Capillary Ectasia
Capillary ectasia is the enlargement or dilation of capillaries on the surface of the vocal cords. Some believe it to be an estrogen effect similar to “spider veins” that one might see on the legs, for example. At our practice we think of these as mainly being another manifestation of overuse of the voice, and a response to ongoing injury of the vocal cords.
Symptoms
Once established, it may cause symptoms of reduced vocal endurance and exaggerated premenstrual huskiness. Capillary ectasia may also increase the risk of vocal cord bruising (hemorrhage) and hemorrhagic polyp formation.
Treatment
Many affected individuals, however, may “coexist” with this when armed with appropriate information about this disorder and through carefully managing amount and manner of voice use. When indicated, it is easily corrected via vocal cord microsurgery.
Vocal Cord Bruises (Hemorrhage) often Initially Obscure the Ectatic Capillary “Culprit”
A person can experience sudden hoarseness at a time of sustained heavy voice use, or even immediately following a “scream,” or even a loud sneeze. The explanation might be a bruise of a vocal cord. This can happen to anyone but is far more likely if the person has underlying capillary ectasia.
When a bruised vocal cord is seen, therefore, the question is: “Is this a fluke bruise that can happen to anyone, or is it one explained by capillary ectasia?” In this instance, the answer is “yes.”
Singer’s Bruised Vocal Cord (1 of 8)
In this singer, bilateral margin swellings are seen, but the right cord (left of photo) is bruised. Sometimes we must wait to see the culprit capillary or capillaries. Here, we can already suspect that this is the explanation (from following photos) since the bruise is a few weeks old and the blood in tissue partially resorbed.
Bruise under Strobe Light (2 of 8)
Strobe views (giving us apparent slow-motion vibration) help us see the margin elevations more clearly.
Abnormal capillary (3 of 8)
At very close range, the suspicion of an abnormal capillary is confirmed. But will it be there when the bruise is completely gone?
Bruise is gone (4 of 8)
Several weeks later, the bruise is indeed gone, and the vulnerability-inducing capillaries are seen clearly in this distant view.
Capillaries under narrow band light (5 of 8)
At close range under narrow band light, the capillaries come into full view. Notice one small capillary also on the left cord margin (right of photo).
Capillaries touch during phonation (6 of 8)
Phonatory view again reveals the margin swellings bilaterally, but with the ectatic capillaries in the point of maximum vibratory contact, where they increase the risk of another bruise.
Post-surgical repair (7 of 8)
After surgical repair of the ectasia and margin swellings (distant view), open for breathing.
Margins match (8 of 8)
Also after repair, voicing position showing again absence of the capillary ectasia and much better match of the margins. Upper voice is restored; vibratory flexibility is normal even at very high pitch.
Capillary Ectasia, Before and After Laser Coagulation
Capillary ectasia (1 of 7)
Abducted, breathing position, standard light. This is a vascular abnormality and not a polyp. We use the term “capillary lake.”
Capillary ectasia (2 of 7)
Pre-phonatory instant, standard light.
Capillary ectasia (3 of 7)
Strobe light, open phase of vibration. Mucus is consistent with the patient’s known acid reflux laryngitis.
Closed phase (4 of 7)
Strobe light, closed phase of vibration.
Capillary ectasia, after laser coagulation (5 of 7)
Abducted breathing position, standard light, some weeks after pulsed-KTP laser coagulation of the dilated capillaries, which are no longer visible.
Capillary ectasia, after laser coagulation (6 of 7)
Same view, but under narrow-band illumination.
After laser coagulation (7 of 7)
Prephonatory instant, narrow-band illumination.
Example 2
Capillary ectasia (1 of 3)
Bilateral capillary ectasia, made to stand out with the help of narrow-band illumination.
Capillary ectasia, right after laser coagulation (2 of 3)
At the conclusion of pulsed-KTP laser coagulation, performed in a videoendoscopy procedure room with patient awake and sitting in a chair.
Capillary ectasia, 6 weeks after laser coagulation (3 of 3)
Six weeks later; the capillaries have vanished, as expected.
A Vocal Cord Bruise That Could Happen To Anyone
While capillary ectasia (as seen in other photo series here) markedly increases vulnerability to vocal cord bruising, every human vocal cord has capillaries on its service, and even normal capillaries can leak and cause a bruise with sufficient vocal trauma. In this person, with an aggressive cough, her normal capillaries are the source of the bruise.
Bruised Vocal Cord (1 of 2)
View from a distance, showing a bruise of the right cord. But is there a vulnerable (ectatic) capillary that explain this bruise?
Bruised Vocal Cord (2 of 2)
At closer range, the normal capillaries are seen; there is no dilated capillary to explain the bruise. This bruise could happen to anyone, with sufficient vibratory (loud voice) or cough trauma.
Capillary Ectasia and Hemorrhagic Polyp, Before and After Treatment
Capillary ectasia and hemorrhagic polyp (1 of 4)
Open phase of vibration, strobe light.
Capillary ectasia and hemorrhagic polyp (2 of 4)
Partially closed phase of vibration, strobe light.
Capillary ectasia and hemorrhagic polyp, after treatment (3 of 4)
Abducted breathing position after vocal cord microsurgery, standard light. Note that the right cord is normalized, the capillary ectasia on the left is smaller, but persists in spite of spot-coagulation. A simple pulsed-KTP laser procedure in the videoendoscopy procedure room abolished this residual lesion.
Capillary ectasia and hemorrhagic polyp, after treatment (4 of 4)
Pre-phonatory instant, standard light, showing excellent match. Oscillatory ability entirely normal into extreme upper range in this professional singer.
Capillary Ectasia with Vocal Nodules
Capillary ectasia with vocal nodules (1 of 2)
Breathing position, note insignificant microweb at anterior commissure.
Capillary ectasia with vocal nodules (2 of 2)
Phonatory position, with poor match of vocal margins.
Example 2
Capillary ectasia with vocal nodules (1 of 3)
Standard light reveals dilated capillaries, especially left vocal cord (right of image), as well as bilateral vocal nodules.
Capillary ectasia with vocal nodules (2 of 3)
Narrow-band light makes the dilated capillaries stand out more clearly.
Capillary ectasia with vocal nodules (3 of 3)
Same patient, during voicing (phonation), shows how capillary ectasia can be less easily seen.
Capillary Ectasia and Hemorrhagic Polyp
Capillary ectasia and hemorrhagic polyp (1 of 2)
Note the differing patterns of capillary ectasia—fine “stream;” meandering “river,” and “pond.” Brilliant white areas are reflection of light; more indistinct submucosal white area right cord raises question of possible cyst (arrow).
Capillary ectasia and hemorrhagic polyp (2 of 2)
Strobe illumination better reveals the polypoid component of the swellings. Some mucus accumulation, especially posteriorly.
Vocal Nodules, Leukoplakia, and Capillary Ectasia
Vocal nodules, leukoplakia, and capillary ectasia (1 of 4)
Abducted breathing position, standard light. Notice not only the margin swellings (nodules) but also the ectatic capillaries and the roughened leukoplakia. This person illustrates well the idea that vibratory injury can be manifested differently. Many express the injury more in the form of sub-epithelial edema and other changes; this person also has considerable epithelial change.
Vocal nodules, leukoplakia, and capillary ectasia (2 of 4)
Prephonatory instant, standard light.
Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (3 of 4)
Partial resolution of mucosal injury as a result of behavioral changes directed by a speech pathologist. Strobe light, open phase of vibration.
Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (4 of 4)
Strobe light, moving towards closed phase of vibration.
Capillary Ectasia and Hemorrhagic Polyp, Treated by Thulium Laser
Capillary ectasia and hemorrhagic polyp (1 of 7)
Open position for breathing, standard light. There is capillary ectasia on both vocal cords, and there is also a hemorrhagic polyp of the left vocal cord margin (right of photo).
Capillary ectasia and hemorrhagic polyp (2 of 7)
During voicing, the polyp interferes with accurate approximation of the vocal cords, which explains this man’s chronic hoarseness.
Capillary ectasia and hemorrhagic polyp, thulium laser treatment (3 of 7)
Using the thulium laser to spot-coagulate and interrupt the flow in dilated capillaries.
Capillary ectasia and hemorrhagic polyp, thulium laser treatment (4 of 7)
Coagulation of the polyp, with fiber tangential to the vocal cord and sometimes lifting medially during contact mode. A second, similar procedure was needed a few weeks later, only for residual polyp.
Capillary ectasia and hemorrhagic polyp, after treatment (5 of 7)
Several weeks later, capillary areas are blanched, but the vocal cord mucosa is fully mobile.
Vocal cord margin (6 of 7)
Vocal cord margin match and mucosal flexibility are best tested in high voice. This is strobe light, closed phase of vibration, at F4 (~349 Hz).
Capillary ectasia and hemorrhagic polyp, after treatment (7 of 7)
Also at F4 (~349 Hz). The mucosa of both cords is completely supple. The patient considers his voice to be perfectly normal—”original equipment.”
Capillary Lake and KTP
Capillary lake (1 of 8)
This teacher struggles with reduced mucosal endurance: the sense of slight laryngitis after extensive talking. This is likely due to the increased mucosal vulnerability to either swelling or hemorrhage caused by this capillary lake. This is a stable finding, whereas a hemorrhage resolves at least intermittently over time. Note that there was a recent surgical procedure performed elsewhere on the left cord (right of photo); the nature of the prior lesion is unknown to the patient.
Mucosal fatigue (2 of 8)
At D4 (294 Hz) under strobe light, the capillary lake and bilateral translucent swelling is seen, verifying in another way that “mucosal fatigue” is the likely cause of his reduced vocal endurance.
Prep for laser coagulation (3 of 8)
The same capillary lake seen with the smaller-chip channel scope, in preparation for pulsed-KTP laser coagulation. Note the red color and compare with post-KTP images that follow.
KTP laser coagulation (4 of 8)
The glass fiber is delivering KTP laser energy that is preferentially coagulating the red hemoglobin.
Post laser ablation (5 of 8)
Immediately after laser ablation, the red lake has changed color due to denaturation/ coagulation.
Post laser ablation, distant view (6 of 8)
More distant view after ablation is complete. Compare with photos 1 and 3.
After a weekend of vocal overuse (7 of 8)
Several months later, after a brutal weekend of coaching. Strobe view, closed phase of vibration. No evidence of residual ectasia that had been causing such reduced ability of the mucosa to “endure” vibratory trauma. Note the margin swellings and slight pinkness from vibratory trauma.
Capillary (8 of 8)
Open phase of vibration shows that the longstanding capillary “lake” has been abolished.
Choral Singer’s Voice Fully Restored
Hoarse choral singer (1 of 4)
Older amateur but experienced and committed choral singer is grossly hoarse due to this chronic vascular lesion, left vocal cord (right of photo).
Residual bruising (2 of 4)
Less than a week after surgical removal, residual bruising is seen.
2 months post-surgery (3 of 4)
Nearly 2 months after surgery, only a bit of ectasia (non-threatening as it is upper surface e of the cord) is seen. The patient says voice is fully restored.
Margins match (4 of 4)
Under strobe light, the margins match perfectly at D5 (587 Hz) and vibratory flexibility is equal to the unoperated side.
Red Herring Capillary Ectasia and Mucosal Injuries
Ectatic capillary (1 of 4)
This young performer has a sense of a weakened voice and loss of vocal stamina. Here, we see an ectatic capillary of the left vocal cord (right of photo). Is the problem intermittent vocal hemorrhage from this vulnerable capillary? Is there increased susceptibility to edema due to this margin capillary?
Ectatic capillary, narrow band light (2 of 4)
Under narrow band light, the capillary is even more evident. The additional network of prominent capillaries prompt the same questions as in caption 1.
Margin swelling (3 of 4)
Under strobe light at B-flat 4 (494 Hz), we see subtle margin swelling (arrows), here of only “indicator lesion” magnitude.
Bowing, atrophy, and flaccidity (4 of 4)
The large amplitude of the open phase of vibration at the same pitch, along with the lack of closure in photo 3, reveals the actual problem to be bowing, atrophy, and flaccidity. These findings fit with the “bowing” symptom complex: loss of edge to voice quality and the tendency of voice quality and strength to “fade” as the day progresses.
Ask Both Voice (via vocal phenomenology) and Larynx (via a motivated examination) to Give up their Secrets
Obvious mucosal injury (1 of 3)
This young woman is hoarse, but two examinations elsewhere returned no significant findings. Her upper voice limitations during vocal capability testing already tell us “for certain” that there is mucosal injury, even before we look at the larynx. In this mid-range view, we can see early contact at the mid-cords, but the full extent and nature of the injuries are seen in the closer views that follow.
Vocal nodules (2 of 3)
At a more appropriate level of magnification, the vocal nodules are seen. But we want to know more…
Capillary ectasia (3 of 3)
Slightly greater magnification and narrow band light point out more clearly the capillary ectasia. Now we know that for complete restoration of voice and of mucosal endurance, surgery will likely be needed, assuming this fits with the patient’s goals.
The Evolution of Vocal Cord Bruising and Emergence of a Vulnerable Capillary
Margin swelling and bruising (1 of 2)
This professional woman is extraordinarily dynamic and intense, and must talk all day to do her work. Here, the right vocal cord (left of photo) is bruised due to vibratory trauma. The margin swelling on the right causes her hoarseness more than the bruising, however.
Six weeks later (2 of 2)
Six weeks later, the bruise is mostly resolved. The capillary that “leaked” blood to form the bruise is now seen more clearly (long arrow). This ectatic capillary can be seen easily now when looking back at photo 1. The short arrows indicate the residual “smudges” of discoloration caused by breakdown products of the bruise. The last evidence of widespread vocal cord bruising is always in these two locations.
Pulsed KTP Laser Treatment of Vascular Abnormalities in a Singer
Ectatic capillary (1 of 7)
In this musical theater singer, under narrow band (blue-green) light, we see an ectatic (dilated) capillary leading to a small hemorrhagic polyp on the left vocal cord (right of photo).
Polyp (2 of 7)
Now under strobe light, at E5 (660 Hz), there is also a projecting component that interferes with margin approximation.
Feeding capillary (3 of 7)
Just prior to pulsed-KTP ablation, again under narrow band light. The arrows point out the feeding capillary, for comparison with photo 5.
Glass fiber (4 of 7)
Under standard light, the glass fiber is seen. The “white” spot is only the aiming beam; no laser energy is being delivered at this moment.
At the conclusion of the laser procedure (5 of 7)
You can see that not only is the blood in the polyp coagulated but the flow of blood in the feeding capillary has also been (note discontinuity at the arrows, where the capillary has “disappeared.” Compare with photo 3.)
Blanched area (6 of 7)
Three weeks later, voice is restored to “original equipment” capabilities. The area of treatment (surrounded by tiny dots) is arguably “blanched” with fewer capillaries in general, but with no loss of mucosal flexibility under strobe light. Compare with Photo 1.
Polyp is gone (7 of 7)
Under standard light at F5 (698Hz), the projecting polyp is also virtually gone. Compare with Photo 2.
Capillary ectasia (including KTP laser treatment)
This video illustrates the various causes of capillary ectasia and the treatment options that are available to patients, including pulsed-KTP laser treatment.
Nodules and Other Vocal Cord Injuries: How They Occur and Can Be Treated
This video explains how nodules and other vocal cord injuries occur: by excessive vibration of the vocal cords, which happens with vocal overuse. Having laid that foundational understanding, the video goes on to explore the roles of treatment options like voice therapy and vocal cord microsurgery.