Laryngopedia

To educate about voice, swallowing, airway, coughing, and other head and neck disorders

Laryngopedia By Bastian Medical Media

Multimedia Encyclopedia


  1. A
  2. B
  3. C
  4. D
  5. E
  6. F
  7. G
  8. H
  9. I
  10. J
  11. K
  12. L
  13. M
  14. N
  15. O
  16. P
  17. Q
  18. R
  19. S
  20. T
  21. U
  22. V
  23. W
  24. X
  25. Y
  26. Z
You're viewing encyclopedia entries under A. You can click a different letter above to browse other entries.

Abdominal Distention of R-CPD Including Before and After Botox Injection

One of the primary symptoms of R-CPD (inability to burp) is bloating. Bloating is often accompanied by actual abdominal distention due to excess air in both stomach and intestines. Since the person is unable to burp, air must now pass through the entire GI tract and be dispelled as flatulence.

Photos:

Visual Portfolio, Posts & Image Gallery for WordPress
x-ray of Gastric Air Bubble

Gastric Air Bubble (1 of 3)

This abdominal xray of an individual with R-CPD shows a remarkably large gastric air bubble (dotted line), and also excessive air in transverse (T) and descending (D) colon. All of this extra air can cause abdominal distention that increases as the day progresses.

Bloated Abdomen (2 of 3)

Flatulence in the evening and even into the night returns the abdomen to normal, but the cycle repeats the next day. To ask patients their degree of abdominal distention, we use pregnancy as an analogy in both men and women. Not everyone describes this problem. Most, however, say that late in the day they appear to be “at least 3 months pregnant.” Some say “6 months” or even “full term.” In a different patient with untreated R-CPD, here is what her abdomen looked like late in every day. Her abdomen bulges due to all of the air in her GI tract, just as shown in Photo 1.

Non-bloated Abdomen (3 of 3)

The same patient, a few weeks after Botox injection. She is now able to burp. Bloating and flatulence are remarkably diminished, and her abdomen no longer balloons towards the end of every day.


Abductor spasmodic dysphonia

A variant of spasmodic dysphonia in which the spasms pull the vocal cords apart, causing the voice to drop out or sound weak and breathy. Abductor spasmodic dysphonia (AB-SD) is an uncommon variant of spasmodic dysphonia, comprising only about 10% of the cases. It is to be distinguished from adductor spasmodic dysphonia (AD-SD), a much more common variant in which the spasms push the vocal cords together.

In its classic variant, the abductory spasms of abductor spasmodic dysphonia are intermittent, each time pulling the vocal cords apart momentarily, so that a person’s voice drops out intermittently to a whisper or breathy sound. Hence, this classic variant of abductor spasmodic dysphonia is sometimes called intermittent whisper phonation. In its tonic variant, the abductory spasms are more constant and sustained than intermittent, so that instead of interrupting the person’s speech, the spasms produce a more constant breathy quality to the voice.

Occasionally, a person has both abductory and adductory spasms; this is called mixed AB-AD spasmodic dysphonia. For more about spasmodic dysphonia in general and the treatment options for it, see our main entry.


Photos of abductor spasmodic dysphonia:

Abductor spasmodic dysphonia: Series of 4 photos

Visual Portfolio, Posts & Image Gallery for WordPress
rytenoid cartilages involuntarily positioned apart

AB-SD (1 of 4)

Prephonatory instant, with arytenoid cartilages involuntarily positioned apart. Mostly tonic position giving voice relatively constant breathiness.
phonatory blur

AB-SD (2 of 4)

Phonatory blur, standard light. Again note the separation of the arytenoid cartilages posteriorly (upper end of the photo), and broad vibratory blur, both consistent with breathy voice.
posterior cords

AB-SD (3 of 4)

Occasionally, patient is able to bring posterior cords together for an instant of normal-sounding voice.
vocal cords involuntarily seperate

AB-SD (4 of 4)

An instant later, the vocal cords involuntarily separate due to an abductory spasm, dropping the voice again to a whispery quality.

Abductor spasms, worsened by cognitive loading: Series of 4 photos

Visual Portfolio, Posts & Image Gallery for WordPress
Vocal cords in normal breathing position

Abductor spasmodic dysphonia patient (1 of 4)

Vocal cords in normal breathing position, in a person with abductor spasmodic dysphonia (SD). The next three photos show how the vocal cord spasms seen with SD can get worse when the person performs more cognitively loaded or involved tasks (that is, the person has to think more). This pattern is related to the widespread understanding that SD's symptoms can be task-specific.
blurry vocal cords making voice

Limited abductor spasms (2 of 4)

When making voice with guttural vocal fry or sustained creaky falsetto, this person is able to keep the vocal cords together, at least part of the time.
vocal cords involuntarily separate

Increased abductor spasms (3 of 4)

When the person tries to sustain a sung tone (slightly more cognitively loaded), the vocal cords involuntarily separate, producing a very breathy voice.
vocal cords separate even further

Even greater abductor spasms (4 of 4)

When the person speaks (even more cognitively loaded), the vocal cords separate even further, and the voice's breathiness is pronounced.

 



Absent swallow reflex

When a person’s automatic swallow reflex—which normally kicks in when liquid or chewed food in the mouth reaches the base of the tongue—is entirely absent. In such cases, saliva, food, or liquid in the mouth can slip back to the base of the tongue and then downward to fill the lower part of the throat and flow into the airway without a swallow reflex ever being triggered. Such an individual should not be allowed to swallow by mouth, for fear of incurring aspiration pneumonia. He or she would require an alternate method of feeding, such as a gastrostomy tube. Compare this disorder with delayed swallow reflex.



Achalasia

Achalasia is the failure of a ring of muscle, such as the lower esophageal sphincter (LES), to relax appropriately at the moment that food arrives at the end of its journey down the esophagus. This muscular non-relaxation creates a functional obstruction, interfering with normal passage of food into the stomach. This term is most commonly used in relation to the LES, but may also be used in reference to the upper esophageal sphincter (UES) or even anus.



Acid Reflux

The backward flow (reflux) of acid from stomach up into the esophagus or, even further up, to the level of the laryngopharynx. Symptoms may be esophageal, laryngopharyngeal, or both. Esophageal symptoms include heartburn, indigestion, and acid belching. Laryngopharynx symptoms tend to include dry throat, husky (especially morning) voice, frequent morning throat clearing, excessive mucus, and mildly sore throat.

Sometimes acid reflux is diagnosed when it isn’t the real problem. The do-it-yourself trials in this downloadable article can help a person and his or her personal physician verify if acid reflux is the appropriate diagnosis: When Acid Reflux Treatment Takes You Down a Rabbit Trail

Q:  I’m told I have acid reflux, but how can that be if I don’t have heartburn?

A: It is possible to have an MI (heart attack) without any chest pain. In the same way, it is possible to have acid reflux up the esophagus without any heartburn. Beyond this, even if acid comes up into the throat at night, this may not waken you unless it is major. Think of gentle-to-moderate rain in the night as an analogy. If you do have the nighttime reflux, however, you may notice symptoms such as a dry or scratchy/sore throat, increased mucus production with throat clearing, a deep morning voice requiring more warmup if you must sing early in the day. The potential for “silent” reflux explains why physicians may suggest a treatment trial even when you have no awareness of actual acid either during the day, or at night.

See also: gastroesophageal reflux disease and laryngopharynx acid reflux disease.

1. Originally published in Classical Singer, April 2009. Posted with permission.


Endoscopic View of Esophageal (Acid) Reflux: Series of 2 photos

Visual Portfolio, Posts & Image Gallery for WordPress
Liquid in the lower esophagus

Liquid in the lower esophagus (1 of 2)

After swallowing blue food-colored water, it sits momentarily in the lower esophagus waiting to enter the stomach. The saliva bubbles indicated by arrow and dotted lines are for reference with the next photo.
Acid reflux in the lower esophagus

Acid reflux in the lower esophagus (2 of 2)

A moment later, without effort or gag, the blue water refluxes (zooms upwards from the lower esophagus and stomach) towards the stationary camera chip. If this occurred with acidic stomach contents, the esophagus would suffer chemical irritation and the patient might experience “heartburn.”

 

Acid reflux: Series of 2 photos

Visual Portfolio, Posts & Image Gallery for WordPress
Phonation under strobe light

Acid reflux (1 of 2)

Phonation under strobe light. Mild capillary prominence.
large amounts of viscous white mucus

Acid reflux (2 of 2)

As phonation proceeds, appearance of large amounts of viscous white mucus.

 

Acid reflux: Series of 2 photos

Visual Portfolio, Posts & Image Gallery for WordPress
Open phase of vibration

Acid reflux (1 of 2)

Open phase of vibration, strobe light, with white mucus sometimes but not always suggestive of acid reflux laryngitis.
Closed phase of vibration

Acid reflux (2 of 2)

Closed phase of vibration, strobe light, with same mucus findings.

 

Acid reflux and sicca syndrome: Series of 4 photos

Visual Portfolio, Posts & Image Gallery for WordPress
classic interarytenoid pachyderma

Acid reflux (1 of 4)

This man has obvious clinical symptoms of acid reflux such as heartburn, excessive morning mucus, husky morning voice. Note classic interarytenoid pachyderma, diffuse pinkness.
upper trachea shows evidence of redness

Redness and inflammation (4 of 4)

Even the upper trachea shows evidence of redness and inflammation. This is not seen that often except with truly severe nocturnal acid reflux/ LPR.
Closer view of the prominent capillaries.

Closer view (3 of 4)

Closer view of the prominent capillaries.
Prominent capillaries and mucus

Prominent capillaries and mucus (2 of 4)

Here we see loss of color differential between true and false cords. Capillaries are prominent (like bloodshot eyes) on the true cords. There is also adherent mucus.


Acoustic analysis of voice

The measurement or graphing of acoustic (sound) information about the voice. This acoustic analysis includes such voice measures as fundamental frequency, formant pattern and energies, decibel level (a physical measure of sound pressure level that roughly correlates to perception of loudness), signal-to-noise ratio, jitter, and shimmer.

At present it is difficult to find unique diagnostic information from any set of acoustic measures. Hence, acoustic analysis is arguably justified for now in the realm of voice research and when used as a feedback tool in the therapy room. Although this may change in the future, at present acoustic analysis is superfluous to the diagnostic process, and specifically to the integrative diagnostic model.



Addition of loudness

Refers to the ability to increase the loudness of the voice. An individual may, either apparently or due to physical limitation, be unable to add loudness because of vocal cord paralysis, a nonorganic disorder, or vocal cord bowing – though when three individuals representing these three diagnoses try to add loudness, the phenomenology observed differs markedly.



Adductor spasmodic dysphonia

A variant of spasmodic dysphonia in which the spasms push the vocal cords together, choking off or straining the voice. Adductor spasmodic dysphonia (AD-SD), also called strain-strangle phonation, is the most common variant of spasmodic dysphonia, comprising about 90% of the cases. It is to be distinguished from abductor spasmodic dysphonia (AB-SD), a variant in which the spasms pull the vocal cords apart.

In its classic variant, the adductory spasms of adductor spasmodic dysphonia are intermittent, each time clamping the vocal cords together momentarily, so that words or syllables in a person’s speech are intermittently choked out. In its tonic variant, the adductory spasms are more constant and sustained than intermittent, so that instead of interrupting the person’s speech, the spasms cause a constant strained or “tight” vocal quality.

Occasionally, a person has both abductory and adductory spasms; this is called mixed AB-AD spasmodic dysphonia. For more about spasmodic dysphonia in general and the treatment options for it, see our main entry.


Photos:

Adductory spasmodic dysphonia: Series of 2 photos

Visual Portfolio, Posts & Image Gallery for WordPress
The false vocal cords are in normal relation to the true vocal cords

AD-SD (1 of 2)

Sustained, clear phonation, standard light. Note vibratory blur of the vocal cord margins. The false vocal cords (lines) are in normal relation to the true vocal cords.
Involuntary adductory spasm

AD-SD (2 of 2)

Involuntary adductory spasm. Note that the false vocal cords suddenly over-close (arrows) as a result of the adductory spasm, and voice momentarily stops (along with vibratory blur).

Adductory spasm: Series of 2 photos

Visual Portfolio, Posts & Image Gallery for WordPress
Adductory spasm

Adductory spasm (1 of 2)

Continuous phonation, standard light. Note the position of the false cords in relation to each other, and also the distance between the anterior face of the arytenoids and the petiole of the epiglottis.
inward squeezing of the entire supraglottis

Adductory spasm (2 of 2)

A moment later, an adductory spasm occurs. The spasm may momentarily stop the voice (phonatory arrest). Note the inward squeezing of the entire supraglottis (false cords, arytenoids, and petiole).

Audio:

Pure AD-SD tonic only, moderate severity:



Aerodynamic analysis of voice

Instrument analysis of the power supply for voice pulmonary air. Aerodynamic analysis of voice can include spirometry, which assesses various capacities and capabilities of the respiratory system, apart from phonation. It also allows determination of the pressure and flow through the vocal folds during phonation.

Our clinicians believe that aerodynamic analysis of voice has yet to earn a place as part of the routine diagnostic workup (see the integrative diagnostic model). Aerodynamic analysis of voice, however, may be of interest for voice research, and when the equipment is used as a biofeedback tool in the therapy room.



Air-wasting dysphonia

Air-wasting dysphonia is a kind of hoarseness that refers to the breathiness (see breathy dysphonia) that one is hearing. Typically, the length of time a person can sustain voice without taking a new breath (maximum phonation time) is decreased. The voice may be described as whispery or foggy or fuzzy. Among other things, possible causes include vocal fold paralysis or paresis, vocal fold bowing and atrophy, or functional (especially nonorganic) voice problems.




Amyloid

A waxy, translucent protein substance deposited into tissue in response either to unknown local factors, or as a manifestation of systemic disease, such as multiple myeloma. Treatment is generally directed at improving function, for example via local laser excision.

See also: Amyloidosis



Amyloidosis

A condition in which abnormal proteins (called amyloids) become deposited in the spaces between cells. In some cases, the cause of amyloidosis is a systemic disorder in which the body over-produces proteins–for example, multiple myeloma, a blood disease; in this scenario, the amyloid deposits can be dispersed widely across the body. In other cases, the amyloid deposits do not seem to reflect systemic disease and can be more organ-specific.

Amyloidosis in the larynx:

In laryngeal amyloidosis, the deposits seem to be localized either just to the larynx, or to the larynx and pharynx. One sees what looks like yellowish candle wax within the tissues. The amyloid deposits are quite firm, and when biopsied, there is little bleeding.

Treatment for laryngeal amyloidosis:

Because of their infiltrative nature, amyloid deposits typically cannot all be dissected out of the larynx; instead, then, an operating physician will aim to debulk the deposits in areas where they impair breathing or the voice. That is, when deposits are widespread in the larynx, there does not seem to be any point in removing them except in locations where removal will improve function. Often, repeated procedures are required over many years’ time, though occasionally the condition seems to stop progressing.


Photos:

Amyloidosis, before and after debulking: Series of 4 photos

Visual Portfolio, Posts & Image Gallery for WordPress
ubmucosal amyloid deposits in pharyngeal walls and epiglottis

Amyloidosis, before debulking (1 of 4)

Panoramic view. Submucosal amyloid deposits in pharyngeal walls and epiglottis, with examples at arrows.
anterior subglottis

Amyloidosis, before debulking (2 of 4)

View of anterior subglottis shows diffuse infiltration of yellowish, submucosal amyloid.
deposit at anterior commissure tethering upper surface of left vocal cord

Amyloidosis, before debulking (3 of 4)

Phonation under strobe light shows deposit at anterior commissure tethering upper surface of left vocal cord, and resultant vibratory asymmetry.
Amyloidosis, after debulking

Amyloidosis, after debulking (4 of 4)

Some months later, after laser debulking at short arrow, showing improvement of vibratory closure after tethering reduced. Note increase of nearby supraglottic amyloid deposit does not need to be addressed because it has no functional consequence to the patient, who has other asymptomatic deposits in subglottis, epiglottis, and nasopharynx.

Amyloidosis: Series of 1 photo

Visual Portfolio, Posts & Image Gallery for WordPress
Amyloid deposits

Amyloidosis (1 of 1)

Amyloidosis, before and after debulking: Series of 8 photos

Visual Portfolio, Posts & Image Gallery for WordPress
large spherical mass of amyloid material bulging submucosally

Amyloidosis, before debulking (1 of 8)

Panoramic view of a large spherical mass of amyloid material bulging submucosally (contour at dotted line) in the false and aryepiglottic cords. The patient has only a harsh stage whisper, and glottic voice only with inspiratory (inhaling) phonation. The posterior vocal cord and ventricle of the opposite side (left of photo) are visible, but the amyloid mass obscures all but a few millimeters of the posterior cord on its side.
Amyloidosis, before debulking

Amyloidosis, before debulking (2 of 8)

Closer view.
edge of the amyloid mass

Amyloidosis, before debulking (3 of 8)

View yet further down, showing the upper trachea (top-center of photo), the posterior end of one of the vocal cords (left of photo), and the edge of the amyloid mass (bottom-right of photo, again marked by a dotted line). The mass is again obscuring a view of the vocal cord on its side; in fact, it is pressing the cord downward, which affects the voice.
mass overlies most of both vocal cords

Amyloidosis, before debulking (4 of 8)

Phonation, while attempting to see the vocal cords beyond the large overhanging mass. The vocal cords are each marked with an F, one of the posterior ventricles with a V, and the amyloid mass with an A. This mass actually overlies most of both vocal cords and presses them both downward.
Amyloidosis after debulking

Amyloidosis, after debulking (5 of 8)

Twenty-four hours after laser removal, i.e., debulking.
deepest recess of the dissection

Amyloidosis, after debulking (6 of 8)

Looking into the deepest recess of the dissection. The parallel lines indicate the upper border of the thyroid cartilage.
Amyloidosis after debulking

Amyloidosis, after debulking (7 of 8)

After debulking, both vocal cords are now visible from this angle (compare with photo 2). Remaining swollen overhanging tissue did not appear to be infiltrated with amyloid deposition.
Complete healing

Complete healing (8 of 8)

Many months after debulking, and with complete healing, the voice can pass for normal, and the laryngeal vestibule is no longer filled with the enormous bulk of amyloid. The nubbin at anterior false cord would only need removal if it became large enough to interfere with voice.

Proteinaceous deposits of primary laryngeal amyloidosis can occur anywhere and “everywhere” in the larynx: Series of 4 photos

Visual Portfolio, Posts & Image Gallery for WordPress
narrowed airway and protruding lesions

Airway Passage (1 of 4)

This middle-aged woman has experienced gradual deterioration of voice across several years. Note the narrowed airway and protruding lesions.
irm submucosal masses

Submucosal Masses (2 of 4)

In a closer view, one gets the sense of firm submucosal masses (most prominent deposits circled, at arrows). Note the yellowish cast as well. Vocal cord margins are marked with dotted lines.
diffuse subglottic infiltration

Diffuse Subglottic Infiltration (4 of 4)

Just below the vocal cords, diffuse subglottic infiltration is also seen, with the most prominent deposit posteriorly at the arrow.
yellowish amyloid deposits

Amyloid Deposits (3 of 4)

At closer range, the yellowish cast typical of amyloid deposits is seen better.

Videos:

Amyloidosis
This video gives an example of amyloidosis, which is a condition in which abnormal proteins (called amyloids) become deposited in the spaces between cells.


Ankylosis

Immobility and fusion of a joint due to disease, injury, or a surgical procedure. Ankylosis of the cricoarytenoid joint may be seen after traumatic dislocation, or in rare instances of the disease rheumatoid arthritis.

Photos of Ankylosis:

Ankylosis, not paralysis, despite a “not-that-great examination”: Series of 2 photos

Visual Portfolio, Posts & Image Gallery for WordPress
paralyzed vocal cords

Paralysis or vocal cord fixation? (1 of 2)

Right vocal cord (left of photo) immobility in young woman who was intubated more than 20 years earlier, at 5 months of age. Voice has been weak and air-wasting ever since. Both vocal cord paralysis and vocal cord fixation are potential complications of intubation: In this case, which is it? In this distant view, one can already see a “divot” in the right posterior cord (left of photo) that is not seen with any of the permutations of vocal cord paralysis or paresis. The area of shading also suggests an area of scarring where the tube traversed the medial arytenoid cartilage.
scarring of the posterior right cord

Scarring seen, no flaccidity (2 of 2)

Under strobe light at closer range. As the cords begin to oscillate, one can again see the scarring of the posterior right cord and arytenoid face. In addition, there is no flaccidity of the right cord (left of photo) such as would be seen with a neurogenic cause. The problem is vocal cord fixation, not paralysis.


Anterior

Toward the front side of a person’s body. For example: the toes are anterior to the heel. The opposite of posterior.



Anterior commissure

The point at which the vocal cords are joined together, which is at the most anterior end of each cord. Compare this with the posterior commissure.



Anterior commissure microweb

A tiny webbing between the vocal cords at the anterior commissure, where the two cords meet. Some think that an anterior commissure microweb can help to cause vocal nodules, but we do not see any such relationship.


Photos:

Microweb: Series of 2 photos

Visual Portfolio, Posts & Image Gallery for WordPress
mid-membranous cord

Microweb (1 of 2)

Subtle vocal cord swellings, mid-membranous cord. This patient also has a microweb, not visible in this view.
microweb at the anterior commissure

Microweb (2 of 2)

Same patient, at closer range, showing the microweb at the anterior commissure.


Aryepiglottic cord

The aryepiglottic cord is the membranous sheet of tissue that stretches from the lateral edge of the epiglottis to the arytenoid cartilage. The upper edge of the aryepiglottic cord is like the gunwale of a boat, so that liquid or saliva can pool in the pyriform sinus without immediately spilling over into the laryngeal entrance.



Arytenoid Cartilages

A pair of small triangular cartilages in the larynx that help to move the vocal cords. The arytenoid cartilages sit on the upper surface of the cricoid cartilage ring’s posterior section. Each arytenoid has a body, apex, muscular process, and vocal process. The vocal process is the only part of the arytenoid cartilage that is sometimes clearly visible when viewing the larynx endoscopically, such as in the photos provided on this site (see the photo below), since the vocal process projects into the posterior part of the vocal cord with thin enough soft tissue covering it that it may “shine through.”

Attachments of the arytenoid cartilages:

The arytenoid cartilages help to move the vocal cords because the vocal cords are attached to them and because several muscles also attach to the arytenoids and can move them around. The joint capsule (tiny ligaments and fibrous tissue) attaches the arytenoid cartilage to the cricoid cartilage; the vocal cord (comprised mostly of the thyroarytenoid, or TA, muscle) attaches to the arytenoid cartilage at its vocal process. The PCA and LCA muscles attach to the arytenoid at what is called the muscular process, which points more laterally, at 90 degrees from the vocal process. The interarytenoid muscle (IA) attaches to the arytenoid on the concave posterior surface of each arytenoid’s body; the IA muscle also connects the arytenoids to each other.

Movement of the arytenoid cartilages:

The IA muscle pulls the arytenoid cartilages together for coughing, voicing, and so forth. The PCA muscles move the arytenoids apart simultaneously to open the larynx widely for breathing. The LCA muscles can move the arytenoids, and especially the vocal processes, toward each other, and can also rock the arytenoids anteriorly.

As the arytenoids move in all these different ways, the vocal cords—being attached to the arytenoids—move along with them. Thus, via the arytenoid cartilages, these muscles cause the vocal cords to separate (abduct) for breathing or come together (adduct) for voicing, throat clearing, coughing, and so forth. There are also other muscles that affect the vocal cords, but apart from the involvement of the arytenoids: the TA muscle that makes up most of the bulk of each cord can isometrically contract and affect the tension of the cords, for varying the quality and (somewhat) the pitch of the voice, and an external muscle, the cricothyroid, has a major role for creating high pitches.


Photos:

Arytenoid’s vocal process: Series of 1 photo

Visual Portfolio, Posts & Image Gallery for WordPress
Vocal process of the arytenoid, artificially highlighted

Vocal process of the arytenoid, artificially highlighted

Strobe light, as the vocal cords are just coming into contact for phonation. The vocal process of each arytenoid is brightly highlighted; the extension of each vocal process back into the arytenoid is moderately highlighted.

Vocal processes of the arytenoid cartilages, accentuated by vocal cord atrophy: Series of 4 photos

Visual Portfolio, Posts & Image Gallery for WordPress
vocal processes

Vocal processes, accentuated by vocal cord atrophy (1 of 4)

The vocal processes in this patient are extremely visible because the rest of the vocal cord on each side is atrophic and bowed.
eft vocal process projects further anteriorly

Vocal processes, accentuated by vocal cord atrophy (2 of 4)

The vocal cords approach each other for voicing. Note the evident asymmetry between the vocal processes. The left vocal process (right of image) projects further anteriorly than does the opposite process. It is also at a higher (more cephalad) level.
closed phase of vibration

Vocal processes, accentuated by vocal cord atrophy (3 of 4)

Phonation, closed phase of vibration, under strobe lighting. Note the overlap (scissoring) of the left vocal process (right of image) on top of the other process.
vocal cord atrophy

Vocal processes, accentuated by vocal cord atrophy (4 of 4)

Phonation, at a higher pitch, at which the scissoring of the left vocal process (right of image) on top of the other becomes even more evident.


Arytenoid chondritis / perichondritis

An infectious or inflammatory response with ongoing ulceration or granulation on the superstructure of the arytenoid cartilage. Here we are talking of the arytenoid cartilage and/ or its thin “envelope” of fibrous tissue called perichondrium. The root chondr- refers to cartilage.

A similar and much more common disorder, contact granuloma or contact ulcer, occurs on the medial surface of the arytenoid cartilage, but low and at the level of the vocal process. When arytenoid chondritis or perichondritis occurs, it causes significant chronic pain (in contrast to contact granuloma, which can be pain-free or bring only minor discomfort). We have never diagnosed the underlying cause. Treatment tends to require definitive removal of the area of cartilage involved (not the entire arytenoid, of course), and then typically the area will heal, though often only after a time of re-granulation.


Photos:

Arytenoid chondritis, before and after removal: Series of 5 photos

Visual Portfolio, Posts & Image Gallery for WordPress
Festering arytenoid chondritis

Arytenoid chondritis (1 of 5)

Festering arytenoid chondritis of over a year's duration. Several biopsies done elsewhere showed only inflammation.
Arytenoid chondritis

Arytenoid chondritis, removed (2 of 5)

Two weeks after aggressive partial arytenoid superstructure excision, in an attempt to get down to healthy cartilage.
healed vocal cords

Arytenoid chondritis, removed and healed (3 of 5)

After complete healing. Note loss of anterior arytenoid prominence on the operated side as compared with the unoperated side.
resolution of the lesion and inflammation

Arytenoid chondritis, removed and healed (4 of 5)

At this point, patient is entirely symptom-free. Notice resolution of the lesion and inflammation. The arytenoid mound is a little lower on right (left of image) than on left (right of image), due to surgical removal of part of the superstructure of the arytenoid.
healed chondritis

Arytenoid chondritis, removed and healed (5 of 5)

The area of festering chondritis has completely healed. The arrow shows center of where the lesion was.

Arytenoid chondritis: Series of 3 photos

Visual Portfolio, Posts & Image Gallery for WordPress
arytenoid ulcer

Arytenoid chondritis (1 of 3)

This person has twinges of pain every time she swallows, like “ground glass” or “razor blades.” She locates the sensation by pointing precisely to the upper part of the thyroid cartilage on the left. The exam reveals an arytenoid ulcer (upper right of image), with surrounding erythema.
central depression of lesion

Arytenoid chondritis (2 of 3)

A closer view shows more clearly the central depression and rolled border of the lesion.
Arytenoid chondritis

Arytenoid chondritis (3 of 3)

Using narrow-band illumination at even closer range.

Arytenoid chondritis: Series of 1 photo

Visual Portfolio, Posts & Image Gallery for WordPress
Small ulcer with surrounding erythema

Arytenoid chondritis (1 of 1)

Small ulcer with surrounding erythema, right arytenoid superstructure.

Arytenoid chondritis at the glottic level NOT likely from reflux!: Series of 3 photos

Visual Portfolio, Posts & Image Gallery for WordPress
dilation of this inflammatory subglottic stenosis

2 weeks post dilation (1 of 3)

Two weeks after dilation of this inflammatory subglottic stenosis. Treatment elsewhere with esomeprazole for 2 years had not resolved this. This is likely forme fruste Wegener’s-type stenosis, which in this patient has required dilation every few years, with marked resolution of shortness of breath/ noisy breathing.
otted lines indicate where the ulcer would be if still present

3 months later, ulcer is gone (3 of 3)

Within a few weeks, the pain resolved. Here, 3 months later, the ulcer and erythema are gone. Dotted lines indicate where the ulcer would be if still present. Compare with photo 2.
flat ulcer with surrounding redness

Ulcer not caused by tube or reflux (2 of 3)

There was no postoperative pain at all until on the 4th postoperative day, when she developed left throat pain radiating to the left ear. Note within dotted line a flat ulcer with surrounding redness, resembling an apthous ulcer more than endotracheal tube injury or acid reflux. Observation was counseled, and even discontinuation or reduction of her esomeprazole.

Arytenoid perichondritis: Series of 5 photos

Visual Portfolio, Posts & Image Gallery for WordPress
Arytenoid perichondritis

Arytenoid perichondritis (1 of 5)

Singer with constant right throat pain and vocal impairment, worsened by singing and speaking. Examination finding: arytenoid perichondritis. Note the erosion exposing the arytenoid cartilage, and the associated swelling.
pseudopolyp

Pseudopolyp (2 of 5)

Swelling creates a “pseudopolyp” (at arrow) that interferes with vocal cord closure and vibration.
Phonatory view under strobe light.

Phonation (3 of 5)

Phonatory view under strobe light.
Minimal residual erosion

Two weeks post treatment (4 of 5)

Two weeks after antibiotic treatment. He has intermittent mild discomfort only when singing, and his voice is much improved. Minimal residual erosion (see arrow), with mild inflammatory changes.
voice is entirely normal

Normal voice (5 of 5)

Pseudopolyp has resolved and no longer interferes with voice. At follow-up 6 weeks later, his voice is entirely normal and he has no pain.

Arytenoid perichondritis awaiting surgery: Series of 2 photos

Visual Portfolio, Posts & Image Gallery for WordPress
inflamed, rolled border

Inflammation (1 of 2)

Spontaneous onset of sore throat, laryngitis, without any other URI symptoms approximately 6 months earlier. Biopsy elsewhere showed 'acute and chronic inflammation.' Note the inflamed, rolled border outlined by dotted line, and a sense of central excavation.
lesion

Surgery likely (2 of 2)

At closer range. The solution here will likely be to remove the lesion to include a central "festering" area of perichondrium, as for the other cases on this page. Cause of this kind of lesion is always unknown.

Arytenoid perichondritis going…coming…gone!: Series of 4 photos

Visual Portfolio, Posts & Image Gallery for WordPress
lesion on the left vocal cord

Throat pain (1 of 4)

Very localized throat pain, left mid-neck, has been present for about 5 months with no sign of improvement despite trials of antibiotics, and fluconazole elsewhere. The location of pain correlates well to the lesion (bold arrow). The pain is very troublesome, fluctuating between 5 and 7 on a ten-point scale, worse with talking and tending to increase as the day progresses. The patient was also experiencing frequent laryngospasm. The patient was offered further observation vs. excision at her option.
festering point of lesion

1 week post removal (2 of 4)

After waiting an additional month, the patient became motivated to have the lesion removed. This examination is one week after excision of perichondrium and a small amount of cartilage, seeking to remove the “festering point.” The surgical wound is indicated by small dotted line on the left (right of photo). The patient’s pain is already much reduced, in spite of this wound, but peculiarly, she now has just a slight similar pain on the right. Note the small lesion indicated by the arrow, and visible in retrospect, in photo 1.
Five weeks after surgical removal

5 weeks post removal (3 of 4)

Five weeks after surgical removal, left-sided pain is still gone, and after a course of antibiotics and steroids, right sided lesion (arrow) and pain are nearly gone. It is not known whether healing was spontaneous or the result of steroid and antibiotic. This is because treatment of longstanding lesions often fails, and early, minimal lesions like this one sometimes heal without treatment.
larynx is entirely healed

3 months post removal (4 of 4)

Now 3 months after surgical excision, the larynx is entirely healed; pain and laryngospasm are gone.


Aspiration

The entry of foreign material, such as saliva, ingested liquid or food, or gastric contents refluxed up to the level of the throat, into the airway below the vocal cords. If this foreign material only enters the laryngeal vestibule but does not descend below the vocal cords, this is not considered aspiration, but instead laryngeal penetration. Significant or recurring aspiration puts a person at risk of pneumonia; laryngeal penetration alone does not, though a person with laryngeal penetration is more likely to aspirate trace amounts than is the person with completely normal swallowing function.

Aspiration can occur before, during, or after the act of swallowing. Aspiration before the swallow means that liquid or food in the mouth dribbles or spills down into the larynx and beyond before the swallow is initiated.  This is seen most commonly when there is a neurological disorder, such as after a cerebrovascular accident (stroke).

Aspiration during swallowing happens when, as the swallowed material travels from the base of the tongue toward the entrance to the esophagus (in the pharyngeal phase of swallowing), some of that material drops into the larynx and straight down through it to enter the airway. This kind of aspiration can happen because a person’s vocal cords don’t close properly, due to paralysis, paresis, or tissue loss such as after a partial laryngectomy.

Aspiration after swallowing happens when some of the ingested liquid or solid remains pooled in the lower throat after the swallow is complete, and when the patient takes the first post-swallow breath, it enters the airway. To try to prevent aspiration after swallowing, the supraglottic swallow technique can help.


Photos:

Aspiration: Series of 1 photo

Visual Portfolio, Posts & Image Gallery for WordPress
blue applesauce in trachea

Aspiration (1 of 1)

After patient swallows blue-stained applesauce, some enters the trachea. Vigorous coughing can clear this away so that even chronic aspiration of this sort does not necessarily cause pneumonia.

Tracheal aspiration of saliva: Series of 2 photos

Visual Portfolio, Posts & Image Gallery for WordPress
Trachea

Trachea, normal view (1 of 2)

Looking down the trachea.
Water in trachea

Trachea, aspiration (2 of 2)

The patient aspirates a drip of saliva. If this were a larger amount of food material, and if it frequently descended much lower, to the level of the air sacs, this person would develop pneumonia.

Aspiration: Series of 7 photos

Visual Portfolio, Posts & Image Gallery for WordPress
laryngopharynx

Aspiration (1 of 7)

Panoramic laryngopharynx view. The patient is holding a sip of liquid in his mouth and preparing to swallow it.
liquid in the pharynx

Aspiration (2 of 7)

Before he initiates the swallow, a small drip of liquid "escapes" and drips downward into the pharynx. The patient does not yet suspect this. There are only a few drops of liquid, even though it looks like a larger amount due to the close-up view.
water in the larynx

Aspiration (3 of 7)

A few milliseconds later yet, the tiny drip has fallen halfway down the length of the pharynx. One can see that the patient is not aware of this drip, as he has not fully closed the vocal cords.
water in the pyriform sinus

Aspiration (4 of 7)

A few milliseconds later, the drop is arriving at the left (right of image) pyriform sinus. The patient is still not aware of this swallowing "mistake". The vocal cords remain open, so if this liquid had dripped instead into the laryngeal opening, it would have entered the airway and made him cough.
water on the epiglottis

Aspiration (5 of 7)

With a second sip of faintly blue-stained water, a small trickle escapes "early" before the swallow. One can see the leading edge of water flowing onto the epiglottis (indicated by the dotted line).
water advancing down the larynx

Aspiration (6 of 7)

The leading edge of the water has advanced and continues to flow downwards. This is indicated by the dotted line and arrows.
water causes coughing in the laryngeal vestibule

Aspiration (7 of 7)

The leading edge of the water has again advanced and continues to flow downwards into the laryngeal vestibule and through the open vocal cords. This time, the patient coughs.

All It Takes Is A Drip to Make You Cough: Series of 4 photos

Visual Portfolio, Posts & Image Gallery for WordPress
Laryngeal vestibule

Coughing (1 of 4)

This patient is annoyed by occasional coughing when she sips liquids. She has had no pneumonias, weight loss, or increased time required to eat/drink. Here, the patient has just taken a sip of blue water and holds it in her mouth.
blue water flowing into laryngeal vestibule

Coughing (2 of 4)

Just before swallowing, a tiny drip of blue water “gets away” and begins to trickle down into her throat. Vocal cords remain unsuspectingly open.
blue water in left aryepiglottic fold

Coughing (3 of 4)

The drip (arrow) has now reached the left aryepiglottic fold, which is the “side of the boat” that keeps liquid out of the airway. The drip looks smaller than in photo 2 because it is farther away. She does not cough.
blurry blue water in throat

Coughing (4 of 4)

During a different swallow, if a much larger amount of water were to drip prematurely down into her throat, a part of it would enter the laryngeal entrance and provoke coughing. If coughed back up, there would be little risk of pneumonia.


Aspiration pneumonia

Pneumonia, or an infection of the lungs, that has resulted from aspiration—that is, from passage of food, liquid, saliva, or vomited stomach contents down into the larynx, trachea, and air sacs of the lungs. Aspiration pneumonia can occur in individuals who have chronic swallowing deficits (e.g., presbyphagia), or can be a result of intoxication, seizure, loss of consciousness, etc.



Atypical spasmodic dysphonia

A benign neurological voice disorder caused by laryngeal dystonia. Atypical cases of spasmodic dysphonia (SD) may be challenging to diagnose, even by clinicians with some experience with the disorder. Examples of reasons that this may be so: In the atypical case, contrary to what is usually seen, singing may be more affected than talking; falsetto/head voice may be more affected than chest voice, and so forth. There may also be no phonatory arrests in the less common tonic variant spasmodic dysphonia.



Auditory perceptual evaluation of voice

The sense of hearing applied to assessment of the voice. In some locations, auditory perceptual evaluation of voice refers primarily to characteristics of the patient’s spontaneous speaking voice, and sometimes very basic additional elicitations.

However, in clinics where the integrative diagnostic model has been mastered, the clinician’s auditory perception has been informed by extensive knowledge and experience of normal and abnormal vocal capabilities and vocal limitations. This knowledge, along with his or her own voice used for modeling and elicitation, are the tools used when conducting the vocal capability battery. It is auditory perceptual evaluation of elicited vocalizations at the extremes of normal capability that provide powerful diagnostic information about the voice, as distinct from the larynx.



Auto-immune laryngitis

Inflammation of the vocal cords, especially of the layer just beneath the mucosa, caused by an auto-immune disorder. Auto-immune disorders that can potentially cause laryngitis (albeit infrequently) include rheumatoid arthritis, lupus erythematosus, Wegener’s granulomatosis, and combined auto-immune disorder. Some individuals develop an inflammatory picture of capillary prominence and mucosal edema which is unrelated to vibratory trauma; that is, these individuals do not have the profile of the “vocal overdoer.” Others form rheumatoid nodules of the vocal cords, aka “bamboo nodes.”



Average/anchor frequency

Average/anchor frequency is a term used at our practice to designate the pitch (and by extension, fundamental frequency) that an individual is using during spontaneous, running speech, as determined via auditory perception. We use both “average” and “anchor” together, because some persons speak in a perceptually monotone voice, at which point we consider the pitch extracted via auditory perception to be virtually synonymous with “average” fundamental frequency (proven to be the case in informal study comparing Fo extracted by auditory perception vs. by machine measures).

Other individuals speak with a great deal of pitch inflection. In these cases, we listen for the lowest common pitch to which the voice seems to be “anchored.” When highly inflected speakers become generally fatigued or “depressed,” they tend to default to this pitch, which then becomes more of an “average” pitch for them. Of course, using machine measures of fundamental frequency (primarily using equipment for acoustic analysis), a formal average fundamental frequency can be determined. The ability to determine average/anchor pitch via auditory perception during the vocal capability battery can be learned by clinicians with good pitch perception.




  1. A
  2. B
  3. C
  4. D
  5. E
  6. F
  7. G
  8. H
  9. I
  10. J
  11. K
  12. L
  13. M
  14. N
  15. O
  16. P
  17. Q
  18. R
  19. S
  20. T
  21. U
  22. V
  23. W
  24. X
  25. Y
  26. Z