Dental and Vocal Cord Damage During Intubation: Is it Malpractice?

How Intubation Causes Dental Damage

During direct laryngoscopy, the anesthesiologist or CRNA uses a metal blade (laryngoscope) to lift the tongue and epiglottis, creating a line of sight to the vocal cords. The laryngoscope blade rests against the upper teeth, using them as a fulcrum. If excessive force is applied, or if the technique is improper, the blade can chip, crack, or avulse (knock out) teeth.

Dental damage from intubation includes:

- Chipped or fractured teeth: The laryngoscope blade chips the enamel or fractures the tooth structure. - Avulsed (knocked out) teeth: The blade dislodges a tooth entirely. - Damaged dental work: Crowns, bridges, veneers, implants, or fillings are dislodged or damaged. - Subluxated (loosened) teeth: The tooth is loosened but not fully dislodged. - Root damage: The root of the tooth is fractured, often requiring extraction.

Risk factors for dental damage include poor dentition, loose teeth, prominent upper front teeth (incisors), extensive dental work, and difficult intubation requiring multiple attempts or excessive force.

While some dental damage may occur despite careful technique — particularly in patients with fragile teeth or difficult airways — extensive damage from forceful or careless intubation may constitute negligence.

How Intubation Causes Vocal Cord Injury

The endotracheal tube passes between the vocal cords on its way to the trachea. During placement, and while the tube remains in place, it can injure the vocal cords in several ways:

• Mechanical trauma: The tube or stylet can bruise, lacerate, or scrape the vocal cords during insertion, causing swelling, hematoma, or ulceration.
• Pressure injury: The inflated cuff of the endotracheal tube presses against the vocal cords and surrounding tissues. Prolonged pressure can cause ischemic injury, granuloma formation, or nerve damage.
• Arytenoid dislocation: The tube can dislocate the arytenoid cartilage — the structure that supports and moves the vocal cord — causing vocal cord dysfunction. This is a specific and serious injury that often requires surgical correction.
• Vocal cord paralysis: The tube can compress the recurrent laryngeal nerve (which controls vocal cord movement), causing temporary or permanent vocal cord paralysis. This may also result from surgical procedures (particularly thyroid, cardiac, or cervical spine surgery) rather than the intubation itself.
• Granuloma formation: Pressure from the tube can cause tissue irritation that leads to the formation of granulomas (benign growths) on the vocal cords, which may require surgical removal.

Arytenoid Dislocation: A Specific Vocal Cord Injury

Arytenoid dislocation is a specific and serious vocal cord injury that occurs when the endotracheal tube dislocates the arytenoid cartilage — one of the paired cartilages that support and control the vocal cords. The arytenoid cartilages anchor the back of the vocal cords and control their tension and position.

When an arytenoid is dislocated, the affected vocal cord cannot move properly, causing:

- Hoarseness and breathy voice - Vocal fatigue - Difficulty projecting the voice - Aspiration (food or liquid entering the airway) - Coughing or choking when eating

Arytenoid dislocation is often preventable with careful intubation technique. It is more likely to occur with forceful intubation, use of a stylet that extends too far, or multiple intubation attempts. Diagnosis requires stroboscopy (a specialized laryngeal examination using a strobe light to visualize vocal cord vibration) or direct laryngoscopy by an otolaryngologist.

Treatment may require closed reduction (manipulating the cartilage back into position) performed by an ENT specialist. If diagnosed and treated promptly (within days to weeks), the prognosis is often good. If delayed, the cartilage may fuse in the wrong position, causing permanent vocal cord dysfunction. This makes prompt diagnosis and treatment critical — and delay in diagnosis may itself be malpractice.

When Dental or Vocal Cord Damage Constitutes Malpractice

Dental or vocal cord damage from intubation constitutes medical malpractice in New York when the healthcare provider deviated from the accepted standard of care and that deviation caused the injury. Key considerations include:

- Forceful or careless technique: Using the teeth as a fulcrum with excessive force, rather than lifting the tongue and epiglottis properly, can cause dental damage. This is a deviation from the standard of care. - Failure to protect dental work: In patients with extensive dental work, the standard of care may require using a tooth guard or other protective device. - Failure to assess dentition: The pre-anesthesia evaluation should include assessment of dentition, loose teeth, and dental work that may be at risk. - Multiple traumatic attempts: Repeated forceful intubation attempts without escalating to alternative techniques (video laryngoscopy, LMA, fiberoptic intubation) may constitute negligence. - Stylet extending beyond the tube tip: A stylet that extends beyond the tip of the endotracheal tube can cause airway trauma. The standard of care requires the stylet to be recessed within the tube. - Failure to diagnose arytenoid dislocation: When a patient has persistent hoarseness after intubation, the standard of care requires evaluation by an otolaryngologist, including stroboscopy, to diagnose arytenoid dislocation or other vocal cord injury. Failure to diagnose and treat promptly can cause permanent harm.

Under New York law, expert testimony from a board-certified anesthesiologist or otolaryngologist is required to establish the standard of care and prove it was breached. [Link to: /anesthesia-errors/intubation]

The Standard of Care for Protecting Teeth and Vocal Cords

The standard of care for preventing dental and vocal cord injury during intubation includes:

- Pre-anesthesia dental assessment: Documenting loose teeth, dental work, and fragile dentition that may be at risk during intubation. - Proper laryngoscope technique: Lifting the tongue and epiglottis with the laryngoscope blade, rather than using the teeth as a fulcrum. - Use of tooth guards: In patients with extensive dental work or at high risk, using a tooth guard or other protective device. - Gentle, controlled tube placement: Avoiding forceful advancement of the tube or stylet through the vocal cords. - Proper stylet placement: Ensuring the stylet does not extend beyond the tip of the endotracheal tube. - Appropriate cuff pressure: Avoiding overinflation of the endotracheal tube cuff, which can cause pressure injury to the vocal cords and surrounding tissues. - Escalation for difficult intubation: When direct laryngoscopy is difficult, escalating to video laryngoscopy, LMA, or fiberoptic intubation rather than making repeated forceful attempts. - Post-extubation evaluation: Assessing for hoarseness, vocal changes, or aspiration after extubation, and referring to an otolaryngologist for persistent symptoms.

Failure to follow these standards may constitute negligence.

Recognizing Vocal Cord Injury After Intubation

Signs of vocal cord injury after intubation include:

• Persistent hoarseness lasting more than a few days after surgery
• Breathy or weak voice
• Vocal fatigue — voice becomes weaker with use
• Difficulty projecting the voice or speaking loudly
• Coughing or choking when eating or drinking (aspiration)
• Sensation of something stuck in the throat
• Shortness of breath or noisy breathing (stridor)
• Voice changes that do not improve over time

Treatment and Long-Term Consequences

Treatment for dental damage may include dental restoration (fillings, crowns, implants, or bridges), root canals, or tooth extraction and replacement. Costs can be significant, particularly for implants and extensive restoration.

Treatment for vocal cord injury depends on the type and severity:

- Vocal cord bruising or swelling typically resolves with rest and time. - Granulomas may require surgical removal and voice therapy. - Arytenoid dislocation requires prompt closed reduction by an ENT specialist, ideally within days to weeks. Delayed treatment may require open surgical correction and may result in permanent dysfunction. - Vocal cord paralysis may resolve spontaneously (if the nerve recovers) or may be permanent. Treatment options include voice therapy, injection augmentation (bulking up the paralyzed cord), or surgical procedures (medialization thyroplasty, reinnervation).

Long-term consequences of vocal cord injury can include permanent voice changes, difficulty with professional voice use (for singers, teachers, attorneys, and others who rely on their voice), aspiration risk, and reduced quality of life.

Proving Your Dental or Vocal Cord Damage Claim

To prove a dental or vocal cord damage claim, the evidence includes:

- Anesthesia records: Documenting the intubation, number of attempts, difficulty, and any complications noted. - Dental records: Before and after the procedure, showing pre-existing dental condition and the extent of damage. - Otolaryngology evaluation: Stroboscopy or direct laryngoscopy showing the vocal cord injury (arytenoid dislocation, paralysis, granuloma). - Voice evaluation: By a speech-language pathologist documenting voice quality and functional impairment. - Expert testimony: From a board-certified anesthesiologist (on the standard of care for intubation) and an otolaryngologist (on the nature and cause of the vocal cord injury).

The defense may argue that the injury was a known risk of intubation. We use expert testimony to distinguish between unavoidable minor injury and preventable damage from negligent technique.

New York Statute of Limitations

Dental and vocal cord damage claims are subject to New York's 2.5-year statute of limitations for medical malpractice (CPLR § 214-a). The clock starts on the date of the intubation. Lavern's Law may extend this to the date of discovery, with a 7-year outer limit — important for vocal cord injuries that may not be diagnosed until weeks or months after surgery, when hoarseness persists.

For minors, the statute is tolled until age 18, plus 2.5 years. [Link to: /misdiagnosis/laverns-law]

Common Defense Arguments and How We Counter Them

Defense: "Dental damage is a known risk of intubation."

Defense attorneys use several arguments in dental and vocal cord damage cases:

• Our Counter: Some minor dental damage may be a recognized risk, particularly in patients with poor dentition. However, extensive damage — avulsed teeth, fractured roots, or damaged extensive dental work — from forceful or careless technique is not a simple 'known risk.' We use expert testimony to distinguish between unavoidable minor injury and preventable damage from negligent technique.

Defense: "The vocal cord injury was not caused by the intubation."

Our Counter: We use otolaryngology evaluation, stroboscopy, and expert testimony to establish the causal connection between the intubation and the vocal cord injury. The timing (onset of hoarseness immediately after surgery) and the type of injury (arytenoid dislocation, pressure injury) are consistent with intubation trauma.

Defense: "The hoarseness is temporary and will resolve."

Our Counter: While some hoarseness is common after intubation and typically resolves within days, persistent hoarseness lasting weeks or months indicates a more serious injury that requires evaluation. If the provider failed to refer the patient for otolaryngology evaluation when hoarseness persisted, that delay in diagnosis may itself be malpractice.

Defense: "The patient had pre-existing dental/voice problems."

Our Counter: We obtain pre-procedure dental and voice records to establish the baseline condition. Even patients with pre-existing conditions are entitled to intubation that does not cause additional harm.

Compensation Available

A successful dental or vocal cord damage claim in New York can provide compensation for:

• Dental restoration costs (fillings, crowns, implants, bridges, root canals)
• Otolaryngology treatment (surgical correction, voice therapy, augmentation)
• Lost wages if the injury affects employment (particularly for professional voice users)
• Pain and suffering (NY has no cap on non-economic damages)
• Loss of enjoyment of life — particularly if voice changes affect social or professional life
• Future medical care for ongoing treatment or revision surgery

What to Expect Working with MDLaw Firm

When you contact MDLaw Firm about a potential dental or vocal cord damage case:

• Free Consultation: We listen to your story and review the basic facts.
• Record Retrieval: With authorization, we obtain anesthesia records, dental records, and otolaryngology records.
• Expert Review: We engage board-certified anesthesiologists and otolaryngologists to evaluate the standard of care and causation.
• Causation Analysis: We establish the connection between the intubation and the injury using stroboscopy, dental evaluation, and expert testimony.
• Litigation: We file within the statute of limitations and handle all aspects of discovery and trial.
• Resolution: We pursue maximum compensation through settlement or verdict.

Frequently Asked Questions

The value of a medical malpractice case in New York depends on several factors, including the severity of the injury, the strength of liability evidence, and the economic and non-economic damages involved. New York is one of the few states with no caps on medical malpractice damages, meaning there is no artificial limit on what you can recover. Below are typical settlement ranges based on injury severity.