A man in his 50s was injured in a motor vehicle crash and was intubated at the scene. On day 10 of intubation, he underwent a tracheotomy. He was successfully decannulated 8 months later. The patient then presented 1 year later with complaints of hoarseness since intubation. He felt short of breath at the end of sentences. He had undergone a neurosurgical procedure after the motor vehicle crash and was notified by the anesthesiologist that he was a difficult intubation.
On physical examination, he had a rough, hoarse voice without any stridor. His oral cavity revealed a Mallampati classification IV. Flexible laryngoscopy revealed bilateral vocal fold immobility (Figure, A). Results of a computed tomographic scan of his neck were unremarkable. Findings from a laryngeal electromyography were normal. The patient subsequently underwent a microdirect laryngoscopy with jet ventilation for diagnostic and therapeutic purposes. On first attempt of intubation, the Hunsaker tube got stuck in the posterior glottis. The attending otolaryngologist then exposed the airway with a Dedo laryngoscope and intubated the patient (Figure, B). An interarytenoid adhesion with a posterior opening was visualized. Palpation of the cricoarytenoid joints demonstrated that the joints were mobile. There was no evidence of subglottic or tracheal stenosis.