Ep 173 – Glottic Stenosis: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

0:00:00.0 Speaker 1: Ruth Werner's best-selling book, A Massage Therapist's Guide to Pathology is a highly regarded comprehensive resource that sets the standard for pathology education, written for massage therapy students and practitioners. This groundbreaking resource serves up a comprehensive review of the pathophysiology, signs, symptoms and treatment of more than 500 diseases and disorders. Learn more at booksofdiscovery.com.

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0:01:15.2 Ruth Werner: Hi, and welcome to I Have a Client Who, pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice, and sometimes as we have all learned, that is harder than it looks. Today's episode is a story shared by a massage therapist in Georgia who saw my invitation for I Have a Client Who stories on Facebook, and she very kindly and generously sent me this. She says, "Glottic stenosis. Client Lee, recently diagnosed and is or was awaiting surgery for relief. Symptoms previously thought to be related to being immunocompromised with a lyme disease. Client has not been able to be vaccinated, reactions to vaccines.

0:02:33.7 RW: And four out of four docs could not make a decision on one, trying vaccination again or two, moving forward with surgery. In the meantime, client contracted COVID-19 and my last communication with her was, they were going to try monoclonal antibody treatment. That was back on September 15th, and it has been radio silence since. While her pulmonologist believes her stenosis is genetic in nature, he's beginning to see an uptick in his work due to the fact that this can be a complication from being intubated. I've not heard much on this and only learned about it by a client experience and thought this might be of interest to you." And she is absolutely right. This is of deep interest to me. This feels personal because as many people know, I live with a chronic cough and it's hard for me to take a deep breath sometimes, so anything about breathing is likely to catch my attention. But it's interesting also because problems with breathing can have all kinds of impact on the body and it turns out that massage therapy can have a really profound impact on the sensation of breathing, and that could be relevant for cases like this. So come on along for this little exploration, if you're interested in what might be going on for your clients with breathing issues or for those who may have been intubated for COVID or for other reasons.

0:04:00.4 RW: Let's start with just a tiny bit of anatomy review. The glottis is the section of the larynx where the vocal cords are located, it is also the gateway from the throat into the upper part of the trachea. The shape of the glottis and vocal cords determines if and what kinds of sounds emerge. Glottic stenosis. Stenosis, you may know means narrowing. This describes a permanent restriction in the extensibility of the glottis. It can be a genetic condition, people may be born with it, or it can be acquired maybe through a history of trauma or surgery which involves intubation and maybe some ulcerations and subsequent scarring. To be thorough, I should point out that other sections of the larynx can also develop stenosis. But our focus today will be on the glottis specifically. The signs and symptoms of glottic stenosis are listed as stridor, that's a harsh grating sound during breathing, and three other signs built on the word root pnea, which comes from the Greek for breath, and these include apnea, temporary stopping of breathing. Dyspnea, problems with breathing, and sometimes the shortness of breath and tachypnea, which is rapid breathing.

0:05:20.4 RW: The National Institutes of Health resource that I consulted for this suggests that congenital glottic stenosis is very rare and always requires surgical intervention to correct it if it causes symptoms, but acquired glottic stenosis is not so rare, and it's often attributed to the trauma that occurs with endotracheal intubation during surgery. The risk and severity of this complication goes way up if there are multiple surgeries or if the tube is large or if it's in place for more than five days, or if the patient is agitated and moving around a lot. Some data suggests that glottic stenosis occurs in 6-19% of these high-risk patients. Non-surgical glottic stenosis can be the result of some other kinds of trauma. Maybe ingesting corrosive materials that burn these tissues, bad infection, swallowing foreign bodies, and sometimes it is a complication of nasogastric, not endotracheal intubation or to surgery to the larynx itself. Some people think that GERD, gastroesophageal reflux disorder, might contribute to the risk for glottic stenosis because the backsplash of gastric juices into the throat could cause some irritation and scarring, but that has not been demonstrated by research at this moment.

0:06:46.2 RW: The National Organization for Rare Disorders also describes a couple of subtypes of idiopathic glottic stenosis. So these cases are not tied to a congenital malformation or to a history of surgery or other trauma, they just come up, these are diagnosed almost exclusively in perimenopausal white women all around 50-years-old. Many of those patients also reported symptoms that arose during pregnancy, so possibly glottic stenosis for those patients might have something to do with changes in hormone secretion, but it's not clear how one leads to the other. Glottic stenosis regardless of what causes it, doesn't have a widely accepted treatment protocol. If it's mild and it doesn't interfere with activities or quality of life, it might not be treated at all. If treatment is necessary, then we might approach it with medications that could address inflammation and infection or with procedures that work to open up constrictive connective tissue in the throat, and this can be done with lasers or injections or a number of other frankly scary sounding options including open surgery. These surgeries can involve widening the passage with balloons, like we see, say with coronary artery surgeries or cutting out the scarred area and reattaching the remaining segments or this really complicated surgery called laryngotracheoplasty.

0:08:16.5 RW: So let's think for a moment about our client in this story and what it might be like to live with glottic stenosis, her symptoms, which included coughing and frequent throat clearing, had previously been thought to be related to being immunocompromised with lyme disease. Frankly, I'm not sure how the one leads to the other because lyme disease is not notorious for causing respiratory problems, but if we remember that the symptoms of glottic stenosis include problems with breathing, and people who are immunocompromised are especially vulnerable to respiratory tract infections in general. Then maybe we can see how lyme disease and immunocompromised might lead to chronic coughing and frequent throat clearing, but her coughing and breathing issues turned out not to be a result of lyme disease, they were related to a structural problem in her throat, her glottis, and her pulmonologist thinks it might have been congenital, which puts this client in a tiny minority as this is recognized to be pretty rare, and the only way to correct it is with surgery. Now, this client was hesitant about COVID vaccination because of some previous bad reactions, and all of her doctors, four out of four of them could not find consensus on trying the vaccine again or on moving forward with surgery to correct her stenosis.

0:09:38.3 RW: And obviously, there was a sense of urgency about this. Well, ultimately, as we heard, the client did contract COVID-19 and the therapist has not heard from her since. She's genuinely concerned that possibly this woman didn't make it, and we all hope that that's not the case of course, but we just haven't heard back from her at all. But if she had responded, then what could this massage therapist do for her? The problem here was inside the throat structures, well out of reach for any direct influence with manual therapy. I suggested to our contributor that maybe some very skilled work to help relax the anterior throat muscles might have been helpful. Pro-tip, this is work that can be effective, but it requires advanced education, and it is definitely not for dabbling. The massage therapist agreed and added this, she said, "Most of what I could offer would be post-operative lymphatic work and maybe some scar work around her neck, and the reason I thought to send you this is, I wonder if we'll be seeing this glottic stenosis diagnosis in the future, as many more people are being intubated now." Sadly, this is a strong possibility, and if you do end up with clients who have glottic stenosis because they were intubated for COVID or for other reasons, I can say before we even start, they are already wonderful success miraculous stories because it's just a small number of COVID-19 patients who survive being intubated, that's roughly about 15%.

0:11:13.9 RW: And again, we cannot reach inside their throats to manipulate scar tissue or other connective tissue, we can get good education to work with the anterior neck and to work with post-surgical lymphatic flow and scar tissue, and these are great options. In addition, we can work with the breath all together. If you have ever had a problem with breathing, maybe due to asthma or getting over a cold or a flu, you'll know that when we are restricted in taking a free and easy breath, that it has all kinds of other repercussions on the body. The musculature of the thorax can be tight and protective, which limits easy breathing even more, and restrictions in breathing can create a sense of anxiety that then reinforces those muscular patterns and the whole thing can just snowball. Ask me how I know. Gosh, if only there were some good way to interrupt some of those vicious circles, maybe by reducing anxiety and reducing muscle tone in the chest and the upper back and working with the anterior neck. My point is, massage often can't reach in and fix a specific thing, but the changes our work brings about in the most fundamental ways that we feel safe and that we can provide our body with adequate oxygen without being stressed about it. That feeling is miraculous. So let's go and meet our clients with breathing issues related to glottic stenosis or other things, with the confidence that we can be an important part of their quality of life.

0:12:50.2 RW: Hey everybody, thanks for listening to I Have a Client Who pathology conversations with Ruth Werner, remember, you can send me your I Have a Client Who stories to ihaveaclientwho@abmp.com. That's ihaveaclientwho, all one word, all lowercase, @abmp.com. I can't wait to see what you send me and I'll see you next time.