Postintubation Phonatory Insufficiency: A Challenging Diagnosis

Glottic insufficiency is an important cause of dysphonia and can be frequently overlooked in the clinical evaluation. The differential diagnoses of this entity are diverse and include postintubation phonatory insufficiency (PIPI). These patients present with glottic insufficiency symptoms, associated with normal laryngeal imaging evaluation with no evident lesions. There is scarce literature describing this entity, since it is usually underdiagnosed.

The aim of this study is to describe two clinical cases diagnosed with PIPI at our center's Voice Unit, discuss their clinical features, diagnostic evaluation, and treatment alternatives.

We report two clinical cases of prolonged orotracheal intubation (OTI) that developed dysphonia, vocal fatigue, a breathy voice, and poor vocal projection after being discharged from the hospital. Laryngoscopic evaluation showed no lesions in the membranous glottis and normal vocal fold mobility. Respiratory glottis was difficult to evaluate because of redundant arytenoids. To improve visualization, a laryngotracheoscopy with transtracheal anesthesia was performed in-office, exposing scar tissue medial to the vocal processes and respiratory vocal fold, confirming PIPI.

Prolonged OTI can damage the medial arytenoid mucosa producing a posterior glottic gap that determines symptoms of glottic insufficiency. Multiple treatment options have been described yet few achieve a sufficient closure of the defect, so management is initially based on counseling and speech therapy.

PIPI is usually difficult to diagnose and should be sought directly in the clinical evaluation, especially if there are no obvious lesions in the membranous glottis.