Marginal airway (1 of 4)
This woman underwent radiotherapy for larynx cancer several decades earlier. Some years ago, progressive post-radiation fibrosis had nearly fixed the vocal cords in the midline and airway was marginal. A laser posterior commissuroplasty was done as an alternative to tracheotomy. During a recent hospitalization for pneumonia elsewhere, she was told that her airway was inadequate; she returned for examination for this reason. During this kind of distant view, her airway does indeed look marginal.
Airway at close range (2 of 4)
At close range using topical anesthesia, with the patient exhaling, her airway appears adequate. The dotted line is where the margin of the cords would be if the divots had not been removed.
Forced inspiration (3 of 4)
Forced inspiration draws the vocal cord mucosa medially to narrow the airway, and inspiratory noise is heard, but the posterior divots maintain a small but adequate airway and time to fill is only mildly prolonged.
Alternative to tracheotomy (4 of 4)
During phonation, the divots removed from the posterior vocal cords are more clearly seen. Voice is air-wasting, airway is of course suboptimal, but no tracheotomy or additional laser commissuroplasty is needed.