Waiting and Observing
I’m fairly certain that before I devoted myself to the study of the larynx, I placed a tracheostomy in a patient with a nonorganic loss of voice with stridor — noisy breathing. I put the tracheostomy in with the patient’s permission and she felt very relieved, which I thought confirmed my excellent decision-making. Her breathing problem was gone and her voice was recovered the next day, though she now had a plastic tube in her neck. Since, in retrospect, I now understand the natural course of nonorganic stridor, I presently treat similar patients much more efficiently and cost effectively in the office with gentleness, patience, and persuasion.
Over time in my practice, a finite number of voice problems appear over and over. The study of voice seemed to be getting simpler and simpler as hoarseness seemed to boil down to only two types of problems — air leak and vocal cord asymmetry. The less an examiner knows about voice, the more distracted they become by everything they see. The more an examiner understands voice, the simpler the examination of the hoarse voice and the more focused the examiner can be on identifying the problem. The examiner is less likely to harm someone when he understands that a nonorganic stridor doesn’t require the expense of hospitalizations, consults, asthma drugs, and surgeries like tracheostomy.
The Obvious Answer Is Not Always the Correct One
Sarah S. had a procedure where I removed the front portion of the voice box and shortened the vocal cords — a surgery to raise the comfortable speaking pitch, frequently used for transgender females who were exposed to testosterone and have too low a vocal pitch for their appearance. She came back for a check-up the day after surgery saying that she felt short of breath during the night. The vocal cords were not swollen, but it was immediately obvious that the arytenoids above the vocal cords were very swollen and bruised. They leaned in toward the vocal cords and moved in and out with each breath. The swollen arytenoids were narrowing the opening for breathing more than 75 percent.
The problem might seem obvious from that description. Yet my experience suggested otherwise. I see patients with both vocal cords paralyzed who get about their life with about 95% of their visual airway blocked. Usually people do not have trouble from narrowing of the airway until they are making noise with every breath — and Sarah was not making a single sound while breathing. Her sensation was out of proportion to her exam. I also noticed that she felt even more short of breath after I sprayed her nose with the anesthetic, and I know that quite frequently the anesthetic runs down the throat and gives patients the sensation that they cannot breathe even though they can.
Just because something looks abnormal — looks bad or even looks like it might be causing the problem — the seemingly obvious answer may not be the correct one.
I asked her to wait in the office; perhaps her symptoms would change after the numbing medication wore off. A half hour later she coughed and up came a blood clot. She felt much better. We took a look again at her larynx — the vocal cords and the swelling above them were just the same as before, even though she could now breathe essentially normally. The puzzle could now be put together. Some blood from the incision had run down into her lungs, and I had asked her not to cough so as not to bother the sutures in her newly tightened vocal cords. She had followed my instructions completely — and a clot had formed in her airway.
Two Models of Diagnosis
The vibratory model: By understanding that hoarseness is caused by air leak or asymmetry of vocal cord vibration, I will already understand a part of the disease when I see a new pattern — even before I can apply a name to it. Mind the gap.
The color model: Webster Hess, a young general otolaryngologist, took a look at some vocal cords and saw a white lesion. He said, “You have leukoplakia on your vocal cords. It could be cancerous. We should take it out.” On the biopsy, there was no cancer — only dysplasia. John White was relieved, but his voice was worse after the surgery. Several months later, Webster removed more leukoplakia, again benign. Again John’s voice was a bit worse. When I met John two years later, he had been to six doctors for his hoarseness, had several different treatments, and recently another biopsy — this time of the false vocal cord — showed cancer. The cancer was there, causing the hoarseness and continuing to grow while John hunted for an answer.
Webster looked for a lesion to match with the hoarseness. He did not think in terms of whether there was an air leak or an asymmetric vibration. When John didn’t improve after removal of the leukoplakia, Webster didn’t ask himself, “What am I missing?” — rather he told himself, “I was taught that sometimes hoarseness from leukoplakia near the front of the vocal cords doesn’t get better even after surgical removal.” But we know that color doesn’t vibrate — white, red, or even green vocal cords would have no bearing on a hoarse vocal quality. If your method of diagnosis depends on color, you risk completely missing the diagnosis and not knowing why. A precise diagnosis would orient the examiner to the surface of the vocal cord, to the curved margin, or to the false vocal cord — depending on what the audible findings are. He would then know whether to remove the leukoplakia or look elsewhere. He would not be distracted by color.
What you learned
- Nonorganic stridor does not require surgical intervention; understanding its natural course allows treatment with gentleness and persuasion rather than a tracheostomy.
- A visually striking finding (swollen arytenoids) may draw the examiner’s attention so powerfully that the actual cause (a blood clot in the airway) goes unrecognized — sitting back and watching the problem evolve is sometimes the most diagnostic action.
- The vibratory model of diagnosis (air leak or asymmetric vibration) provides a framework for understanding new disorders before they can be named.
- The color model of diagnosis (find a lesion, remove it) can lead to repeated unnecessary surgery and delayed detection of a growing cancer that was present throughout.
- When the hoarseness does not improve after treatment, the examiner’s first question should be “What am I missing?” — not “Why does this diagnosis sometimes fail to respond?”