Vocal cord synechia

Vocal cord synechia is a strand of scar tissue that tethers the vocal cords to each other. It can prevent the vocal cords from opening fully for breathing.

A synechia can also form in other parts of the body. (Note the subglottic synechia shown below.)


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Videos:

Vocal Cord Synechia
This video provides a clear example — using laryngeal videostroboscopy — of a vocal cord synechia.

Laryngocele

 

Laryngocele: A Cause of Hoarseness
A laryngocele is a disorder of the saccule, or laryngeal appendix, in which air abnormally expands it. Watch this video to see how a laryngocele behaves in real-time, and why that can affect the voice.

See also: laryngocele in the encyclopedia.

Recurrent respiratory papillomatosis (RRP) and other HPV-induced lesions

A disorder in which wart-like tumors or other lesions grow recurrently within a person’s airway. These growths are caused by the human papillomavirus (HPV), and they may occur anywhere in a person’s airway, such as on the vocal cords (by far the most common site), in the supraglottic larynx, or in the trachea. If these growths are removed, they will almost always grow back, or recur; hence, “recurrent respiratory papillomatosis.”

Symptoms and risks of recurrent respiratory papillomatosis:

RRP can be life-threatening in young children, if not carefully followed and treated, since a child’s airway is relatively narrow and can potentially be obstructed completely by the disease’s proliferative growths; moreover, RRP in children tends to grow and recur more aggressively. In adults, RRP will usually only impair voice function (when the growths occur on the vocal cords), though it can also impair breathing in severe cases. Occasionally, RRP can also progress to cancer, and therefore patients found to be at high risk for this (see below) need to be monitored carefully.

Characteristics of the growths:

The growths usually associated with RRP are wart-like tumors, or papillomas, that protrude conspicuously from the surface on which they grow, often in grape-like clusters. These kinds of papillomas are usually seen in patients who have HPV subtypes 6 or 11, which are both lower-risk subtypes for incurring cancer. There are some HPV patients, however, who manifest their HPV infection with subtler, velvety growths within the airway—“carpet-variant” growths, so to speak. Although these “carpet-variant” growths do not have the wart-like appearance of the papillomas typically associated with RRP, there at least a few key points of similarity:

  1. Both the “carpet-variant” and wart-like growths are lesions that sometimes appear, either independently or together, in patients who have HPV;
  2. Both the “carpet-variant” and wart-like growths are stippled with polka-dot vascular markings, because each “loop” in the “carpet” or each “grape” in the wart-like cluster has its own fibrovascular core, seen as a red dot;
  3. Both the “carpet-variant” and wart-like growths can disrupt voice function;
  4. Both the “carpet-variant” and wart-like growths usually recur if they are removed.

Because of these similarities, we consider these “carpet-variant” growths, even when the sole expression of the infection, to be at least a cousin to RRP, within the family of HPV-induced lesions. Many patients with this “carpet-variant” condition have HPV subtypes such as 16 or 18 that are higher-risk for cancer; such patients need to be monitored with particular care.

Treatment for recurrent respiratory papillomatosis:

The primary treatment for RRP and other HPV-induced lesions is careful, conservative surgical removal of the growths. Because these growths almost always recur, surgery must usually be performed on a repeated basis, as frequently as every few weeks in children, but on average much less often in adults. A common interval between surgeries for adult patients is between every six months and every two years, depending on how quickly the RRP or other HPV-related lesion recurs and impairs the patient’s voice function again. There are also a few medical treatments that have been used in addition to surgery, including, among others, interferon, indole-3-carbinol, intralesional mumps or MMR (measles-mumps-rubella) vaccine, cidofovir, and bevacizumab.


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Videos:

Papillomas of the Larynx and Trachea
This video shows wart-like growths in the voicebox and windpipe (larynx and trachea) caused by chronic infection with the human papillomavirus (HPV).
Pulsed-KTP Laser Coagulation of Vocal Cord Papillomas
See a video demonstration of laser coagulation of vocal cord papillomas.

Laryngocele

A disorder in which the laryngeal saccule is inflated and becomes abnormally enlarged. A common symptom of a laryngocele is hoarseness.

How it develops:

The laryngeal saccule, or laryngeal appendix, is a very small blind sac—a dead-end corridor, so to speak—which is located just above the vocal cords, one on each side, and is lined with glands that supply lubrication to the cords. When a person makes voice, it is possible for a little bit of the air being pushed up out of the trachea to slip into this saccule. If over time enough air enters the saccule with enough force, the saccule may begin to be inflated and stretched out, leading to a laryngocele.

In some cases, the air that slips into and inflates the laryngocele will slip back out again as soon as the person stops making voice, so that the laryngocele abruptly inflates and deflates with each start and stop of speech or voice-making. (The photos and video below are an example of this.) In other cases, the air cannot exit the laryngocele as easily, but it may be reabsorbed slowly during quiet times or during sleep—only to be inflated again at the next instance of more active speaking.

Laryngocele vs. saccular cyst:

A much more common disorder of the laryngeal saccule (compared with a laryngocele) is a saccular cyst, which can occur if the entrance to the laryngeal saccule becomes blocked. In this scenario, air is absorbed, but secretions build up and gradually expand the saccule.

Symptoms and treatment:

A common symptom is hoarseness, because while the saccule is inflated, it may press press down on the vocal cords, not allowing them to vibrate freely, or it may block the laryngeal vestibule just above the cords and partially muffle the sound produced by the cords. Standard treatment is surgical removal, through one of two approaches: a small incision on the neck that leads into the larynx from the outside, or a laryngoscope that is inserted through the mouth and down into the larynx so that the laryngocele can be removed using a laser.


Photos:


Videos:

Laryngocele: A Cause of Hoarseness
A laryngocele is a disorder of the saccule, or laryngeal appendix, in which air abnormally expands it. Watch this video to see how a laryngocele behaves in real-time, and why that can affect the voice.

Glottic sulcus

A degenerative lesion consisting of the empty “pocket” of what was formerly a cyst under the mucosa of the vocal cord. The lips of a glottic sulcus may be seen faintly during laryngeal stroboscopy. Or, vibratory characteristics may suggest this lesion.

A glottic sulcus may be overlooked unless one is familiar with this entity. To paraphrase eminent French laryngeal microsurgeon Dr. Marc Bouchayer, these lesions are diagnosed much more frequently once you know about them than before. At present, aside from having the patient coexist peacefully with this problem via voice therapy and other measures, surgery is the primary treatment modality.


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Glottic Sulcus: Laryngeal Videostroboscopy
Glottic sulcus is a degenerative lesion consisting of the empty “pocket” of what was formerly a cyst under the mucosa of the vocal fold. The lips of the sulcus may be seen faintly during laryngeal stroboscopy. Or, vibratory characteristics may suggest this lesion.

Stenosis

Abnormal narrowing of a passageway in the body. At our practice, stenosis typically refers to narrowing in the breathing passage, such as for narrowing in the glottic, subglottic, or tracheal areas.

Stenosis in the airway can be the result of prolonged endotracheal intubation, external trauma such as gunshot wound, crush injury, or tracheotomy, an inflammatory or auto-immune process, surgical resection of part of the airway for tumor, or other causes. Persons with airway stenosis will note a reduced capacity for exercise. Often the clinician hears noisy breathing on inhalation, especially when the patient is asked to fill the lungs quickly. Esophageal stenosis gives symptoms of difficulty swallowing solids more so than liquids.


Photos of stenosis:




Videos:

Tracheal Stenosis: Before and After
In this video, trachea (windpipe) blockage causes shortness of breath until the narrowed segment is removed. You will see views of the trachea before and after surgical repair.
Post-Radiation Hypopharyngeal Stenosis
People with larynx or pharynx (voice box or throat) cancer often undergo radiation therapy as part of their treatment regimen. An uncommon complication is stenosis (narrowing, scarring) of the entrance to the upper esophagus at the junction of the throat and esophagus. This video provides an example of this disorder.

Spasmodic Dysphonia

 

Videos:

Spasmodic Dysphonia: A Peculiar Voice Disorder
Dr. Robert Bastian reviews the various types and subtypes of spasmodic dysphonia. Numerous voice examples are included, along with video of the vocal folds.
Spasmodic Dysphonia: When Botox Disappoints
In this video, Dr. Bastian discusses common problems with Botox treatment for spasmodic dysphonia and offers clear, practical advice to increase the effectiveness of these treatments.

See also: spasmodic dysphonia in the encyclopedia.

Mucosal chatter

The term ‘vocal cord chatter’ describes the audible phenomenon one hears when the voice starts and stops in rapid alternation because the mucosa is at the edge of its ability to vibrate at a given pitch, loudness, and subglottal air pressure. So, it “catches” the airstream and vibrates for a fraction of a second, then stops, then restarts, then stops, etc. The best understanding is gained through audio and video examples.

Patient examples:

SLAD-R

SLAD-R (Selective laryngeal adductor denervation-reinnervation). This procedure was introduced by Dr. Gerald Berke of UCLA in the late 1990’s. It is a surgical option for adductory spasmodic dysphonia. The concept is to sever the anterior branch of the recurrent laryngeal nerve. This denervates the spasming laryngeal adductors (particularly thyroarytenoid and lateral cricoarytenoid muscles). The squeezed, strained quality and/ or “catching, cutting out, stopping” of the voice are replaced initially with an extremely breathy and weak voice. This initially weak voice is analogous to what one might sound like after a Botox injection that is far too high a dose. To return strength to the voice, a branch of the ansa cervicalis nerve that normally supplies some relatively “unimportant” neck muscles is anastomosed (connected) to the severed nerve. It takes 3 months to a year for tone to begin to return to the adductory muscles. Since the “unimportant” neck muscles were not affected by the dystonia, the hope is that the new nerve supply to the laryngeal muscles may not be affected by dystonia.


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Videos:

One Man’s Experience Over Time with SLAD-R
SLAD-R is a surgical alternative to ongoing “botox” injections for treatment of adductory spasmodic dysphonia. The surgery involves intentionally cutting the nerves that close the vocal cords for voice and reconnecting a different nearby nerve supply (reinnervating the nerves). This surgery requires the patient’s willingness to endure an extremely breathy voice for many months after the procedure, while awaiting reinnervation.

Forme fruste Wegener’s granulomatosis

An incomplete or frustrated form (forme fruste) of Wegener’s granulomatosis, which we believe to be the cause behind some cases of inflammatory subglottic or tracheal stenosis. Unlike full-fledged Wegener’s, this forme fruste variant may or may not necessarily involve the sinus and nasal cavities, and in the author’s caseload of about 60 patients, it has not ever progressed to involve the lungs and kidneys. Such patients can go for years with only the need for intermittent dilation of the subglottic or tracheal narrowing. This disorder may be the same as what some call “idiopathic subglottic stenosis,” for which some have recommended cricotracheal resection and reanastomosis as treatment.


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Videos:

Wegener’s Granulomatosis: Forme Fruste (incomplete expression)
Wegener’s granulomatosis is a rare autoimmune disorder in which blood vessels become inflamed. The inflammation causes swelling and scarring. Three typical organs attacked are sinus/nasal cavities, lungs, and kidneys. In the forme fruste variant, it is mostly an inflammatory stenosis (narrowing) of the area below the vocal cords, and also the trachea. A person becomes short of breath and begins to make harsh breathing sounds due to the narrowed passageway. This is an example of one means of management: dilation of the narrowed area during a very brief general anesthetic in an outpatient operating room.