Asymmetric Length

Samantha became very ill, almost dying. When she arrived at the hospital’s emergency room late at night, she was no longer breathing and the emergency room doctor intubated her, placing an endotracheal tube through her vocal cords. She remained on a respirator for a few days. When she began to recover, the tube was removed, but she again had difficulty breathing and she was reintubated urgently by the on-call anesthesiologist. She was disconcertingly slow to improve. Each time the breathing tube was removed; she deteriorated, requiring another intubation by another caregiver. When the tube was taken out for the fifth time, she seemed to have recovered her lung function and finally left the hospital.

At home, she found that she wasn’t quite back to normal. Several months later she came to my office with a rough and weak voice. 

“I run out of breath easily. I cannot exercise like I used to and when I try to talk, I just gasp after awhile. My voice never improved.”

With this history, I consider several possibilities. It is possible that on one or more of the tube insertions something was injured during the urgency of putting the breathing tube between the vocal cords. I have seen a torn vocal cord after an intubation. Perhaps as the tube was lying between the cords, some tissue ulcerated and scarred on one side. It is even possible that the cuff on the endotracheal tube, inflated while on the respirator, may have been inflated too tightly. The cuff, if allowed to sit just beneath the vocal cords, can put pressure on and injure the anterior branch of the recurrent laryngeal nerve, in turn causing a paralysis or paresis. So there are a number of plausible reasons to consider as a cause of her vocal impairment.

When I look in her throat with the endoscope, the vocal cords don’t completely come together, so when she goes to initiate a sound, this gap explains the softness of her voice. The left cord is also longer than the right, so they do not line up well when they do come together. Her two cords are different lengths, which will then tend to vibrate at different pitches explaining the roughness in her voice. 

I do not know a way of correcting this type of length difference in her case. However, I did put an implant into the right vocal cord pushing it closer to the midline so that she could more completely close the vocal cords. This reduced the air leak and softness in her voice.