Cancer

A malignant growth or tumor caused by abnormal and uncontrolled cell division. The hallmark of cancer is its potential ability to invade neighboring tissue or to spread (metastasize) to other parts of the body through the lymphatic system or the bloodstream. Early cancers may have done neither, remaining localized to the tissue of origin. The majority of cancers in the head and neck are classified as carcinomas.


Photos of cancer:

Laser surgery for Bilateral Vocal Cord Cancer

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squamous cell carcinoma

Squamous cell carcinoma (1 of 6)

This man developed hoarseness across a few months. Biopsy elsewhere revealed squamous cell carcinoma, seen here on both vocal cords. Based upon a friend’s experience, he rejected radiotherapy, opting for laser resection, knowing it could be very hard on voice.
Tumor on the vocal cords

Tumor on the vocal cords (2 of 6)

At closer range and under narrow band (blue-green) light to accentuate the vascular abnormalities associated with this tumor.
superficial laser cordectomy

Granuloma delays voice recovery (3 of 6)

Six weeks after superficial laser cordectomy, the larynx is almost healed with the exception of a small granuloma, left vocal cord (right of photo). When healing includes granulation, voice recovery is delayed as the granuloma resolves.
granuloma prevents vibratory closure

Closer view of granuloma (4 of 6)

He has hoarse but functional voice, but under strobe light, the granuloma prevents vibratory closure. Note the medial-to-lateral capillary reorientation so typical after laser cordectomy.
Granuloma on vocal cord

Granuloma is smaller (5 of 6)

Now 3 ½ months from surgery, voice has improved further and he considers it “75%” of original...One can see that the granuloma is smaller.
ranuloma no longer prevents vibratory closure

Granuloma doesn't impede voice (6 of 6)

Note that the granuloma no longer prevents vibratory closure and this explains further improvement of voice. Compare with photo 4.

Vocal cord cancer, before and after surgery

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Squamous cell carcinoma

Vocal cord cancer (1 of 4)

Squamous cell carcinoma, right vocal cord (left of image), standard light.
Vocal cord cancer

Vocal cord cancer, 1 week after surgery (2 of 4)

One week after laser excision. See irregular granulation especially at lower margin of excision.
one month after excision

Vocal cord cancer, 1 month after surgery (3 of 4)

Approximately one month after excision, healing progressing.
Vocal cord cancer

Vocal cord cancer, after complete healing (4 of 4)

After complete healing, patient has a voice that passes for normal. Under strobe light, right cord oscillates well except at very high vocal pitch. Note, however, the mild pseudo-bowing of the right cord due to tissue loss, and that there is a mucosal wave on the left, but not on the right.

Glottic Cancer, Laser Removal

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Glottic cancer, laser removal (1 of 3)

Early right vocal fold carcinoma, operative view (OR).

Glottic cancer, laser removal (2 of 3)

Same lesion, at the start of laser removal (OR).

Glottic cancer, laser removal (3 of 3)

Same larynx, after removal is complete. With healing over the next several months, the deficit “fills in” and voice result is often surprisingly good (OR).

Glottic Cancer, After Surgery

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capillary reorientation

Glottic cancer, after surgery (1 of 3)

After superficial cordectomy, right cord, for early vocal cord cancer, standard light. Note capillary reorientation from normal mostly anteroposterior direction to medial-lateral.
matching of the cords at closed phase of vibration

Glottic cancer, after surgery (2 of 3)

Strobe light. Notice excellent matching of the cords at closed phase of vibration, correlating with the patient’s excellent voice quality.
left cord oscillates, but the right doesn’t

Glottic cancer, after surgery (3 of 3)

Strobe light, open phase of vibration. This view reveals that the left cord oscillates, but the right doesn’t. As long as match is good, and there is no vibratory abnormality of the left cord (e.g. flaccidity, or mucosal abnormality), then voice can be essentially normal.

Vocal cord cancer, before and after surgery

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persistent right vocal cord cancer

Vocal cord cancer (1 of 8)

Patient from elsewhere, first seen 9 months after radiotherapy, with obvious persistent right vocal cord cancer.
deep ulceration

Vocal cord cancer (2 of 8)

Closer view, during phonation, showing deep ulceration and rolled upper and lower border of cancer.
Right vocal cord One week after aggressive cordectomy

Vocal cord cancer, 1 week after surgery (3 of 8)

One week after aggressive cordectomy, right, including down to inner perichondrium of thyroid cartilage.
left vocal cord now has no partner against which to vibrate

Vocal cord cancer, 1 week after surgery (4 of 8)

Phonation, showing that the left vocal cord now has no “partner” against which to vibrate, and this explains the marked breathiness.
residual granulation on right vocal cord

Vocal cord cancer, 7 weeks after surgery (5 of 8)

Nearly complete healing after complete cordectomy right vocal cord. Only residual granulation.
residual exposed cartilage, not yet healed over with mucosa

Vocal cord cancer, 7 weeks after surgery (6 of 8)

Closer view of defect. Thin mucosa covers inner surface of thyroid cartilage, and residual exposed cartilage, not yet healed over with mucosa, at arrow.
left vocal process is turned medially

Vocal cord cancer, 7 weeks after surgery (7 of 8)

At maximum phonatory adduction. Note that the left vocal process is turned medially (arrow), signifying maximum adductory “effort” of that side. There is no right vocal cord, and hence there is no possibility of glottic voice.
Vibration of the arytenoid apices

Vocal cord cancer, 7 weeks after surgery (8 of 8)

Vibration of the arytenoid apices (arrows) against the petiole of the epiglottis (line), providing a rough, voice serviceable for quiet conversation, but highly limited in noisy surroundings.

Breaking cancer “rules” intelligently with use of laser

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lesions shows persistent cancer

Post radiotherapy stage (1 of 8)

This woman had completed radiotherapy elsewhere many months ago for early vocal cord cancer. Recent biopsy of these lesions shows persistent cancer. At the same time, she is under treatment for unrelated stage IV lung cancer. Standard treatment here would be total laryngectomy.
tumor crosses the anterior commissure

Laser surgery typically not acceptable (2 of 8)

Under narrow band light and at closer range. Not only due to failure of radiation to cure, but also because this tumor crosses the anterior commissure (where the two vocal cords meet at the bottom of the photo), the widely accepted "rule" is that she should undergo total laryngectomy. The blue lines are located in the same place in the following photo.
area of tumor removal

Laser removal of tumor with careful followup (3 of 8)

In light of the patient’s uncertain future due to advanced lung cancer, her near-refusal of total laryngectomy, and with detailed inclusion of patient in “breaking the rules” thinking, the tumor was removed with the laser. Tissue margins were negative. Still, tumor behavior is not as predictable as it would be in a previously-untreated patient. Careful followup is therefore critical. Hashmarks show area of removal, to include everything even faintly abnormal-looking and the blue lines are located in the same place in the previous photo.
removal of soft tissue from anterior commissure to the inner perichondrium

Second view post laser surgery (4 of 8)

Better view of the anterior commissure, where soft tissue was removed all the way to the inner perichondrium of the thyroid cartilage at the arrow.
Healing is complete 6 months after surgery

Six months post laser surgery (5 of 8)

Nearly 6 months after laser surgery. Healing is complete. No obvious tumor is seen. The patient has developed very serviceable false cord voice (see photos 7 and 8).
Vessels have been stable for 2 months

Blood vessels stable two months post surgery (6 of 8)

Narrow band light allows more intense monitoring for aberrant blood vessels that might indicate tumor regrowth before there is any visible bulk. Vessels in the area of arrows have been stable for 2 months but require careful comparison with future examination photos.
False cord phonation, open phase

Open phase of false vocal cord phonation (7 of 8)

False cord phonation, open phase. The true cords cannot oscillate at all due to dense scarring.
false cord vibratory closure

Closed phase of false vocal cord phonation (8 of 8)

True vocal cords are obscured by the false cord vibratory closure.

Glottic/vocal cord cancer

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Left vocal cord cancer

Glottic/vocal cord cancer (1 of 2)

Left vocal cord cancer, abducted breathing position, standard light.
left cord moves normally with tumor

Glottic/vocal cord cancer (2 of 2)

Phonation, standard light, shows that the left cord moves normally. Tumor is mostly exophytic (growing outward like broccoli, rather than inward, like an onion).

Supraglottic cancer

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circumscribed exophytic squamous cell carcinoma at the petiole

Supraglottic cancer (1 of 4)

Middle-aged woman with sore throat, discovered to have a circumscribed exophytic squamous cell carcinoma at the petiole and anterior false cords.
aberrant tumor vessels

Supraglottic cancer (2 of 4)

Closer view, showing the aberrant tumor vessels especially in the inferior half of the tumor, with less “white-out” from light overexposure.
tumor does not cross the plane of the ventricle

Supraglottic cancer (3 of 4)

As is often the case, this tumor “respects” the ventricle, meaning it does not cross the plane of the ventricle (entrance at dotted line) to invade the true cords. An instrument could lift the inferior border of the tumor to show that the true cords aren’t invaded; the tumor is simply overlapping them.
tumor’s aberrant vessels under strobe light

Supraglottic cancer (4 of 4)

Under narrow-band lighting, the tumor’s aberrant vessels and its relationship to both the true and false cords are clearer. This is a supraglottic (not transglottic) tumor, likely amenable to outpatient endoscopic laser resection, and management of lymphatic compartments of the neck, depending on individual circumstances, via observation, radiotherapy, or selective neck dissection.

Hypopharyngeal cancer, before and after surgery

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new hypopharyngeal cancer

Hypopharyngeal cancer (1 of 10)

Years after successful radiotherapy for glottic cancer, during a routine, yearly follow-up examination, a new hypopharyngeal cancer (invasive squamous cell carcinoma) is barely seen, at arrow. (For reference, X marks the same location in the larynx throughout this series.)
Trumpet maneuver

Hypopharyngeal cancer (2 of 10)

Trumpet maneuver begins, to splay open the post-arytenoid part of the posterior pharyngeal wall (arrows and dotted lines), as well as the pyriform sinuses on each side. The tumor is now seen clearly. (Note the change of perspective from photo 1, using X as a reference point.)
tumor in trumpet maneuver

Hypopharyngeal cancer (3 of 10)

Similar view to photo 2 (still with the trumpet maneuver), but now with the tumor outlined.
tumor in trumpet maneuver

Hypopharyngeal cancer (4 of 10)

Closer view than photos 2 and 3 (again, still with the trumpet maneuver), with the tumor still outlined. Radiation is not an option for this tumor because of prior larynx irradiation; an attempt at laser surgery was selected.
swollen arytenoid mounds

Hypopharyngeal cancer: 1 week after surgery (5 of 10)

One week after laser excision of the tumor. Note the widespread redness, and the swollen arytenoid mounds, especially on the right side of the image. Compare with photo 1.
surgical wound on vocal cord

Hypopharyngeal cancer: 1 week after surgery (6 of 10)

Panoramic view, with the patient beginning the trumpet maneuver. The surgical wound is coming into view. Compare with photo 2 (again, using X as a reference point).
Maximum trumpet maneuver

Hypopharyngeal cancer: 1 week after surgery (7 of 10)

Maximum trumpet maneuver. Closer view of the surgical wound. Compare with photo 4.
left pyriform sinus

Hypopharyngeal cancer: 1 week after surgery (8 of 10)

View into the left pyriform sinus, where the tumor was most bulky.
swallowing crescent

Hypopharyngeal cancer: several months after surgery (9 of 10)

Months after laser resection, panoramic view, showing the swallowing “crescent” (within dotted lines), at the upper limit of where the laser resection occurred. There is surgical stenosis at the entrance to the esophagus (shown in the next photo). This stenosis affects swallowing of solid food, but the patient says this is no problem for him, if he eats a little more slowly and chews well.
hypopharyngeal/ postcricoid stenosis

Hypopharyngeal cancer: several months after surgery (10 of 10)

With the trumpet maneuver, again splaying open the hypopharynx, as in photo 2. Notice the hypopharyngeal/ postcricoid stenosis; the dotted lines represent what would be a normal-sized opening.

Verrucous carcinoma, before and after laser treatment

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Verrucous carcinoma

Verrucous carcinoma (1 of 5)

Verrucous carcinoma, left vocal cord, persistent after radiotherapy elsewhere, in a patient unable to undergo general anesthesia due to severe lung disease.
Verrucous carcinoma during voicing

Verrucous carcinoma (2 of 5)

During voicing.
Verrucous carcinoma after laser treatment

Verrucous carcinoma, after laser treatment (3 of 5)

After several Thulium Laser ablations, using topical and injected local anesthesia, with patient sitting in examination chair, thereby avoiding general anesthesia.
durable resolution of tumor

Verrucous carcinoma, several weeks after laser treatment (4 of 5)

Approximately six weeks later, durable resolution of tumor. Yellow material is mucus.
Verrucous carcinoma, several weeks after laser treatment

Verrucous carcinoma, several weeks after laser treatment (5 of 5)

During voicing. Arytenoid moves, but much of membranous vocal cord has been ablated as intended.

Cancer, HPV Subtype 16, before and after radiation

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Cancer: HPV Subtype 16

Cancer: HPV Subtype 16 (1 of 5)

Cancer, in a patient with HPV subtype 16. The divot and blood seen on the left vocal cord (right of image) are the result of a biopsy performed elsewhere (not by BVI physician) earlier the same day as this examination.
Cancer: HPV Subtype 16

Cancer: HPV Subtype 16 (2 of 5)

Closer view.
tumor is no longer seen 6 months after radiation therapy

Cancer: HPV Subtype 16, after radiation therapy (3 of 5)

Six weeks after the end of radiation therapy, the tumor is no longer seen. However, part of the left cord (right of image) is missing, due to sloughing of the tumor that had eaten away part of the cord’s normal tissue.
margin of the left cord is lower than the right

Cancer: HPV Subtype 16, after radiation therapy (4 of 5)

Phonation. Strobe light, open phase of vibration, shows that the margin of the left cord (right of image) is at a lower level than the right’s, due to loss of some of the bulk of the cord where the tumor died and sloughed away.
ight cord unsuccessfully attempts to reach the left cord’s residual upper surface mucosa

Cancer: HPV Subtype 16, after radiation therapy (5 of 5)

Strobe light, closed phase of vibration. The more normal right cord (left of image) unsuccessfully attempts to reach the left cord’s residual upper surface mucosa. Voice is functional but hoarse.

Vocal cord cancer, before and after radiotherapy

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fullness and irregular contour of the left vocal cord

Vocal cord cancer (1 of 7)

A 66-year-old man who complains of hoarseness. He smoked a pack a day for 50 years but quit five years ago. Note here the fullness and irregular contour especially of the left vocal cord ( right of photo). A biopsy confirmed this was cancer.
scattered leukoplakia and stippled vascular markings

Vocal cord cancer (2 of 7)

At closer range, scattered leukoplakia and stippled vascular markings (suggestive of HPV effect, but HPV tested negative).
Vocal cord cancer

Vocal cord cancer (3 of 7)

During phonation.
radiation-induced mucositis on the false and true cords

Vocal cord cancer, 3 weeks after radiotherapy (4 of 7)

Same patient, three weeks after the end of full-course radiotherapy. Distant view shows radiation-induced mucositis on the false and true cords, seen as areas of white, superficial ulceration. General redness is also a radiation effect.
main tumor of the left vocal cord melted away

Vocal cord cancer, 3 weeks after radiotherapy (5 of 7)

Closer view, showing that the main tumor of the left vocal cord (again, right of photo) has melted away. Note that the mucositis is generalized, and not necessarily focal to the area of tumor sloughing.
visible tumor is gone

Vocal cord cancer, 2 months after radiotherapy (6 of 7)

Same patient, now two months after the end of radiotherapy. All of the visible tumor is gone, and voice is very good. Small anterior web. Compare with photo 1 of this series.
Phonation

Vocal cord cancer, 2 months after radiotherapy (7 of 7)

Phonation. Compare with photo 3 of this series.

Vocal cord cancer, before, during, and after radiation

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Superficial cancer involving both vocal cords

Vocal cord cancer (1 of 8)

Superficial cancer involving both vocal cords. This is stage 1 disease (T1B). The greatest bulk is on the right posterior cord (left of image), but the majority of both cords is involved with at least superficial disease. A faint dotted rectangle indicates the zoomed-in area seen in photo 2.
anterior half of the cords

Vocal cord cancer (2 of 8)

Close-up view of only the anterior half of the cords. Notice the irregular surface, and areas of leukoplakia within this squamous cell carcinoma.
tumor is melting away

Vocal cord cancer, during radiation (3 of 8)

Just over midway through radiation treatment. One can see that the tumor is melting away.
Postcricoid / hypopharyngeal mucositis

Vocal cord cancer, during radiation (4 of 8)

Postcricoid / hypopharyngeal mucositis. In this view, the patient is performing a so-called trumpet maneuver to splay open the lower throat. The radiation delivered to the vocal cords (which inhabit the airway but are hidden here due to the momentary constriction of the laryngeal vestibule, at arrows) also causes superficial ulceration of the swallowing passage (upper half of the photo), directly behind the vocal cords. On occasion, if tissue reaction and mucositis are much more severe than seen here, a stricture can form, requiring dilation.
mucositis has resolved

Vocal cord cancer, 2 months after radiation (5 of 8)

Two months after radiation is complete, showing that the tumor is gone, and the mucositis has resolved. There is a small anterior commissure web (at arrow) just below the free margin of the cords. The patient’s voice can nevertheless pass for normal.
Vocal cord cancer

Vocal cord cancer, 4 months after radiation (6 of 8)

Now four months after the end of radiation. Close-up view of the postcricoid / hypopharynx regions (compare with photo 4 in this series). Mucositis here is resolved as well, and there is no stricture.
contours of the vocal cords are not perfectly normal

Vocal cord cancer, 6 months after radiation (7 of 8)

Now six months after the end of radiation. Strobe illumination, open phase of vibration. Note that the contours of the vocal cords are not perfectly normal, even though voice is very good.
Oscillatory flexibility

Vocal cord cancer, 6 months after radiation (8 of 8)

Strobe illumination, nearly closed phase of vibration. Oscillatory flexibility is preserved, but the vocal cord margins are not perfectly straight.

Vocal cord cancer

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large lobule projecting upwards

Vocal cord cancer (1 of 1)

Carcinoma right vocal cord with a large lobule projecting upwards and medial to the false cord, too.

Radiation induced web

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Marked laryngeal swelling

Post radiation therapy (1 of 4)

Marked laryngeal swelling and inflammation in a woman undergoing radiation therapy to the neck for recurrent thyroid cancer. The larynx is unavoidably in the radiation field. Note swelling of the left arytenoid (right of photo) as compared with right (left of photo). The X's indicate the location of the arytenoids. In the distance, surrounded by the dotted line, is the web between the vocal cords.
superficial ulceration

Web formation (2 of 4)

At closer range, the superficial ulceration is indicated by the dotted line. Dashed line indicates where the cords should remain separated but are not, due to formation of a web.
ulceration and web

Closer view of ulceration and web (3 of 4)

Closer view. The dotted line is yet again seen around the ulceration and web. Dashed line shows where the cords should remain separate.
flexible scope is used to break cords apart

Flexible scope used to separate vocal cords​ (4 of 4)

Using only topical anesthesia with patient in chair and not in the O.R., the flexible scope has been used several times to break the cords apart. Voice is instantly restored. The dotted line helps to see the separation of the forming scar ban.

Larynx cancer managed like “skin cancer”

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mid-cord elevation and subtle haziness

Two years after excision (1 of 4)

Two years after successful laser excision of a right vocal cord cancer, preserving a good voice, despite stiffness of the right cord (left of photo). During this routine followup, slight mid-cord elevation, and subtle haziness catch the eye (within dotted line).
elevation and hazy leukoplakia

Narrow-band lighting (2 of 4)

Under narrow band light, the elevation and hazy leukoplakia are seen more clearly. Medial-to-lateral capillary reorientation is due to the prior superficial cordectomy.
thulium laser coagulation

During thulium laser coagulation (3 of 4)

At the conclusion of thulium laser coagulation. This turns the tissue even whiter, much like when one puts a thin layer of white icing on an already-white cake.
white area will slough off

After thulium laser coagulation (4 of 4)

Distant view at the conclusion of laser treatment. The white area will slough off over the next several days.

Vocal cord CA—a case for radiation instead of laser resection

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vocal cords of long term smoker

Long term smoker (1 of 4)

Distant view of vocal cords of long term smoker who is chronically hoarse. The tumor is at arrow.
tumor

Tumor (2 of 4)

Close-up shows obvious tumor is mostly involving immediate undersurface of the cord. The free margin of both cords is indicated by dotted lines.
Suspicion of submucosal fullness in the anterior subglottis

Radiation therapy suggested (3 of 4)

Suspicion of submucosal fullness in the anterior subglottis. Laser is generally preferred to radiation for non-bulky tumors but undersurface and anterior subglottic suspicion suggests radiation therapy instead.
hazy granularity of the anterior subglottis

Two months later (4 of 4)

Nearly 2 months after completion of radiotherapy, the tumor appears to have melted away; the hazy granularity of the anterior subglottis (arrow) bears careful surveillance.

Scarring after cancer treatment but with very good voice

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Post laser excision

Post laser excision (1 of 4)

Ten years after laser excision of a left vocal cord (right of photo) cancer, viewed from a distance. Voice has been extremely serviceable, if slightly husky.
Prephonatory instant

Prephonatory instant (2 of 4)

Closer visualization at the prephonatory instant. Now the pseudobowing of the left cord (from tissue loss is easily seen.
Phonation

Phonation (3 of 4)

Making voice, the faint blurring of the right cord margin (left of photo), but non-vibrating left cord (right of photo) can be more easily appreciated.
lateral capillary reorientation

Close-up view (4 of 4)

At very close range, medial-to-lateral capillary reorientation—typical of superficial cordectomy after healing.

Cancer beginning to block airway

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tumor

Formerly heavy smoker (1 of 2)

Formerly heavy smoker with several months of deteriorating voice. Note that the dark chink where air must pass to enter the trachea is obstructed by an estimated 50% by the tumor. The remaining space remains sufficient for all normal activities without any sense of airway restriction.
Tumor

Closer view (2 of 2)

At closer range.

Breaking the rules in larynx cancer

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Cancer, recurrent after radiotherapy

Recurrent cancer (1 of 8)

Cancer, recurrent after radiotherapy. Cancer treatment 'rules' dictate a radical anterior commissure resection or more likely, total laryngectomy.
cancer that crosses the anterior commissure

Closer view (2 of 8)

Closer view. The rules just invoked came about because cancer that crosses the anterior commissure is not to be trusted and especially after radiotherapy; cartilage involvement is far more likely; furthermore, laser resection might trigger radionecrosis. With careful patient involvement, an exception to these 'rules' was made here due to concomitant Stage 4 lung cancer of highly uncertain prognosis.
inner perichondrium of the thyroid cartilage

One week post laser resection (3 of 8)

A week after radical laser resection, including to the inner perichondrium of the thyroid cartilage. Wound healing/radionecrosis is a concern, as is the risk of recurrence when rules are bent.
vocal cords are scarred and will not vibrate

One year postop (4 of 8)

A year post-op. There is no sign of recurrence. As expected, the vocal cords are scarred and will not vibrate. The patient has developed highly functional false vocal cord voice. (See the next four photos.)
rue cords approximate but do not vibrate

True cord phonation (5 of 8)

Making voice, the true cords approximate but do not vibrate.
False vocal cords

False vocal cords (6 of 8)

The false cords travel toward each other...
False vocal cord closure

False vocal cord closure (7 of 8)

Here, they have come into full vibratory approximation.
True cords

True cords (8 of 8)

False cords separate, again revealing the non-vibrating true cords.

Biopsy of early vocal cord cancer

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diffusely abnormal-looking tissue on his vocal cords

Chronic hoarseness (1 of 3)

Examination of this man for chronic hoarseness reveals diffusely abnormal-looking tissue on his vocal cords. The area on the upper surface of the right vocal cord (enclosed in dotted circle) appears to be most likely to be diagnostic. Note the bulk, and aberrant blood vessels.
biopsy

Just before biopsy (2 of 3)

A 2 millimeter cup forceps has been passed through a channel scope and is planted on this area in open position, just before the biopsy.
biopsy finds cancer

Cancer finding (3 of 3)

Cup forceps have now been closed to encompass a small fragment of tissue. The pathologist’s answer after looking at this sample under the microscope: cancer

Tumor in trachea

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Tumor growing through wall of trachea

Biopsy (1 of 4)

Tumor growing through wall of trachea, from a paratracheal lymph node. Biopsy forceps are about to close to take a tissue fragment for study.
Biopsy of cell carcinoma

After biopsy (2 of 4)

After biopsy was taken at arrow. The result: squamous cell carcinoma thought to be an unusual metastasis from unusually aggressive larynx cancer.
tumor has melted away

Tumor gone (3 of 4)

Soon after radiation therapy, the tumor has melted away, leaving a depression in the tracheal wall.
slow return of tumor

Slow return (4 of 4)

Eighteen months later, the patient has experienced a fairly durable response, with very slow return of tumor.

HPV 31 cancer cure

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Carcinoma in situ

Carcinoma in situ (1 of 4)

This man developed hoarseness spontaneously a year before this visit. He had accumulated 30 pack-years as a smoker, but had quit 7 years earlier. Removal of “polyps” elsewhere returned a diagnosis of carcinoma in situ (CIS), the earliest stage in the development of cancer.
no stippled or other abnormal vascular marks

Seven years later (4 of 4)

Seven years later, at an annual visit, there are no stippled or other abnormal vascular marks. Voice has been very acceptable to the patient, if occasionally faintly husky.
severe dysplasia/ CIS

Excisions (3 of 4)

After 2 prior excisions elsewhere with positive margins, somewhat aggressive excision was performed in the operating room, attempting to avoid the need for radiotherapy in this fairly young man. The specimen showed severe dysplasia/ CIS, but with negative margins. After some months, voice became very functional.
HPV subtype 31

HPV subtype 31 (2 of 4)

Under narrow band light, note some unusual “suspicious” capillaries, and the stippled “HPV effect” at the arrow. These findings triggered HPV subtyping and identification of high-risk subtype 31.

Before and after radiation for vocal cord cancer

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Bilateral vocal cord cancer

Bilateral vocal cord cancer (1 of 4)

Bilateral vocal cord cancer in an elderly man. Laser excision is preferred for early cancer, except when, as seen in this larynx, the abnormality is bilateral and diffuse, lacking in obvious boundaries.
tumor vessels

"Tumor vessels" (2 of 4)

Note the bulky disease on both sides, with "tumor vessels."
radiotherapy

After radiotherapy (3 of 4)

After radiotherapy, more normal contours are restored to the vocal cords. Voice is also much improved. The arrow points to tiny capillaries to serve as reference for the next photo.
Aberrant vessels

Vascular pattern (4 of 4)

At very close range, under narrow band light, this vascular pattern can be carefully monitored for stability. Aberrant, "suspicious" vessels (none seen here) are often the earliest indication of recurrent cancer.

Small, but dangerous!

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abnormality below the vocal cords

Post radiotherapy (1 of 4)

After radiotherapy for reported early bilateral vocal cord cancer. No photos are available of the original tumor. Distant view here, showing abnormality below the vocal cords, anteriorly.
closure of the vocal cords is good

Normal voice (2 of 4)

Voice is normal, because closure of the vocal cords and their vibration is not impeded.
biopsy-proven persistent cancer

Persistent cancer (3 of 4)

Closer view. This is biopsy-proven persistent cancer. Note infiltrative appearance and submucosal component at arrow.
T4 tumor

T4 tumor (4 of 4)

Why so dangerous? Radiation resistance can indicate a more aggressive tumor. And in this location, infiltration and even cartilage invasion (direction white arrow) may be present, making this a T4 tumor.

Unusual posterior and transglottic epicenter for larynx cancer

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tumor is transglottic

Tumor (1 of 4)

View under standard light shows normal left vocal cord (right of photo) and tumor on right (left of photo). Main bulk is posterior; the cord is mobile, yet (unusually) the tumor is transglottic.
accentuation of the vascularity

Narrow band light (2 of 4)

Slightly more distant view under narrow band light; accentuation of the vascularity makes the tumor even more easily seen.
bulk of tumor involves the cartilaginous glottis

Posterior commissure (3 of 4)

Magnified posterior commissure view shows that the main bulk of tumor involves the cartilaginous glottis. This is highly unusual.
Laser excision

A year later (4 of 4)

Laser excision was satisfying except that the deep margin was the cricoid cartilage and therefore radiation therapy followed laser excision for added "safety." Laser excision and radiotherapy were 9 years prior to this posting, at which point he remained free of disease.

Nice try, but on to radiation

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eft vocal cord lesion

Vocal cord lesion (1 of 4)

Middle aged man with hoarseness and a left vocal cord lesion (right of photo) suspicious for cancer. After extensively educating the patient about options he would have if this were proven to be cancer, a single trip to the O.R. was planned for both frozen section, and possible definitive laser excision.
large bulky tumor

Closer view (2 of 4)

Though this looks bulky, some "large" tumors can be removed definitively with the laser, if they are mostly exophytic (growing outwards) rather than endophytic (deeply infiltrating).
endophytic growth pattern

Removal of tumor (3 of 4)

Frozen section was positive for squamous cell cancer, and much of the tumor was removed, but an endophytic (infiltrative) growth pattern diverted the plan to radiation therapy.
Vocal cords

Nice try, but on to radiation (4 of 4)

If significantly more vocal cord were removed, voice might also have been excessively compromised.

Progressive cricoarytenoid joint fibrosis/ fixation as a late complication of radiation

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oice is deteriorating

25 years post radiotherapy (1 of 4)

During 25 years since radiotherapy for vocal cord cancer, voice had been “80%” and breathing normal. In recent years, voice is deteriorating; breathing also seems restricted during exertion. During “quiet breathing,” the vocal cords are in only partial abduction, due to fixation/ partial fixation of the crico-arytenoid joints. This glottic chink for breathing is likely less at night during sleep, explaining noisy breathing and the need for CPAP.
The left vocal cord lateralizes incompletely

Fibrosis (2 of 4)

Here, the patient is sniffing, in order to reveal maximum possible abduction. Note that the right vocal cord (left of photo) seems “frozen” but not paralyzed (no atrophy) due to fibrosis of the right cricoarytenoid joint. The left vocal cord (right of photo) lateralizes incompletely. Note as well, post-radiation capillary ectasia.
no sense of atrophy of either cord

Closed phase (3 of 4)

Under strobe light, closed phase of vibration. The left cord can move to the midline, and there is no sense of atrophy of either cord.
nly the left vocal cord mucosa is flexible

Open phase (4 of 4)

Open phase of vibration shows that only the left vocal cord mucosa (right of photo) is flexible, and is the source of all of the patient’s voice. The right cord mucosa (left of photo) is stiff and non-vibrating at all pitches. Without an examination from 25 years earlier, it is unknown where this represents early post-treatment stiffness (scarring from biopsy, etc.) or whether it is also the result of progressive fibrosis.

Progressive radiation fibrosis effects on the larynx and a solution to some of it

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forty years after curative radiation for a vocal cord cancer

Forty years post-radiation (1 of 8)

This photo is taken forty years after curative radiation for a vocal cord cancer. Four decades of progressive radiation fibrosis (“leatherization”) has taken away arytenoid movement so that this is the maximum opening. The patient is exercise-intolerant and makes loud inspiratory breathing noises while sleeping. Her voice is also very poor.
mucosa indraws and vibrates

Involuntary inspiratory voice (2 of 8)

With sudden inspiration, the darker mucosa (at the arrows) indraws and vibrates, making an involuntary inspiratory voice.
small mucosa capable of vibration

Only capable of high pitch (3 of 8)

Other than a stage whisper, she can only make a very high pitch, because the only mucosa capable of vibration is the small segment indicated by the arrows.
vibrating mucosa in open phase

Open phase vibration (4 of 8)

Again under strobe light, this is the open phase of vibration, with arrows again indicating the short segment of mucosa that can oscillate.
cookie bites taken from posterior cords

One week post-commissuroplasty (5 of 8)

A week after posterior commissuroplasty, the patient’s breathing is much improved. Despite the distant view, the “cookie bites” taken from the posterior cords are visible.
posterior vocal cord divots

Rapid inhalation, closer view (6 of 8)

In a much closer view, the posterior vocal cord divots are seen well. The segment of flexible mucosa is indrawing here as the patient inhales rapidly (at arrows).
Vocal cords Three months post-surgery

Three months post-surgery (7 of 8)

Three months after the laser surgery, the patient continues to say the improvement of breathing is “large.” In this distant view the full reason why is not seen.
divots are smaller

Closer view, post-surgery (8 of 8)

In a closer view, as is always the case after complete healing, the divots are smaller than just after surgery.

Evolution of the wound after laser removal of a vocal cord cancer: Not pretty at first, but voice result can be very good

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Vocal cord cancer

Vocal cord cancer (1 of 8)

Bulky but superficial right vocal cord cancer (arrow, left of photo).
Voice-making with tumor

Voice-making with tumor (2 of 8)

Voice-making position. Notice the more lateral turning of the right vocal process (left of photo) as compared with the left (right of photo). As the remaining series shows, it is impossible to know if this is compensation for the bulk of tumor, or weakness of the LCA muscle.
One week post-removal

One week post-removal (3 of 8)

A week after definitive removal, swelling, early granulation, and a division of the wound into upper and lower “lips” that must bind together with healing.
lateral turning of right vocal process

Voice-making, post-removal (4 of 8)

Note again the lateral turning of right vocal process (arrow, left of photo).
residual granuloma on the upper surface anteriorly

Six weeks post-op (5 of 8)

Six weeks after surgery, the wound is “bound together,” and there is a residual granuloma on the upper surface anteriorly (arrow).
peculiar lateral turning of the vocal process

Voice-making, post-op (6 of 8)

Making voice, there is still that peculiar lateral turning of the vocal process on the right (left of photo).
anterior upper surface is coated with mucus

Four months post-op (7 of 8)

Now a full 4 months since laser excision, the cord is fully healed though still pink as expected. The anterior upper surface is coated with mucus.
lateral deviation of the right vocal process

Voice-making, four months post-op (8 of 8)

Making voice, again that lateral deviation of the right vocal process (arrow, left of photo). Voice is very functional but a little weak. Vibratory blur is greater for left than right cord.

Laser can beat cancer and spare voice even after radiotherapy failure

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no vascular abnormality or leukoplakia is seen

Healing post-laser excision(4 of 4)

Now at 18 weeks after laser excision, healing is truly complete. Even under narrow band light and at close range, no vascular abnormality or leukoplakia is seen. Voice is remarkably good, without audible " effort," or syllable dropouts. Obviously, close follow up is required.
medial-to-lateral reorientation of capillaries

Post-laser excision (3 of 4)

10 weeks after laser excision, healing is nearly complete. Stippled vascularity is no longer seen; the medial-to-lateral reorientation of capillaries often seen after laser excision is seen especially on the right vocal cord (left of photo).
areas of leukoplakia and stippled vascularity

Leukoplakia and Stippled Vascularity(2 of 4)

At closer range under narrow band light, areas of leukoplakia and stippled vascularity are seen more clearly; all of this must be removed. The options are laser excision, partial laryngectomy, and total laryngectomy. Laser excision was selected as the "next step."
bilateral disease

Return of cancer (1 of 4)

Eight years after radiotherapy for early vocal cord cancer, cancer has returned in a man who never stopped smoking. Radiotherapy is no longer an option. Here, we have bilateral disease.

How a vocal cord heals after laser removal of a cancer

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squamous cell carcinoma

squamous cell carcinoma (1 of 6)

After biopsy performed elsewhere revealed squamous cell carcinoma, this right vocal cord cancer (left of photo) is scheduled to be treated for cure via laser excision.
1 week after laser excision

1 week after laser excision (2 of 6)

A week after laser excision, the typical upper and lower "lips" swell at the margins of resection will need to heal back together to re-establish a normal vocal cord contour.
upper and lower lips with central depression

Difficulty speaking (3 of 6)

As the vocal cords approach each other in preparation for producing voice, the upper and lower lips with central depression are seen more clearly.
round granuloma

Natural granulation after laser excision (4 of 6)

At approximately 2 months after laser excision, healing is nearly complete and voice very functional. There is a round granuloma (exuberant healing response) that will soon fall off spontaneously. Every patient is told about possible granulation of this sort, so that they do not worry that this is a tumor recurrence.
abnormal post-laser capillary pattern

Abnormal capillary pattern (5 of 6)

A year after surgery, the patient's voice can pass for normal. Under strobe light, this closed phase of vibration shows the good match of the vocal cord margins. The regenerated mucosa of the right (upper part of photo) vocal cord has a typically abnormal (but healthy) post-laser capillary pattern.
Stiff right vocal cord

Stiff right vocal cord (6 of 6)

Here during the open phase of vibration, one can see that the right vocal cord is stiff (as expected after laser surgery of any depth) and does not vibrate well. Voice sounds virtually normal, however, due to the precise match of the margins and normal left vocal cord vibration (see again, photo 5). At the time of this posting, this person has remained free of disease for 8 years, and has no sense of vocal limitation.

Videos:

Early Vocal Cord Cancer
This video provides an introduction to early vocal cord cancer (stages 1 and 2) and compares the two main treatment options, laser surgery and radiation therapy.