Unusual "Noisy" Breathing Sounds

by , last modified on 1/25/14
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This section will go over a variety of lesions that leads to breathing that does not sound normal. Voice quality is normal. Treatment depends on the cause of the noisy breathing and may include surgery or just counselling without any intervention.

NOTE: Please allow sufficient time for the audio and movie files to upload. You will need to download and install ActiveX and QuickTime to view these video and audio clips. The plugin is available for free download at Apple.

Click here for audio & video of what normal looks like.
Photos displaying abnormalities can be found in the Photo Library.

How Were These Images/Videos Obtained??? By a Procedure Called Fiberoptic Trans-Nasal Endoscopy...

Example 1: Tracheal Stenosis

Audio - Standard Passage

Audio - Breathing Noises

videoClick here to view video.

Note that the breathing sounds are noticeable on both inspiration and expiration suggesting a fixed lesion somewhere in the airway. The tracheal stenosis responsible for the breathing sounds was discovered on bronchoscopy shown in the movie. On a more significant note, this lesion was NOT seen on CT scan of the chest or soft tissue X-ray. Also, patient was erroneously treated for VCD for several months prior to diagnosis.

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stenosis

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Example 2: Laryngospasm

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This video shows a patient in laryngospasm obtained in the OR. The breathing noise created is called stridor in the truest sense. Note that the vocal cords do move...however, the vocal cords come together when they should move apart. Click here to read more about laryngospasm and other forms of vocal cord dysfunction.

YouTube has 2 examples of what stridor sounds like at least in an infant due to an anatomical obstruction (NOT laryngospasm):
Example #1Example #2

Example provided courtesy of Dr. James Thomas.

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laryngospasm

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Example 3: Exercise Induced Vocal Cord Dysfunction

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This video shows a patient with vocal cord dysfunction induced by exercise. Vocal cord dysfunction is a less severe form of laryngospasm as shown in the previous example. Just as in laryngospasm, the vocal cords come together when inhaling, but incompletely. Notice how the vocal cords come almost together on inhalation, especially in the beginning with fairly rapid resolution with time.

The patient also has an element of non-organic stridor as shown in the next example.

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vcd

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Example 4: Non-Organic Stridor

Audio - Breathing Noises of 2nd Video Example Patient

videoFirst video example (provided courtesy of Dr. James Thomas)

videoSecond video example

This complaint is usually voiced by a high school aged female athlete. The noise that sounds like wheezing is actually produced by thin and pliable vocal cords that vibrate with quick inhalation or exhalation when the vocal cords are APART. Often, these patients are misdiagnosed as having exercise-induced asthma or VCD. Of note, asthmatics usually wheeze only on exhalation.

At rest, breathing sounds normal. After exercise, there is an audible wheeze on inhalation. The videos presented here are both young women (different patients) after running around the block several times until symptommatic.

In essence what is happening during strong inhalation is increased negative pressure at the vocal cord level due to Bernoulli's principle resulting in the vocal cords being pulled together. This phenomenon is much akin to trying to suck on a straw forcefully which will result in wall collapse. When this happens, the body actively tries to keep the vocal cords apart. However, if the negative pressure is strong enough, the vocal cord membranes will start to vibrate and cause "noise," just like a flag makes more noise the stronger a wind blows.

Treatment is simply to slow the breathing down. That's it!

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nonstridor

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nonorganic

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Example 5: Posterior Glottic Web

Audio - Standard Passage

Audio - Breathing Noises

videoClick here to view video.

This examination was performed one year after a traumatic intubation after a motor vehicle accident followed by 14 days of intubation before extubation. The patient noticed progressive shortness of breath as well as "noisy" breathing. Note that the voice itself is normal and clear, but the breathing sounds are noticeable on both inspiration and expiration suggesting a fixed lesion somewhere in the airway. On endoscopy, the fixed lesion was discovered to be a scar band in the back part of the vocal cords (top of picture) preventing the vocal cords from moving apart fully. This scar band is known as a posterior glottic web. This abnormality was addressed by surgical excision of the scar band along with treatment to prevent recurrence of the scar band.

On an educational note, scar bands crossing the back aspect of the vocal cords do not generally affect the voice, but scar bands in the front generally do. Another point to make is that if the patient had undergone a tracheotomy soon after intubation (within 5 days), this complication may have been avoided. Generally speaking, if a patient is expected to be intubated for more than 5 days, tracheotomy should be performed to prevent complications such as this among others.

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web

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Example 6: Bilateral Vocal Cord Paralysis

videoClick to view video #1 and video #2.

In the first video, the patient presented with difficulty breathing and making "noise" while breathing in and out at times, especially when sleeping. On the video exam, it is clearly evident that his vocal cords are not moving apart as well as they should. With such a limited opening, it is no wonder he can't breath well! The still picture shown is at maximum ABduction or vocal cord separation. Unlike example #4 in which a scar band prevented vocal cord separation, this case is due to paralysis of both vocal cords.

The other video is another example of bilateral vocal cord paralysis, but due to traumatic intubation. The vocal cords appear to come together with vocalization, but is not due to muscular activation, but rather airflow from bernoulli's principle given how close the cords are together (try blowing air between two pieces of paper that are close together, but not touching).

Treatment for this is difficult and there is no perfect solution. Treatment to improve breathing usually makes the voice worse. Treatment to improve the voice usually makes the breathing worse. The best (but not perfect) treatment tries to pick a happy medium to address the breathing while trying not to hurt the voice too much, though some degradation in vocal quality is to be expected. Such a treatment includes posterior cordotomy +/- partial arytenoidectomy.

Read more here.

An example of someone with a unilateral vocal cord paralysis is shown here.

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paralysis

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B vocal cord paralysis

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Example 7: Large Ball-Valving Polyp

Audio - Standard Passage

Audio - Breathing Noises

videoClick here to view video.

Patient presented with hoarseness lasting several years with difficulty breathing and making "noise" while breathing in and out at times, especially when laying down. On the video exam, it is clearly evident of a large right true vocal cord polyp that ball-valves in and out. One can actually hear the ball-valving on the breathing audio clip where one can here a "flip" when the polyp moves position from inhalation to exhalation.

This polyp is known as a Smoker's Polyp as it mainly occurs in people who smoke and talk a lot. Treatment was excision with voice therapy and quit smoking.

Read more about vocal cord polyps here.

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polyp

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Example 8: Tracheomalacia

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Patient is a 10 year old child with a 5 year history of noisy breathing with exhalation (especially with coughing) that sounded like the bark of a seal. Patient was physically very active and rarely ill. In the past, he apparently was treated for asthma as well as allergies without any change, let alone improvement. Finally it was felt that he may have vocal cord dysfunction and presented to our clinic for further evaluation and treatment.

On exam, his noisy breathing was found to be actually due to tracheomalacia where the posterior wall of his upper airway collapsed momentarily causing the deep barking noise on exhalation.

Given that he had no functional limitations, no further intervention was recommended other than routine monitoring. Of further note, no medications were prescribed and all asthma & allergy medications discontinued.

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TML

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Example 9: Pediatric Laryngomalacia

Audio - Breathing Noises

videoClick here to view video. (No sound in this video.)

Patient is a 1 month old child who presented with "noisy breathing," especially when agitated or crying. The noise was more apparent on inhalation than on exhalation. Other than the breathing issue, the child was doing fine.

On fiberoptic laryngoscopy, it was apparent that the breathing noise was due to a "floppy epiglottis" that flopped into the airway with strong inhalation causing the noise. This floppy epiglottis is known as laryngomalacia. The child at baseline has an epiglottis that is curved like the letter "U" which is known as an omega-shaped epigottis. An omega-shaped epiglottis is prone to being floppy causing laryngomalacia.

Given the child was doing fine other than making the noise, it was expected that the child will eventually outgrow this problem. Careful monitoring alone was recommended.

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laryngomalacia

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Example 10: Adult Laryngomalacia (and Right Vocal Cord Paralysis)

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Patient is a young woman who experienced an idiopathic right true vocal cord paralysis. Though she did complain of some mild breathy dysphonia, her main complaint was actually shortness of breath, especially with inhalation.

In the video, one can see that the right vocal cord does not move. However, even more significant is the mucosal hooding that occurs such that her airway is partially blocked, more pronounced with sudden inhalation. A slight wheeze can also be heard.

Treatment was surgical by excising some of the excess tissue that flopped into her airway (supraglottoplasty).

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laryngomalacia

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