The answer lies in diagnosing the source of the problem, which I place in four broad categories: 1) breathing, or more specifically, imbalanced
subglottic breath pressure; 2) resonance, or more specifically, mistuned formants; 3) lack of awareness or indifference to how the vocal line fits within the fabric of the musical work as a whole; and, 4) carelessness or lack of respect for the musical situation at hand.
Subglottic stenosis developed in four patients, the attribution remained uncertain as whether it was due to prolonged intubation for more than 10 days or isolated complication of tracheostomy.
These complications include laryngeal carcinoma, vocal cord nodules, laryngospasm and
subglottic stenosis.
On direct examination with laryngoscope during surgery, a web was found just below the vocal cords leading to obstruction in the
subglottic region.
One such measure is the use of endotracheal tubes with
subglottic secretion drainage (SSD), which claim to reduce the incidence of VAP by preventing the formation of micro-aspirations around the cuff of the endotracheal tube.
[1,2] It reported about the incidence of severe
subglottic narrowing in a 2-year-old child ventilated for prolonged period.
Fourteen patients had high cervical /
subglottic stenosis and were operated by high anterior cervical collar incision, while five had lower tracheal stenosis, and two had carinal lesions and were operated by right thoracotomy (Figure 3).
Magnetic resonance imaging (MRI) showed an enhancing soft-tissue tumor measuring approximately 1.27 X 1.72 X 3.56 cm (figure 1) in the supraglottic, glottic and
subglottic area without destruction of the adjacent thyroid cartilage.
Repeat direct laryngoscopy revealed a large area of granulation tissue at the site of the anastomosis from his prior surgery as well as grade 2/3
subglottic stenosis.
(4) Children with PHACES syndrome can also be afflicted by
subglottic hemangiomas, which commonly present with biphasic stridor worsened by crying.
Subglottic stenosis (SS) occurs in patients as a result of active disease or chronic recurrent inflammation.