The n e w e ng l a n d j o u r na l of m e dic i n e

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Dynamic Extrathoracic Airway Obstruction

A B Posterior
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4
Flow (liters/sec)

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Volume (liter)
Anterior

A 
Deepak Pradhan, M.D. 53-year-old woman with a history of traumatic laryngeal frac-
Kenneth Berger, M.D. ture in childhood was referred for evaluation of excessive daytime somno-
New York University School of Medicine
lence. Inspiratory stridor was evident on physical examination. A spirometric
New York, NY flow-volume loop (Panel A) revealed an abnormal inspiratory airflow plateau (dashed
deepak.pradhan@nyumc.org line) and inspiratory flow oscillations (arrowhead), a pattern suggesting the presence
of a dynamic extrathoracic airway obstruction (a normal flow-volume loop is shown
in orange). Polysomnography confirmed that intermittent dynamic limitation of
inspiratory flow was resulting in snoring and sleep disruption. Laryngoscopy re-
vealed redundant supraglottic mucosa of the aryepiglottic folds (Panel B, arrows)
that fluttered during inhalation and exhalation (Video). Dynamic extrathoracic air-
way obstructions cause the greatest limitation of flow during inspiration, when
subatmospheric intraluminal pressure draws the obstructing lesion inward, reduc-
ing the diameter of the airway lumen. This results in a flow-volume loop that is
distinctly different from that produced by dynamic intrathoracic airway obstruction
(Fig. 1 in the Supplementary Appendix) or fixed airway obstruction (Fig. 2 in the
Supplementary Appendix). In this patient, supraglottoplasty was performed to re-
move the redundant tissue, resulting in a moderate improvement in daytime som-
nolence on follow-up several weeks later.
DOI: 10.1056/NEJMicm1010669
Copyright © 2012 Massachusetts Medical Society.

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