SESSION TYPE: Bronchology Cases
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Posterior glottic stenosis (PGS) is a complication of long term intubation. Impairment of mobility of one or both arytenoid cartilages causes narrowing of the airway at the posterior aspect of the glottic space. PSG often presents with stridor, voice changes and respiratory distress. We present a case of PGS and interarytenoid scar band formation, misdiagnosed for asthma for over 15 years.
CASE PRESENTATION: A 39 year old black South African female was referred to our outpatient pulmonary clinic for evaluation of worsening untreatable asthma and stridor. Her past medical history was remarkable for a shoulder dislocation and surgery, 15 years ago. After her shoulder surgery requiring intra-operative intubation, she started to have mild shortness of breath and occasional hoarseness. She was clinically diagnosed with asthma, but bronchodilator therapy never resulted in any benefit. Her symptoms progressed slowly and she started to have stridor on exertion 5 years ago. On exam she had a HR of 80, oxygen saturation of 96% on room air. She had audible mostly expiratory stridor at rest. Lung exam revealed bilateral vesicular breath sounds on auscultation. Her FEV1 was 1.31 L (45% predicted) and her flow-volume loop showed significant flattening of the inspiratory limb (figure 1). Bronchoscopic evaluation revealed an intraarythenoid scar band (figure 2) with limited motion of the cords resulting in post glottic stenosis. Unfortunately following endoscopic division of the adhesion there was minimal improvement. Endoscopic visualization of her cords showed minimal mobility secondary to bilateral arythenoid ankylosis. Patient is currently being considered for arythenoidectomy.
DISCUSSION: Post intubation trauma is a common cause of PGS. Laryngoscopy reveals bilateral impaired vocal cord mobility in a median or paramedian position with limited glottic patency. It results from scarring of the mucosa of the interarytenoid region or the cricoarytenoid joints (1, 2). Majority of posterior glottic injuries heal after extubation with reepithelialization and no scarring. There are no reports of PGS and interarythenoid scar band formation after short intraoperative intubations. Our patients vocal cord injury had gone un-noticed for 15 years resulting in subsequent bilateral arythenoid ankylosis. Diagnosis of asthma made based on clinical presentation and years of delayed surgical management resulted in chronic fixation of the larynx.
CONCLUSIONS: While PGS after short intubation is unusual, delayed diagnosis and management can result in fixed stenosis. Diagnosis of asthma should be reconsidered in such patients and further investigation is necessary to evaluate vocal cord injuries secondary to intubation trauma.
1) Bogdasarian RS and Olson NR et al, Posterior glottic laryngeal stenosis. Otolaryngol Head Neck Surg 1980;88:765-72
2) Gardner GM. Posterior glottic stenosis and bilateral vocal fold immobility: diagnosis and treatment. Otolaryngol Clin North Am 2000;33:855-7
DISCLOSURE: The following authors have nothing to disclose: Samira Shojaee, Elvis Irusen, Andreas Diacon
No Product/Research Disclosure InformationDartmouth Hitchcock Medical Center, Lebanon, NH