How Long Do Swallowing and Voice Problems Last After C-Spine Surgery ACDF?

I often see patients for swallowing and/or voice difficulties after cervical spine surgery (ACDF). In the vast majority of cases, reassurance that such "side effects" are not uncommon is the only thing I need to provide after a complete exam.

After all, both the voice box and swallowing tube are manipulated and pushed over to one side in order to perform cervical spine surgery from an anterior approach. Check out the video below that illustrates how this happens.

Beyond reassurance, the next question patients have is how long before things go back to normal. Until now, that was a hard question to answer.

A recent report was able to provide some numbers I can now use to help explain to patients. After anterior approaches to cervical spine surgery:

• 60% had a postoperative issue, including 27% with postoperative voice complaint and 48% with postoperative swallowing complaint
• Swallowing complaints that lasted beyond 1 year occurred in 28%
• Voice complaints that lasted over 1 year occurred in 9%
• Approaching spinal levels above C4 and exposing more than 3 spinal levels were 2 factors that significantly resulted in voice and swallowing problems

In certain patients with more extreme swallowing difficulties, barium swallow studies may be ordered. Swallow therapy can be helpful as well.

Should vocal cord paralysis be seen on endoscopy, voice therapy and even vocal cord medialization injections can be performed to alleviate voice problems.

Reference:
Factors Predictive of Voice and Swallowing Outcomes after Anterior Approaches to the Cervical Spine. Otolaryngol Head Neck Surg. 2013 Dec 23. [Epub ahead of print]

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Surgeries on a Weekend Have More Complications

The New York Times published an interesting story regarding how patients with ulcerative colitis suffered significantly more surgical complications when performed on a weekend compared to a weekday. Just how much worse?

The cited research reported that the most common post-operative complication was post-operative infections (Weekend 30% vs. Weekday 20%). However, there was also an increased risk of need for repeat laparotomy, mechanical wound complications, and pulmonary complications. Of note, there was no difference in disease severity between weekend and weekday groups.

Oddly, this increase in complications did not occur with Crohn's disease patients.

Although these findings can not and should not generalize to other surgical procedures, the following logistical issues ARE present when decision for urgent surgery is made after hours or on weekends.

The following issues are probably what prompts this type of research to occur in the first place.

During such off-periods, there are no surgical support staff present in the hospital. They need to be called in from home. As such, there may be a slightly higher time delay before surgery begins. Furthermore, the surgical tech that assists the surgeon may be unfamiliar with the surgery as well as instruments used leading to a surgical procedure that may be "inefficiently" performed.

For example, if I need to take a child back to the OR who is suffering from excessive bleeding after a tonsillectomy, the surgical technician who may be assisting me may be an orthopedic technician unfamiliar with ENT instruments as well as unfamiliar with how the procedure is performed.

Although one may like to select who assists in the surgery, unfortunately, the patient nor the surgeon gets to choose who their surgical support staff is. It is whoever happens to be on-call when the need for urgent surgery arises. You get who you get...

However, during the weekday, the surgical support staff helping with the surgery is the team that does that particular surgery all the time... the "A" team so to speak.

The other factor is the surgeon himself. During the weekday, the patient will most likely have surgery performed by "their" surgeon who knows and is already familiar with the patient.

After-hours or on the weekend, the patient may or may not get the surgeon who knows the patient personally. It would be whoever the on-call surgeon is.

So now you know...

Now to be fair, there have been studies that both support as well as refute the assertion that weekend surgeries/admissions place patients at elevated risk of complications.

Source:
Weekends Worse for Surgery. New York Times. 3/22/13

Reference:
Weekend hospitalisations and post-operative complications following urgent surgery for ulcerative colitis and Crohn's disease. AP&T Article first published online: 4 MAR 2013. DOI: 10.1111/apt.12272

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What to Do and Care After Vocal Cord Surgery

When surgery is performed on the vocal cords, there are some very specific after-care that is required to allow for optimal healing. In order to understand the "why" such post-operative care is required, one must first understand how the vocal cords normally work. If you already know, just skip down to the bottom.

The vocal cords are arranged in the shape of a "V". When breathing, the vocal cords are open to allow air to pass through and down into the windpipe. When talking, the vocal cords come together and vibrate. Click here to watch a video.

When surgery is performed on the vocal cords, one is actually cutting into the actual organ that allows one to talk and make other noises.


As such, the care required after vocal cord surgery requires the elimination of any activity that may lead to damage to the surgery site and allow proper and safe healing.

I should mention that the following instructions are our opinion. Other laryngologists may have different after-care instructions.

Strict Voice Rest! 

This means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the surgery site. I even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking.

The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.

Strict voice rest typically lasts for 1-2 weeks after surgery.

No Coughing or Throat-Clearing

Just as with talking, coughing and throat-clearing also causes the vocal cords to come together and should be avoided if at all possible. Narcotic strength cough-suppressants (ie, hycodan) are often prescribed to help suppress the urge to cough.

Take Reflux Medications

Reflux medications should be taken both before and after surgery to prevent any possibility of acid damage to the surgery site. Such medications should be taken EVEN IF you do not have any symptoms of acid reflux. I typically recommend patients to start such medications one week before surgery and to continue for as long as 3 months after surgery.

Voice Therapy

Voice therapy is recommended before surgery so that patients will understand what and how they are supposed to talk once cleared to do so after surgery. It's much easier to answer questions and practice proper talking technique before surgery rather than after surgery when you are on strict voice rest!

The rationale for voice therapy is to prevent continued phono-trauma to a freshly healing surgery site on the vocal cord. Often, if improper talking technique persists after surgery, the surgery site becomes damaged again or heals with abnormal scar tissue leading to the possibility of needing surgery again.

Voice therapy minimizes the likelihood of needing repeat vocal cord surgery in the future!

Restricted Voice Rest

Once the period of strict voice rest ends, the patient is slowly allowed to talk under voice therapy guidance. From this point forward over the next 4-6 months, the patient is under restricted voice rest.

Restricted voice rest is a fairly broad phrase, but essentially means to:

• NEVER abuse the voice (ie, yelling, screaming, loud talking, etc)
• Talk only when you must (ie, no social talking)

This period of restricted voice rest is important because it allows time for the new vocal cord tissue that has developed to not only heal, but also strengthen. Abusing the voice may tear the freshly healed surgery site which must be avoided at all costs!

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After Surgery, Do Patients Have Out-of-Pocket Costs for Follow-Up Visits?

Assuming a patient has insurance, the answer is generally no for a certain period of time...

For a period of time after surgery, insurance specifies that a surgeon provides any and all routine post-operative care for "free" without any patient out-of-pocket charges.

This period after surgery is called "global period" and is based on the assumption that the insurance has already paid for not only the surgery, but all the post-operative care that goes along with the surgery.

BUT... there are certain situations where global period does not apply... such as if a problem arises that is separate from the surgery like seeing the surgeon for a sinus infection after having a skin wart removed.

The sinus infection is a separate problem from the skin wart removal procedure and out-of-pocket copays will apply.

Also, global period does not apply if you decide to see a different surgeon in a different office for any post-operative care. It only applies to the surgeon who actually performed the procedure.

The next question is how long the global period is for post-operative care?

For most surgical procedures, it is 90 days after which any subsequent care is NOT "free".

However, especially for ENT-type procedures, there are a significant number of procedures where the global period is substantially shorter... even zero days.

Here's a sampling of common ENT-type procedures and the global period number of days.

90 Days Global Period
Tonsillectomy +/- Adenoidectomy
Uvulopalatopharyngoplasty
Parotidectomy
Thyroidectomy
Septoplasty

10 Days Global Period
Ear Tube Placement
Coblation Turbinate Reduction
Closed Nasal Reduction for Nasal Fracture

0 Day Global Period
Sinus Surgery
Vocal Cord Surgery
Nosebleed Control

For procedures that have a short global period, depending on circumstances, the surgeon may elect to not charge if a patient is seen past the specified number of days.

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