Medical Image of the Week: Bilateral Vocal Cord Paralysis

Figure 1. Flow-volume curve demonstrating flattening of both the inspiratory and expiratory limbs consistent with extra-thoracic obstruction.

Figure 2. Video demonstrated the vocal cords essentially fixed in the adducted position during the inspiratory and expiratory cycle.

A 59-year-old morbidly obese woman with acute hypoxemic respiratory failure secondary to pulmonary emboli required emergency intubation. She was described by the anesthesiologist as having a difficult airway. The patient was liberated from the ventilator after two days. Following extubation she complained of hoarse voice and dyspnea. Physical exam revealed audible stridor. The upper airway was normal by CAT imaging. Flow-volume curve demonstrated marked flattening of both the inspiratory and expiratory limbs, consistent with a fixed extra-thoracic obstruction (Figure 1). Endoscopy revealed the vocal cords to be in the adducted position, with minimal movement throughout the respiratory cycle, consistent with bilateral vocal cord paralysis (Figure 2).

Traumatic intubation follows thyroid surgery as the most common cause of bilateral vocal cord paralysis (1). In a minority of patients spontaneous recovery may occur. Surgical treatment options include cordotomy or tracheostomy. Nocturnal BIPAP has been used in patients who decline surgery (2).

Charles J. Van Hook MD, Britt Warner PA-C, Angela Taylor MD,  and Jacquelynn Gould MD.

Longmont United Hospital

Longmont, CO USA

References

1. Brandwein M, Abramson AL, Shikowitz MJ. Bilateral vocal cord paralysis following endotracheal intubation. Arch Otolaryngol Head Neck Surg. 1986 Aug;112(8):877-82. [CrossRef] [PubMed]
2. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope. 2007 Oct;117(10):1864-70.[CrossRef] [PubMed]

Cite as: Van Hook CJ, Warner B, Taylor A, Gould J. Medical image of the week: bilateral vocal cord paralysis. Southwest J Pulm Crit Care. 2017;15(2):82-3. doi: https://doi.org/10.13175/swjpcc099-17 PDF

Medical Image of the Week: Idiopathic Subglottic Stenosis

Figure 1. Flow-loop demonstrating fixed large airway obstruction.

Figure 2. Subglottic stenosis.

A 40 year-old previously healthy woman presented with a three-month history of exercise-induced shortness of breath. Clinical exam revealed inspiratory stridor. Spirometry was remarkable for flattening of the inspiratory and expiratory limbs of the flow-volume loop (Figure 1). Fiberoptic bronchoscopy revealed subglottic tracheal stenosis (Figure 2). The patient subsequently underwent successful balloon dilation of the involved segment and has remained symptom free.

Tracheal stenosis may be related to previous airway trauma, collagen vascular disease, sarcoidosis, or vasculitis. The clinical presentation is characterized by exertional dyspnea with stridor.  The flow-volume loop classically demonstrates a pattern of fixed upper airway obstruction, with flattening of both the inspiratory and expiratory limbs of the curve. CAT scanning is usually supportive of the diagnosis, and bronchoscopy is confirmatory. In the absence of an identifiable etiology, the condition is termed idiopathic tracheal stenosis. Idiopathic subglottic stenosis is a subgroup of tracheal stenosis that occurs in young women, and that is limited to the first two rings of the proximal trachea (1). Bronchoscopic tools, including balloon dilation, laser, and electrocautery have all been used with safety and efficacy for the treatment of idiopathic subglottic stenosis (2).

Charles J. Van Hook MD and Britt Warner PA

Longmont United Hospital

Longmont, CO USA

References

1. Nussbaumer-Ochsner Y, Thurnheer R. Images in clinical medicine: subglottic stenosis. N Engl J Med. 2015 Jul 2;373(1):73. [CrossRef] [PubMed]
2. Solly WR, O'Connell RJ, Lee HJ, Sterman DH, Haas AR. Diagnosis of idiopathic tracheal stenosis and treatment with papillotome electrocautery and balloon bronchoplasty. Respir Care. 2011 Oct;56(10):1617-20. [CrossRef] [PubMed]

Cite as: Van Hook CJ, Warner B. Medical image of the week: idiopathic subglottic stenosis. Southwest J Pulm Crit Care. 2017;15(1):39-40. doi: https://doi.org/10.13175/swjpcc076-17 PDF 

Medical Image of the Week: Carcinoid at the Carina

Figure 1. Flow-volume loop showing flattening of expiratory loop suggesting variable intra-thoracic obstruction.

Figure 2. CT of the chest showing pedunculated tracheal lesion at the level of main carina.

Figure 3. Bronchoscopic view of endobronchial tumor before (Panel A) and after removal (Panel B).

A 74-year-old woman with history of 30 pack-year smoking, allergic rhinitis and asthma presented to pulmonary clinic with cough and dyspnea on exertion. She was placed on inhaled corticosteroids and long-acting beta-agonist. Pulmonary function test showed moderate obstructive ventilator defect and flow volume loop suggested variable intra-thoracic obstruction (Figure 1). In the meantime, she was hospitalized with complaint of dyspnea and possible COPD exacerbation. Het CT chest revealed an endobronchial 12 mm pedunculated lesion at anterior aspect of main carina (Figure 2). She underwent flexible bronchoscopy and lesion was removed using electro-surgical snare and cryoprobe (Figure 3). Her symptoms improved post-procedure. Pathologic examination of lesion revealed a carcinoid tumor.

Endobronchial tumors are masses confined within the bronchus, and may be associated with atelectasis or pneumonia of the distal parenchyma. These tracheobronchial tumors are classified as malignant or benign. Malignant tumors arising from surface epithelium include squamous cell carcinoma and neuro-endocrine tumors; and those arising from mesenchyme include sarcoma and malignant lymphoma. On the other hand, benign tumors arising from surface epithelium include squamous cell papilloma and mucus gland adenoma; and those arising from mesenchyme include hamartoma, lipoma, fibroma, leiomyoma, and neurogenic tumor. Hamartomas may present as a fatty mass, nodules with calcification, or as soft-tissue-density nodules on CT scans. The lipomas manifested as fat density on CT scans. The other benign tumors were low-attenuating, soft-tissue-density masses without characteristic findings on CT scans.

Tauseef Afaq Siddiqi, MD; Muhammad Alzoubaidi, MD; James Knepler, MD and Kenneth Knox, MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona, Tucson, AZ

Reference

1. Ko JM, Jung JI, Park SH, Lee KY, Chung MH, Ahn MI, Kim KJ, Choi YW, Hahn ST. Benign tumors of the tracheobronchial tree: CT-pathologic correlation. AJR Am J Roentgenol. 2006;186(5):1304-13. [CrossRef] [PubMed] 

Reference as: Siddiqi TA, lzoubaidi M, Knepler J, Knox KS. Medical image of the week: carcinoid at the carina. Southwest J Pulm Crit Care. 2015;10(6):341-2. doi: http://dx.doi.org/10.13175/swjpcc052-15 PDF 

Medical Image of the Week: Tracheal Stenosis

Figure 1. Pulmonary function tests showing a flat inspiratory loop.

Figure 2.  When viewed from vocal cords, tracheal stenosis seen distally (arrow).

Figure 3. Tracheal stenosis seen on bronchoscopy (arrow).

Figure 4. Area of tracheal stenosis after balloon dilation.

A 43-year-old woman was seen in clinic for dyspnea on exertion that began several months ago.  Prior workup included a computed tomography of the chest with mild narrowing noted in the upper trachea.  Pulmonary function tests (Figure 1) showed a flat inspiratory loop with a normal expiratory loop, which suggests a variable extrathoracic obstruction.  On bronchoscopy, a tracheal stenosis was seen just past the vocal cords (Figure 2, Figure 3).  Balloon dilation (Figure 4) of the stenosis returned the area to normal caliber.

Wendy Hsu, MD and James Knepler, MD

Division of Pulmonary and Critical Care

University of Arizona

Tucson, AZ

Reference as: Hsu W, Knepler J. Medical image of the week: tracheal stenosis. Southwest J Pulm Crit Care. 2013:7(1):53-4. doi: http://dx.doi.org/10.13175/swjpcc099-13 PDF