Glottic granulation tissue
Because the flaps move with inspiration and expiration, they may cause inspiratory obstruction. Removal of the flaps may be beneficial, at least from one side, thereby possibly improving the airway and the prospect of extubation. Removal from both sides is not recommended, as the two raw surfaces may form an interarytenoid synechia, adhering to each other across the midline and joining the vocal folds. Others have suggested removal at the time of tracheostomy, should extubation have failed [18]. Removal of the flaps is usually unnecessary, however, because most cases completely resolve after extubation. Should the granulation tissue not heal properly, scarring (covered by mucous membrane) or a reddish-yellow intubation granuloma may form on the medial edge of the vocal process of the arytenoid cartilage [7].
Ulcerated Trough and Chronic Healed Furrows
Ulcerated trough and subsequent chronic healed furrow in the interarytenoid space
Miscellaneous Injuries
These include, but are not limited to, damage to muscles [19], perforation of the airway, and laceration of the true or false vocal folds. These injuries are more likely to result from difficult intubations and may be caused by either the endotracheal tube or the inducer. Perforation of the airway may lead to spreading surgical emphysema and infection into the soft tissues of the neck or mediastinum. Acute lacerations typically heal but may leave a small scar permanently. Without complete healing, a granuloma may form [15].
Speech-Language Pathologist Approach
Posterior glottic insufficiency (PGI) results in a posterior glottic gap that results in dysphonia. The dysphonia is characterized by breathiness due to air escape, asthenia due to poor glottic closure, and roughness due to aperiodic vibrations. The management of PGI is important for a child’s educational and psychosocial development, as well as physical and emotional health [20]. While current surgical intervention is being investigated to manage PGI, voice therapy can also be beneficial. Voice therapy techniques specifically to treat PGI have not been thoroughly explored. Of equal importance is the detailed preoperative and postoperative assessment conducted by a speech and language pathologist to provide invaluable diagnostic information and possible treatment options [21].
Treatment
Beginning treatment with a child with PGI may first involve optimizing voicing technique. It has been our experience that over time of using a chronic weak, breathy, rough voice, the child may develop poor voicing techniques as they are accustomed to having a voice that does not meet their daily functions (projection, quality, etc.). This may include reduced breath support, an increase in pitch to aid in vocal fold closure, rapid rate of speech to produce as many words on one breath as possible, and poor overall effort. The opposite may also occur where the child becomes hyperfunctional to compensate for a dysphonic voice. Increasing breath support, implementing elements of Conversational Training Therapy (CTT), and promoting vocal hygiene to reduce laryngeal irritants can optimize voice production in children with PGI [22]. Specifically within CTT, the use of “clear speech” facilitates a reduction in speaking rate, an increase in amplitude and prosody ranges and phrase and speech sound lengths, and more precise vowel productions [22]. To accomplish these common voice therapy goals, an increase in breath support is necessary and indirectly gained.
Additionally, use of vocal fold adduction exercises, resonant voice therapy, inhalation phonation, and vocal function exercises have shown to assist in maximizing vocal fold closure. Adduction exercises must be closely monitored to prevent development of hyperfunction. Optimizing vocal fold contact through resonant voice therapy and increasing frontal tone focus increase resonant projection [23]. Inhalation phonation can be useful when aphonia, abnormal methods of vocal fold phonation (i.e., ventricular phonation), or hyperfunction is present [24]. This maneuver approximates true vocal fold adduction, activates true vocal fold vibration, relaxes the ventricles, and stretches the vocal folds [24]. Vocal function exercises are a systematic procedure designed to strengthen and coordinate laryngeal musculature, increase vocal fold adduction, and improve balance to the vocal mechanism [25].
Summary
Evidence-based treatment options specifically for PGI are scarce. More research is necessary for this particular patient population. Stimulability testing for the particular patient is vital to developing the most appropriate treatment plan. Overall, the above techniques are beneficial in optimizing vocal production and encouraging vocal fold adduction.
Otolaryngologist Approach
Traditionally, PGI was treated by injection laryngoplasty to improve vocal fold approximation; the treatment was ultimately found to be effective mainly for anterior gaps, as opposed to the posterior gaps seen in PGI [26, 27]. Aryepiglottic fold flaps and endoscopic posterior cricoid reduction laryngoplasty (EPCRL) are newer techniques that have been shown to produce better outcomes [2]. In one retrospective study, six of seven patients (11 months–20 years) presenting to pediatric otolaryngologists/laryngologists for PGI had minimal or no improvement with injection laryngoplasty. In comparison, three of three patients (15–20 years) who had undergone EPCRL had significant improvement in voice function without any resulting dyspnea or stridor [1]. EPCRL, however, involves removal of a segment of the posterior cricoid cartilage, thereby narrowing the airway. Patients that are at risk of airway obstruction should be reevaluated when they are older, or other options should be considered [1].
Another surgical option is grafting of buccal mucosa into the damaged interarytenoid space. Although the operation has exhibited strong outcomes for adults, results have not yet been reported for children. Regardless of the extent of injury, it is recommended that the graft encompass the entire posterior glottis. This is partially because the graft is thicker than the normal posterior glottic mucosa. Even for unilateral injuries, the resulting graft provides better outcomes, including greater posterior glottic obstruction, better airflow through the vocal folds, and a stronger voice [28].
Potential Chronic Complications
In addition to posterior glottic insufficiency, the otolaryngologist should be aware of other potential chronic complications which may arise and can impact patient voice and airway patency.
Complete Obstruction
Obliteration of the glottic or subglottic lumen may occur in advanced cases of intubation trauma. This can be caused by poorly judged repeated attempts to dilate the lumen or from excessive laser surgery that worsened existing injury from prolonged intubation [15].
Ductal Retention Cysts
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