Most laryngoscopy stops at the vocal cords. That is where the eye is busy — the margins, the capillary pattern, the mucosal wave — and it is where most voice problems live. But it is not where all of them live.
When the voice complaint doesn’t explain the breathing complaint, keep going. A patient who is hoarse and short of breath on exertion, whose cords look reasonable, is telling you the answer is somewhere you haven’t looked yet.
The glimpse
Sometimes a subglottic abnormality announces itself only briefly — a flash of hypervascularity below the plane of focus as the cords abduct on a sniff. It is easy to skate past at full speed. Record the exam and slow it down. A narrowing that is invisible in real time can be obvious frame by frame.
That glimpse is a key to open a door, not a diagnosis. When you see one, look properly.
Examining below
Topical anesthesia first — 4% lidocaine gargled onto the larynx (see Topical Anesthesia). Then pass the endoscope through the vocal cords and examine the airway all the way to the carina. Don’t accept guessing: a stenosis you have seen is a diagnosis, and a stenosis you have inferred is a hunch.
The endoscope as a measuring tool
The scope also measures. Have the patient take a few breaths with the endoscope through the cords but above the narrowing. Then pass the scope — whose diameter you know — through the narrowing, have them keep breathing, and compare the effort. That gives you a sense of how much additional occlusion this patient could still tolerate, which is a more useful number than a percentage.
A case where this was missed for ten years: When symptoms of cough and hoarseness might be hidden
When a narrowing is found, the treatment options are on Microlaryngoscopy: Stenosis and Office Steroid Injection.