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1802 www.ccmjournal.org December 2019 • Volume 47 • Number 12 Endotracheal intubation (ETI) is performed routinely in ICUs across the world. Although the rate of invasive ventilation declined from 2014 to 2018 in tertiary ICUs in Australasia, about 30% of patients received such therapy (1). As the technology has improved to aid safer operator insertion of endotracheal tubes (ETTs) such as video laryngoscopy, the consequences of ETI on laryngeal structure and function post extubation, have been largely overlooked. Although pulmonary dysfunction is one aspect of the spectrum of the postintensive care syndrome (PICS), it has been largely descripted as impairments in lung function including spirometry and diffusion capacity (2). Voice and speech quality the singular defining characteristic of human existence are largely ignored. Similarly, difficulties with deglutition post extubation although well recognized (3) remain underemphasized as a cause of morbidity in patients discharged from the ICU. Several earlier studies including a more recent systematic review have reported on laryngotracheal injury subsequent to ETI. As early as 1973, the dangers of ETT cuff pressure were reported with damage to the small muscles of the larynx and vocal cord granuloma. Tracheal damage was also reported with ulceration, tracheomalacia, and tracheal stenosis— complications eased using a low pressure cuffed ETT (4). Stauffer et al (5) reported that both ETI and tracheotomy had a high complication rate in particular tracheal stenosis, with the mechanisms likely multifactorial. In this issue of Critical Care Medicine, in the study by Shinn et al (6), late sequelae of ETI were uncommon; however, mortality rate was over 50% and not all patients had follow-up bronchoscopy limiting the validity. Kastanos et al (7) in a 12-month follow-up study using fiberoptic bronchoscopy noted laryngeal lesions in 63% of patients studied, mainly granulomas with hoarse voice and swallow difficulties. Tracheal lesions were associated with cough and dyspnea. More vigorous follow-up was recommended for both tracheotomized and extubated patients. Tadié et al (8) in a prospective study of 136 patients with a median duration of intubation of 3 days noted 73% had laryngeal injuries associated with duration of intubation. In those with stridor after extubation, abnormal vocal cord mobility and edema were frequent and associated with ETT size and emergency ETI. Granulation tissue and restricted vocal cord mobility were common in those reintubated. The study by Shinn et al (6) had no long-term follow-up, so the fate of those patients with granulation tissue or ulceration is unknown. This is important as it has been previously demonstrated that significant granulation tissue can develop some weeks after extubation. Santos et al (9) demonstrating 57% of such granulomas occurred an average of 4 weeks post extubation in a cohort of 97 patients prospectively evaluated. These authors also showing that true vocal cord immobility was present in 20 % of that studied half of which developed up to 4 weeks post extubation, related to larger (size 8) ETT and length of ETI. Although it is clear from the above studies, the prevalence of laryngeal pathology post extubation is common, it is less clear the clinical significance longer term including impact on quality of life. Additionally, factors that can be modulated clinically remain ill-defined with conflicting results noted in studies. For example, variables such as ETT size and length of ETI in some studies have been shown not to correlate with laryngeal injury and vocal fold immobility (10, 11) despite contrary results noted above. A timely systematic review of laryngeal injury after ETI by Brodsky et al (12) provides some clarity on these matters. Nine studies of a total of 775 patients were examined focused upon laryngeal injury post mechanical ventilation. Of the most severe, (grade three) injuries vocal fold immobility was reported with a prevalence of 21% and 19% had either glottic or subglottic stenosis. All injuries being related to the duration of ETI. Of note, symptoms of laryngeal injury were common post extubation with pain, dysphonia, and a 49% prevalence of dysphagia. This latter finding being highlighted by the authors as it poses a major aspiration risk. No conclusions however were made regarding ETT size and injury. The authors calling for further studies and guidelines for the assessment of patients post extubation. With this background in this issue of Critical Care Medicine, Shinn et al (6) present the results of a prospective single-center 100 patient cohort study evaluating risk factors for acute laryngeal injury (ALgI) after mechanical ventilation. Assessment of ALgI was made by otolaryngologists blinded to the patient’s outcome within 36 hours of extubation. All patients were followed at 10 weeks and had the voice handicap index-10 and clinical chronic obstructive pulmonary disease questionnaire (to assess voice quality and dyspnea index) administered by a surveyor blinded to the patient’s endoscopic examination. Additionally, independent variables including intubation time, ETT size, body mass index (BMI), and presence of type 2 diabetes (DM2) *See also p. 1699.