal edema may be a factor in prolonged intubation in these patients, as well as nasogastric tube placement.15,16 Future prospective studies will allow us to determine the role these aspects have on long-term outcomes of airway management in surviving post-COVID patients.
What We Know
Dysphagia occurs in 20%-60% of intensive care unit (ICU) patients with acute respiratory distress syndrome (ARDS) requiring intubation with prolonged mechanical ventilation.17,18 The cause of post-intubation dysphagia is multifactorial, related to sarcopenia, critical illness polyneuropathy, alteration in coordination of swallowing, and respiration from pulmonary disease and direct laryngeal trauma, including edema and vocal fold immobility.17 The duration of intubation can increase the incidence of dysphagia. Tracheostomy was often delayed in patients with COVID pneumonia resulting in longer intubation duration.7 Post-COVID-19 patients often have reduced lung function and increased discoordination of respiration and swallowing resulting in worse dysphagia. For these reasons, it is thought that dysphagia after severe COVID-19 infection may be higher than dysphagia after prolonged intubation from other causes.19
Patients with COVID-19 infection can experience long-lasting neurological symptoms, including loss of smell and taste. Once again, it has been shown that the pharynx and larynx surface cells express ACE-2 receptor and TMPRSS2 proteins, which are an entry route for the virus and may have neurosensory alteration resulting in symptoms of dysphagia.20
What We Are Seeing
Dysphagia has been reported as a post-COVID-19 symptom in patients with mild-to-moderate infection and even after resolution of the acute infection. Several survey studies have shown dysphagia to be common with 74% of patients reporting some swallowing symptoms during the initial infection. This percentage reduced to 23% at one-month post-infection.21 In another multicountry survey study on 3,752 patients, 28 days after first symptom 30% of patients reported difficulty swallowing and globus sensation.22 Sensation of food sticking in the throat and difficulty swallowing liquids were reported as the two most common swallowing-related complaints.23
What to Look for
Patients with COVID-19 infection requiring intubation should be screened for dysphagia prior to initiating a diet. SLP should be consulted for evaluation and diagnostic studies as indicated. Patients presenting to outpatient clinics with symptoms of globus sensation and dysphagia following COVID-19 infection should be counselled that these symptoms have been reported for at least 30 days after the initial onset. Patients should be screened for red flag symptoms, such as weight loss, modifying diet because of difficulty swallowing, and overt symptoms of aspiration.
What We Don’t Know
Although it has been postulated that dysphagia in mild-to-moderate COVID-19 may be related in part to a neurosensory disruption, such as loss of taste and smell, it is unclear if this is truly the mechanism. It is unclear also if there is any specific treatment for post-COVID-19 dysphagia. It is not known how long dysphagia symptoms persist after infection as there are no studies that investigate long-term dysphagia symptoms. Prospective studies that define the specific swallowing-related symptoms patients experience with diagnostic results and timeline for resolution of symptoms are warranted.
- Archer SK, Iezzi CM, Gilpin L. Swallowing and voice outcomes in patients hospitalized with COVID-19: an observational cohort study. Arch Phys Med Rehabil. 2021 Jun;102(6):1084-1090. doi: 10.1016/j.apmr.2021.01.063
- Leis-Cofiño C, Arriero-Sánchez P, González-Herranz R, Arenas-Brítez Ó, Hernández-García E, Plaza G. Persistent dysphonia in hospitalized COVID-19 patients. J Voice. 2021 Jul 24:S0892-1997(21)00234-4. doi: 10.1016/j.jvoice.2021.07.001
- Cantarella G, Aldè M, Consonni D, et al. Prevalence of dysphonia in non hospitalized patients with COVID-19 in Lombardy, the Italian epicenter of the pandemic. J Voice. 2021 Mar 14;S0892-1997(21)00108-9. doi: 10.1016/j.jvoice.2021.03.009
- Allisan-Arrighi AE, Rapoport SK, Laitman BM, et al. Long-term upper aerodigestive sequelae as a result of infection with COVID-19. Laryngoscope Investig Otolaryngol. 2022 Mar 9;7(2):476-485. doi: 10.1002/lio2.763
- Rapoport SK, Alnouri G, Sataloff RT, Woo P. Acute vocal fold paresis and paralysis after COVID-19 infection: a case series. Ann Otol Rhinol Laryngol. 2021 Oct 13;34894211047829. doi: 10.1177/00034894211047829
- Piazza C, Filauro M, Dikkers FG, et al. Long-term intubation and high rate of tracheostomy in COVID-19 patients might determine an unprecedented increase of airway stenoses: a call to action from the European Laryngological Society. Eur Arch Otorhinolaryngol. 2021 Jan;278(1):1-7. doi: 10.1007/s00405-020-06112-6
- Sommer DD, Engels PT, Weitzel EK, et al. Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic. Otolaryngol Head Neck Surg. 2020;49(1):23. doi: 10.1186/s40463-020-00414-9
- Ahmed Y, Cao A, Thai A, et al. Tracheotomy outcomes in 64 ventilated COVID-19 patients at a high-volume center in Bronx, NY. Laryngoscope. 2021 Jun;131(6):E1797-E1804. doi: 10.1002/lary.29391
- McGrath BA, Brenner MJ, Warrillow SJ. Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. Lancet Respir Med. 2020;8:717-725.
- 10. Lowery AS, Malenke JA, Boldauan AJ, Shinn J, Wootten CT, Gelbard A. Early intervention for the treatment of acute laryngeal injury after intubation. JAMA Otolaryngol Head Neck Surg. 2021;147(3):232-237. doi:10.1001/jamaoto.2020.4517
- Prince ADP, Cloyd BH, Hogikyan ND, Schechtman SA, Kupfer RA. Airway management for endoscopic laryngotracheal stenosis surgery during COVID-19. Otolaryngol Head Neck Surg. 2020;163(1):78-80.
- Nouraei SA, Singh A, Patel A, Ferguson C, Howard DJ, Sandhu GS. Early endoscopic treatment of acute inflammatory airway lesions improves the outcome of postintubation airway stenosis. Laryngoscope. 2006;116(8):1417-1421.
- Lowery AS, Kimura K, Shinn J, Shannon C, Gelbard A. Early medical therapy for acute laryngeal injury (AlgI) following endotracheal intubation: a protocol for a prospective single-centre randomised controlled trial. BMJ Open. 2019;9(7):e027963.
- Meister KD, Pandian V, Hillel AT, et al. Multidisciplinary safety recommendations after tracheostomy during COVID-19 pandemic: state of the art review. Otolaryngol Head Neck Surg. 2021 May;164(5):984-1000. doi: 10.1177/0194599820961990
- McGrath BA, Wallace S, Goswamy J. Laryngeal oedema associated with COVID-19 complicating airway management. Anaesthesia. 2020 Jul;75(7):972. doi: 10.1111/anae.15092
- Brodsky MB, Freeman-Sanderson A, Brenner MJ. Voice, swallow, and airway impairment after late tracheostomy: defining features of COVID-19 survivorship. Laryngoscope. 2021 Jul;131(7):E2311. doi: 10.1002/lary.29562.
- Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest. 2010;137:665-73.
- Frajkova Z, Tedla M , Tedlova E, Suchankova M, Geneid A. Postintubation dysphagia during COVID-19 outbreak – contemporary review. Dysphagia. 2020;35:549-557.
- Zuercher P, Lang B, Moser M, Messmer A, Waskowski J, Schefold J. Dysphagia incidence in ICU patients with COVID-19 – a retrospective analysis following systematic dysphagia screening. J Laryngol Otol. 2022 Jun 22;1-17. doi: 10.1017/S0022215122001517
- Zanon A, Cacciaguerra L, Martelli G, Filippi M. Neurosensory dysphagia in a COVID-19 patient. J Neurol. 2021;268:3992-3994.
- Verma H, Shah J, Akhilesh K, Shukla B. Patients’ perspective about speech, swallowing and hearing status post-SARS-CoV-2 (COVID-19) recovery: E-survey. Eur Arch Otorhinolaryngol. 2022;279:2523-2532.
- Huang C, Huang L, Wang Y, Li X, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021;397(10270):220–232. doi: 10.1016/S0140-6736(20)32656-8
- Halpin SJ, McIvor C, Whyatt G, et al. Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation. J Med Virol. 2020;93(2):1013-1022. doi: 10.1002/jmv.26368