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Example 4: Posterior Glottic Web

Audio - Standard Passage

Audio - Breathing Noises

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This examination was performed one year after a traumatic intubation after a motor vehicle accident followed by 14 days of intubation before extubation. The patient noticed progressive shortness of breath as well as "noisy" breathing. Note that the voice itself is normal and clear, but the breathing sounds are noticeable on both inspiration and expiration suggesting a fixed lesion somewhere in the airway. On endoscopy, the fixed lesion was discovered to be a scar band in the back part of the vocal cords (top of picture) preventing the vocal cords from moving apart fully. This scar band is known as a posterior glottic web. This abnormality was addressed by surgical excision of the scar band along with treatment to prevent recurrence of the scar band.

On an educational note, scar bands crossing the back aspect of the vocal cords do not generally affect the voice, but scar bands in the front generally do. Another point to make is that if the patient had undergone a tracheotomy soon after intubation (within 5 days), this complication may have been avoided. Generally speaking, if a patient is expected to be intubated for more than 5 days, tracheotomy should be performed to prevent complications such as this among others.

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Example 5: Bilateral Vocal Cord Paralysis

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Patient presented with difficulty breathing and making "noise" while breathing in and out at times, especially when sleeping. On the video exam, it is clearly evident that his vocal cords are not moving apart as well as they should. With such a limited opening, it is no wonder he can't breath well! The still picture shown is at maximum ABduction or vocal cord separation. Unlike example #4 in which a scar band prevented vocal cord separation, this case is due to paralysis of both vocal cords.

Treatment for this is difficult and there is no perfect solution. Treatment to improve breathing usually makes the voice worse. Treatment to improve the voice usually makes the breathing worse. The best (but not perfect) treatment tries to pick a happy medium to address the breathing while trying not to hurt the voice too much, though some degradation in vocal quality is to be expected. Such a treatment includes posterior cordotomy +/- partial arytenoidectomy.

An example of someone with a unilateral vocal cord paralysis is shown here.

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Example 6: Large Ball-Valving Polyp

Audio - Standard Passage

Audio - Breathing Noises

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Patient presented with hoarseness lasting several years with difficulty breathing and making "noise" while breathing in and out at times, especially when laying down. On the video exam, it is clearly evident of a large right true vocal cord polyp that ball-valves in and out. One can actually hear the ball-valving on the breathing audio clip where one can here a "flip" when the polyp moves position from inhalation to exhalation.

This polyp is known as a Smoker's Polyp as it mainly occurs in people who smoke and talk a lot. Treatment was excision with voice therapy and quit smoking.

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Example 7: Tracheomalacia

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Patient is a 10 year old child with a 5 year history of noisy breathing with exhalation (especially with coughing) that sounded like the bark of a seal. Patient was physically very active and rarely ill. In the past, he apparently was treated for asthma as well as allergies without any change, let alone improvement. Finally it was felt that he may have vocal cord dysfunction and presented to our clinic for further evaluation and treatment.

On exam, his noisy breathing was found to be actually due to tracheomalacia where the posterior wall of his upper airway collapsed momentarily causing the deep barking noise on exhalation.

Given that he had no functional limitations, no further intervention was recommended other than routine monitoring. Of further note, no medications were prescribed and all asthma & allergy medications discontinued.

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