A 19 y.o. with a hx of asthma ( not on steroids but a previous intubation) comes to the ED with shortness of breath

You think you hear stridor so you do a scope.

what do you see?

This patient  has vocal fold granulomas, likely due to the size 8 tube used to intubate her.  Injuries due to intubation often occur in the posterior portion of the larynx; as the glottis is a “V” shape, this is where the tube rests and exerts pressure.  The larger the tube, the more likely local tissue damage is to occur.  Vocal cord granulomas may be managed conservatively, as many fall off on their own, but sometimes require surgical intervention (especially in the case of airway compromise) . This patient was a small female and a size 8 tube was unnecessarily large for her. The size of the tube is a problem which should be distinguished from other post intubation complications like subglottic stenosis caused by an overinflated cuff or prolonged intubation causing tracheal stenosis. These vocal fold granulomas have been report with just two days of intubation. 

The risk for complications from intubation are three times higher in patients who are 50-69, in agitated patients and those with diabetes.

this view is upside down from the view during intubation with the ant portion of the neck on the bottom

PATHOPHYSIOLOGY

This inflammation of the posterior larynx in more severe cases can cause ulceration and eventual scarring of the back of the vocal cords (posterior glottis). The fibrosis i in the posterior glottis prevents the vocal cords from opening, simulating bilateral vocal cord paralysis. Although  vocal fold  granulomas can be removed, posterior glottic stenosis requires more complex treatment and some patients require a permanent tracheostomy.

Suspect these injuries if hoarseness persists more than 72 hours after intubation or the pt presents with aspiration, dyspnea or  stridor post intubation.

A second patient was recently intubated in the ED for a bradycardic arrest with a 7.5 tube. She was intubated for 8 days and developed stridor after extubation.  She had granulation tissue of the posterior arytenoids requiring removal due to airway compromise.  Eventually, she developed scarring that led to bilateral vocal fold immobility and required an emergent tracheotomy.

the glottis is the small area right under the cords

REMEMBER: TUBE SIZE MATTERS WHEN YOU INTUBATE SOMEONE

Mota L, Cavalho G, Brito V. Layngeal complications by orotracheal intubation: Literature review 2012 Int Arch Otorhinolaryngol. Apr; 16(2):236-245.

Kikura M, Suzuki K, Itagaki T, et al. Age and comorbiditiy as risk factors for vocal cord paralysis associated with tracheal intubation. British Journal of Anaesthesia. 2007;98(4):524-30.

Courey M, Bryant G, Ossoff R.  Poserior glottis stenosis: a canine model. 1998 Ann Otol rhino Laryngol. Oct;107(10Pt 1):839-46

Huston M, Naunheim K, Naunheim M. Managing Otolaryngological Complications in Cardiothoracic Surgery. Ann Thorac Surg. 2020 Jan 23. Pii: S0003-4975(20)30073-4. Doi:10.1016/j.athoracsur.2019.12.022. {epublis ahead of print}