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Laryngopedia

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

Laryngopedia By Bastian Medical Media

Multimedia Encyclopedia


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Bacterial Laryngitis

Bacterial laryngitis is an infection of the vocal cord mucosa by bacteria. During this infection, mucus produced in the larynx is usually colored yellow, green, or brown. If the patient’s laryngitis isn’t reasonably self-limited, antibiotics can be prescribed, along with relative voice rest and hydration.



Bilateral Vocal Cord Fixation

Immobility of both vocal cords due to a scarring rather than paralytic cause. The scarring might manifest as a synechia that tethers the vocal cords to each other and prevents them from separating during breathing. Or it could mean that both cricoarytenoid joints are ankylosed, or “frozen.”

The most common cause of bilateral vocal cord fixation is prolonged endotracheal intubation, such as in gravely ill or injured persons, who may spend weeks in an intensive care unit and on a ventilator. Vocal cord fixation can rarely be caused by rheumatoid arthritis. It is also seen infrequently as a progressive, late complication of radiation therapy for larynx cancer.


Photos:

Bilateral vocal cord fixation: Series of 2 photos

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keyhole shaped glottis

Bilateral vocal cord fixation (1 of 2)

After bilateral posterior cordotomies, “keyhole” shaped glottis. Size of opening at posterior commissure is exaggerated by the wide-angle lens of the distal-chip video-endoscope.
Bilateral vocal cord fixation

Bilateral vocal cord fixation (2 of 2)

Persistent posterior opening, but musculomembranous cords come into good contact and have not been damaged by either the original endotracheal tube or the posterior cordotomies, and voice is very serviceable.


Biopsy

Refers to both the process of removing a bit of tissue from a person so that it can be studied and “diagnosed” by the pathologist, and also to the piece of tissue itself. “The surgeon biopsied (verb) the vocal cord and then sent the biopsy (noun) to the pathologist for examination under the microscope.”


Photos:

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2-millimeter forceps being used to scrape the area of leukoplakia

Biopsy (1 of 2)

2-millimeter forceps being used to scrape the area of leukoplakia to retrieve cells for HPV testing. In this case, it was negative.
scraping of the surface of the cords

Biopsy (2 of 2)

Cup forceps closed. Note that there is no biopsy, per se, but just scraping of the surface of the cords.
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Biopsy of lesion involving the petiole

Biopsy, epiglottis (1 of 1)

Biopsy of lesion involving the petiole (low laryngeal surface of epiglottis). The pathology report revealed squamous cell carcinoma, usually caused by smoking.


Botox™

Botox™, the trade name of botulinum toxin, is a drug produced by the same bacterial organism (Clostridium botulinum) that causes the disease process called botulism. Tiny, entirely safe quantities of this medication have been used for decades to treat strabismus, facial spasms, spasmodic dysphonia, cervical dystonia, and other neurological disorders characterized by abnormal muscle contractions. Botox is also used by cosmetic surgeons to smooth wrinkles temporarily.



Botulinum Toxin

See Botox.



Bowing of the vocal cords

This is a descriptive term to specify that the vocal cords are not matching in a straight line, with only a thin dark line between them at the moment of pre-phonation. Instead, the cords become gently concave or bowed outwards. At the moment of pre-phonation, there is a wider, oval slit between the cords.

Bowing can be physiologic, asymptomatic, and a genetic “given.” In this physiologic type, the bowing will be subtle to mild and there will be good vibratory pattern. When moderate or severe, bowing may more likely be the result of aging, vocal disuse, Parkinson’s disease, or other conditions. Moderate and severe bowing correlate with a degree of vocal cord atrophy and the vibratory pattern can be more flaccid. The voice tends to have a soft-edged quality, a little higher in pitch than normal, and can fade with use. Voice building is the primary treatment, but very occasionally severe bowing is treated with bilateral vocal cord implants.


Photos:

Vocal Cord Bowing

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Vocal cord bowing

Vocal cord bowing (1 of 4)

Open phase vibration, strobe light. Notice the large amplitude of vibration. The wide lateral excursions suggest flaccidity, especially when this is seen in middle voice.
anterior cords are more flaccid, with delayed return to midline contact

Vocal cord bowing (2 of 4)

Partially closed phase. Notice that the anterior cords (arrows) are more flaccid, with delayed return to midline contact. When this is seen, that anterior segment may vibrate independently and cause a rough, gravelly voice quality. The capillary ectasia, left vocal cord (right of image), is an incidental finding and not related to the patient’s rough voice quality.
persistent anterior open segment

Vocal cord bowing (3 of 4)

Coming to closed phase, but with the persistent anterior open segment.
Closed phase of vibration.

Vocal cord bowing (4 of 4)

Closed phase of vibration.
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Vocal cords at the prephonatory instant

Vocal cord bowing (1 of 3)

Vocal cords at the prephonatory instant under standard light. Note the highly bowed glottic gap.
vibratory blur consistent with bowing

Vocal cord bowing (2 of 3)

After vibration begins. Note the very wide “vibratory blur,” consistent with bowing under standard light.
Open phase of vibration under strobe light

Vocal cord bowing (3 of 3)

Open phase of vibration under strobe light, showing unusually wide lateral excursions of the cords resulting from their flaccidity.
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Vocal cord bowing

Vocal cord bowing (1 of 2)

Vocal cord bowing, at the prephonatory instant.
Vocal cord bowing

Vocal cord bowing (2 of 2)

Immediately after phonation, showing better closure, but only due to vibratory blur.
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bowing at prephonatory instant

Vocal cord bowing (1 of 4)

Bowing of vocal cords as seen under continuous light, at prephonatory instant, just before vibratory blur.
bowing under strobe light

Vocal cord bowing (2 of 4)

Under strobe illumination, at maximum open phase (greatest lateral excursion).
Maximum closed phase of vibration

Vocal cord bowing (3 of 4)

Maximum "closed" phase of vibration, which is not fully closed; greatest medial vibratory excursion does not bring the cords into full contact.
Vocal cord bowing

Vocal cord bowing (4 of 4)

Due to vocal weakness, when effort is increased the false cords come into near contact, and can even add a rough second sound to the voice.
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Vocal cord bowing (1 of 4)

Prephonatory instant shows an oval gap between the cords, rather than a thin line.

Vocal cord bowing (2 of 4)

Bowing, as seen in abducted, breathing position.

Vocal cord bowing (3 of 4)

Strobe light, maximum closed phase, with poor closure especially anteriorly. The greater flaccidity anteriorly may cause an independent vibratory segment and chaotic vibration with rough, gravelly quality.

Vocal cord bowing (4 of 4)

Strobe light, maximum open phase of vibration.
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Bowed vocal cords

Vocal cord bowing (1 of 5)

Bowed vocal cords, abducted breathing position.
bowing of the musculomembranous

Vocal cord bowing (2 of 5)

As the cords begin to adduct, medial turning of vocal processes accentuates the bowing of the musculomembranous (anterior 2/3) of the vocal cords.
bowed free margins and an elliptical gap

Vocal cord bowing (3 of 5)

The prephonatory instant under continuous illumination, showing bowed free margins and an elliptical gap rather than the straight-line match of more normal vocal cords.
open phase of vibration

Vocal cord bowing (4 of 5)

Under strobe illumination, open phase of vibration.
cords' return to midline is flaccid

Vocal cord bowing (5 of 5)

Under strobe illumination, closed phase of vibration. The closure here isn't complete because the cords' return to midline is flaccid.

Bowing of vocal cords and effect of pitch

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prephonatory instant at a low pitch, D3

Weak voice (1 of 8)

This patient has a weak, air-wasting, and gravelly voice. In this distant view, prephonatory instant at a low pitch, D3 (147 Hz), severe bowing can be seen.
producing voice at D3

Phonatory view (2 of 8)

Also at D3 (147 Hz), but while producing voice. Note that the vibratory blur occurs only in the posterior membranous vocal cord.
closed phase at D3

"Closed" phase (4 of 8)

At D3 again, now closed phase, which is not closed except posteriorly, explaining the lack of vibratory blur anteriorly in photo 2. Some vibratory cycles are chaotic, too, explaining the gravelly, rough quality of the voice.
open phase of vibration

B3, open phase (5 of 8)

At B3 (247 Hz), open phase of vibration, the anteroposterior stretch required to produce higher pitch, also somewhat reduces the tissue flaccidity. Vibratory amplitude (lateral excursion) is diminished as well.
open phase of vibration at D3

D3, open phase (3 of 8)

Under strobe light, open phase of vibration at D3 (147 Hz), note that the amplitude of vibration is enormous, as the air stream easily throws flaccid vocal cords very far laterally.
Reduced closure anteriorly is typical for flaccid vocal cords

B3, closed phase (6 of 8)

At B3 again, closed phase of vibration is not really closed, yet is more successful than at the lower pitch in photos 3 and 4. Reduced closure anteriorly is typical for flaccid vocal cords.
Open phase of vibration at B-flat 4

Bb4, open phase (7 of 8)

Open phase of vibration at B-flat 4 (466 Hz). Added antero-posterior stretch subtly reduces vibratory amplitude further, especially anteriorly.
excess lateral amplitude anteriorly is no longer seen

Bb4, closed phase (8 of 8)

Closed phase at same pitch as photo 7, is not closed, but the excess lateral amplitude anteriorly is no longer seen.

Four views of vocal cord bowing in the same person

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bowed vocal cords at medium range in partial abduction

Bowed vocal cords (1 of 8)

An older man has a foggy voice, worsening with use. At medium range in partial abduction, note the bowed vocal cord margins.
large oval gap between the cords

Prephonatory view (2 of 8)

At a greater distance but at the prephonatory instant, there is a large oval gap between the cords.
lateral excursions of the cords are huge due to the flaccidity of the cords

Open phase (3 of 8)

Now under strobe light, at C3 (131 Hz). The lateral excursions of the cords are huge due to the flaccidity of the cords. Compare with photos 5 and 7.
closed phase of vibration is not fully closed

Gravel voice (4 of 8)

At the same pitch, the closed phase of vibration is not fully closed, and the anterior segment that remains open is often unstable and flutters or vibrates as an independent segment, causing ‘gravel.’
vocal cords must lengthen to produce this higher pitch of F#3

Reduced flaccidity (5 of 8)

The vocal cords must lengthen to produce this higher pitch of F#3 (185 Hz). Lengthening also reduces flaccidity, explaining reduced amplitude (lateral travel) of vibration. Compare with photo 3 and 7.
completely closed phase of vibration at F#3

Closed phase (6 of 8)

The closed phase of vibration, also at F#3, is completely closed, and the voice is more stable at this pitch. Compare with photo 4 and 8.
cords are stretched and thinned at B-flat 5

Falsetto, open phase (7 of 8)

Now at B-flat 5 (932 Hz), the cords are stretched and thinned. Amplitude is quite large, because falsetto tends to de-activate tension within the thyroarytenoid muscles. Compare with photos 3 and 5.
Closed phase of vibration at the same pitch in falsetto

Falsetto, closed phase (8 of 8)

Closed phase of vibration at the same pitch in falsetto is not closed at all for the same reasons described in the caption for photo 7. Compare with photos 4 and 6.

Red herring capillary ectasia and mucosal injuries

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ectatic capillary of the left vocal cord

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

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.
subtle margin swelling

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.
arge amplitude of the open phase of vibration

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.

Glottic furrow—not just bowing and not glottic sulcus

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Bowing vocal cords with furrows

Bowing vocal cords with furrows (1 of 4)

This middle-aged man's voice has become increasingly husky and weak across many years. In retrospect, it was never a "strong" voice. The cords are bowed, and the furrows seen here (arrows) become more visible in subsequent photos.
closed" phase of vibration

"Closed" phase (2 of 4)

Under strobe light at B-flat 2 (117 Hz), this is the "closed" phase of vibration, perhaps better defined in this instance as the "most closed" phase.
open phase shows linear groove just below the margin of each cord.

Open phase (3 of 4)

The open phase at the same pitch, shows a linear groove just below the margin of each cord. Some might call these glottic sulci, but "furrow" would be the better definition, as seen in the next photo.
open mouth of a right-sided glottis sulcus

Glottic sulcus is visible (4 of 4)

At close range and high magnification, the open mouth of a right-sided glottis sulcus is seen. This side can be operated safely due to the excess, thick mucosa and would be expected to improve the margin match. On the left (right of photo), a sulcus is also seen, but the thinner mucosa makes successful surgery on the left more challenging.

Voice Building:

Voice Building (shorter version):

 



Breathing Tube Injury: Synechiae

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Vocal cords

Breathing Tube Injury (1 of 4)

Some weeks after a 3-day intubation for a nonorganic breathing problem, some ongoing (and different) breathing symptoms are caused by a synechiae that will not permit full abduction of the vocal cords. The * allows comparison with photo 2.
post-intubation synechiae

Breathing Tube Injury (2 of 4)

Extremely close visualization of the post-intubation synechiae (* to orient with photo 1). Note the opening posterior to the synechiae indicated by the arrows. This makes it less likely that there is a concomitant ankylosis (fixation) of either cricoarytenoid joint.
corrected vocal cords

Breathing Tube Injury (3 of 4)

Several months after surgical release of the synechiae, notice that abduction of the vocal cords again makes a normal, wide-open “v.” Compare with photo 1 to see this clearly.
Closer visualization of the posterior commissure

Breathing Tube Injury (4 of 4)

Closer visualization of the posterior commissure shows evidence of scar at the left base of the synechia. This could be easily overlooked if the patient’s history were not known.

 



Breathy Dysphonia

Breathy dysphonia is a kind of hoarseness caused by “wasting” of air through the glottis (vocal cord level). Also called air-wasting dysphonia. The voice may also be described as whispery, foggy, or fuzzy.



Breathy-pressed phonation or dysphonia

Breathy-pressed phonation or dysphonia is an easily identified dysphonia that combines two phenomenologies – audible muscular effort + a breathy, air-wasting quality. The classic disorder in which this is noted is severe intubation injury.



Bronchoscopy

Bronchoscopy is a procedure during which the examiner looks inside the trachea and bronchial tubes, typically using a slender, flexible fiberoptic or videoscope. At our practice, this procedure is usually performed using topical anesthesia with or without sedation, “in the chair” rather than in a hospital setting.



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