Idiopathic subglottic stenosis

A subtype of subglottic stenosis that is inflammatory.  One view is that this entity is actually a limited expression of Wegener’s Granulomatosis (aka Granulomatosis with polyangiitis).

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Subglottic stenosis

Subglottic stenosis is narrowing just below the vocal cords, in the lowest part of the larynx and immediately above the first tracheal ring. Examples of causes include scarring from a breathing tube used during a long ICU stay, Wegener’s Granulomatosis (aka Granulomatosis with polyangiitis), and idiopathic subglottic stenosis (aka limited Wegener’s Granulomatosis).


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Vocal cord synechia

Vocal cord synechia is a strand of scar tissue that tethers the vocal cords to each other. It can prevent the vocal cords from opening fully for breathing.

A synechia can also form in other parts of the body. (Note the subglottic synechia shown below.)


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Vocal Cord Synechia
This video provides a clear example — using laryngeal videostroboscopy — of a vocal cord synechia.

Stenosis

Abnormal narrowing of a passageway in the body. At our practice, stenosis typically refers to narrowing in the breathing passage, such as for narrowing in the glottic, subglottic, or tracheal areas.

Stenosis in the airway can be the result of prolonged endotracheal intubation, external trauma such as gunshot wound, crush injury, or tracheotomy, an inflammatory or auto-immune process, surgical resection of part of the airway for tumor, or other causes. Persons with airway stenosis will note a reduced capacity for exercise. Often the clinician hears noisy breathing on inhalation, especially when the patient is asked to fill the lungs quickly. Esophageal stenosis gives symptoms of difficulty swallowing solids more so than liquids.


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Tracheal Stenosis: Before and After
In this video, trachea (windpipe) blockage causes shortness of breath until the narrowed segment is removed. You will see views of the trachea before and after surgical repair.
Post-Radiation Hypopharyngeal Stenosis
People with larynx or pharynx (voice box or throat) cancer often undergo radiation therapy as part of their treatment regimen. An uncommon complication is stenosis (narrowing, scarring) of the entrance to the upper esophagus at the junction of the throat and esophagus. This video provides an example of this disorder.

Pharyngocele

A dilated outpouching from the normal contour of the pharynx.


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Redundant supraglottic mucosa

An excess of mucosa overlying one or more structures in the larynx above the vocal cords. Mucosa in this area should “fit” snugly, like leggings, but in the case of redundant supraglottic mucosa, the fit becomes more like baggy pants.

Symptoms and treatment:

This redundant supraglottic mucosa most commonly develops on the apex and posterior surface of the arytenoid cartilage. Such mucosa sometimes draws inward during breathing and fills the laryngeal vestibule. In a severe case, inspiration can become noisy (stridor) or even effortful. When symptoms like these become troublesome, the excess mucosal tissue can be removed with endoscopic laser surgery.

Redundant supraglottic mucosa vs. laryngomalacia:

Redundant supraglottic mucosa is similar to the disorder laryngomalacia. In both disorders, supraglottic tissue is pulled into the laryngeal vestibule during breathing and can cause stridor. However, the causes of these symptoms are different. In the case of redundant supraglottic mucosa, the main problem is an excess of overlying mucosa, but in the case of laryngomalacia, the main problem is that the underlying structural tissue, such as that which comprises the aryepiglottic cord and epiglottic cartilage, is abnormally weak or soft.


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Nonorganic breathing disorder, laryngeal

A nonorganic disorder in which a person’s vocal cords partially or fully close during breathing, which causes noisy breathing. Also called vocal cord dysfunction (VFD) or vocal cord dysfunction (VCD).

The fundamental disorder is not in the mechanism itself, but rather in the patient’s “use” of the mechanism. Consciously or sub-consciously, the patient inappropriately narrows the space between the vocal cords, usually for secondary gain. Unlike with asthma or nonorganic breathing disorder of the trachea, the noisy breathing is mostly heard when the person breathes in (inspiration). Still, on occasion, individuals with this disorder are treated for years as having asthma before this diagnosis is finally made.


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Nonorganic Breathing
This video portrays a breathing abnormality that is non-organic / functional.

Nonorganic breathing disorder, tracheal

A breathing disorder, often mistaken for asthma, in which a person induces his or her trachea to narrow, causing wheezing or apparent shortness of breath. The person’s oxygen saturation remains normal, but his or her description of the problem and apparent breathing distress may be quite dramatic; in severe instances, the person may have been intubated and placed in intensive care, based purely upon the “drama”—that is, the person’s distressed appearance and audible noises. The extent of medical intervention prompted by this pseudo-asthma can be remarkable.

How it happens:

The person’s trachea momentarily narrows or collapses, but unlike with tracheomalacia, this narrowing or collapse is not due to any anatomical or physiological disorder of the person’s trachea. Instead, it can be seen as an added capability of the trachea: an unusual, heightened capability of the membranous tracheal wall to flex inward and decrease the caliber of the “pipe.” A person whose trachea has this added capability may figure out how, with inconspicuous excessive expiratory effort—a sort of semi-Valsalva maneuver that isn’t evident to observers—to induce this tracheal or tracheobronchial collapse that creates the wheezing heard by family, friends, or co-workers.

The nonorganic element:

Often, this upper airway wheezing ability can be just a personal quirk (like double-jointedness) that has no particular significance to the person’s life; think of a “wheezy laugh.” Such a case would not be a nonorganic breathing disorder case. In extreme cases, however, a person may begin to use this wheezing ability to masquerade (perhaps sub-consciously) as having asthma, in order to achieve some kind of “secondary gain”; this added element puts a case into the category of a nonorganic breathing disorder. Sometimes, the person does have asthma, but is able to markedly amplify the asthma’s apparent severity by overlaying on it this dramatic nonorganic upper airway wheezing ability.

How it is diagnosed:

If a clinician listens to this person’s breathing with a stethoscope placed over the lung fields, the wheezing can indeed sound exactly like asthma. However, there are some key diagnostic criteria that help the discerning clinician to recognize a case of nonorganic breathing:

  • The wheezing is louder over the manubrium (uppermost part of the sternum) than over the peripheral lung fields.
  • There is a surprising incongruity between, on the one hand, the person’s apparent distress and, on the other hand, his or her objective findings, such as oxygen saturation, pulmonary function tests, blood gas measurement, and so forth.
  • Potent treatments for asthma do not seem to diminish or abolish the wheezing.
  • There appears to be some kind of “secondary gain” (mentioned above). Examples of secondary gain might be simple increased attention from family, healthcare workers, and so forth, or else avoidance of school or work, or an enhancement of the chance of winning a lawsuit, or release from responsibility for losing a competitive race, or the ability to manipulate others who have high levels of empathy combined with low levels of discernment of others’ motivations.

Upper airway wheezing

Expiratory wheezing caused by the narrowing of a person’s trachea and, possibly, mainstem bronchi. As expiratory air rushes out through the narrowed trachea or mainstem bronchi, the wheezing sound is created.

This tracheal narrowing and its accompanying wheezing can occur in a variety of circumstances or scenarios. In the case of tracheomalacia, a person’s trachea is unusually flaccid and fails to stay open at its normal diameter. In other cases, there is no anatomical or physiological disorder of the person’s trachea, but the person is able, with a sort of semi-Valsalva maneuver, to flex inward the membranous tracheal wall and decrease the caliber of the “pipe.” Think, for example, of a “wheezy laugh.” This ability may have no particular significance to the person’s life, but in certain cases, a person may use an unusual degree of this wheezing ability to masquerade (perhaps sub-consciously) as having asthma: we call this nonorganic breathing disorder, tracheal. Finally, there are also cases in which a person who is grossly obese is susceptible to this momentary tracheal narrowing or collapse, because the added weight on the abdomen puts a kind of constant upward pressure on the diaphragm and serves as a kind of constant mild Valsalva.


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