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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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.


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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.


Candida albicans

Candida albicans is a fungal organism, normally part of human upper aerodigestive tract flora. Candida albicans may become pathogenic (creating a disease state) when there is a disturbance in the balance of other normal organisms. Such an imbalance may occur due to use of steroids, either taken by mouth or inhaled, as for asthma. Other causes of candida albicans overgrowth include use of broad-spectrum antibiotics, and/or immunosuppression. The resulting disease state in the upper aerodigestive tract may cause hoarseness or an outbreak of thrush.


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Candida laryngitis and pharyngitis

Infection with candida albicans, a ubiquitous commensal organism in the upper aerodigestive tract. While this organism normally causes no problem, under certain circumstances it can overgrow. These circumstances include (1) when other (competing) normal flora are killed through administration of antibiotics, (2) when surface immunity of the mucosa is decreased via inhalation of steroid medication, and (3) when the individual is immunosuppressed by disease or other drugs.

Typical symptoms of candida laryngitis and pharyngitis include slight sore throat and hoarseness. Treatment may consist of reducing or withdrawing listed potentiators, or using an antifungal agent such as fluconazole.


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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.

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. 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.


Photos of capillary ectasia:
















Videos:

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.


Carcinoma

Carcinoma is a malignancy originating in the tissues that line the surfaces and cavities of the body. See also: cancer, carcinoma in situ, and verrucous carcinoma.



Carcinoma in situ (CIS)

A lesion comprised of “cancer cells,” but with those cells limited to the lining mucosa and without evidence of extension to adjacent structures. In other words, there is no sign of invasion beyond the mucosa. Carcinoma in situ (CIS) is typically a localized and highly curable precursor to invasive cancer. CIS is sometimes called intraepithelial carcinoma.

In laryngology, CIS is found primarily on the vocal cords themselves, where a tiny, early lesion can change the quality of the voice. In other locations, CIS would ordinarily be “silent.”



Cartilaginous glottis

The posterior one-third of the vocal cord’s visible length and also, during breathing, the space between this segment of both cords. This posterior third of the cord, or cartilaginous glottis, is inhabited by the arytenoid cartilage and covered by a relatively thin layer of perichondrium and, on top of that, a layer of mucosa.

It is on the cartilaginous glottis that contact granulomas occur, on the cord’s medial surface. The other two-thirds of each vocal cord’s visible length is called the membranous glottis.


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Ceiling effect

Ceiling effect is a synonym for lowered vocal ceiling. This is a type of vocal phenomenology most often seen in the perimenopausal voice. It may also be seen in cases of superior laryngeal nerve paralysis, or cricothyroid joint ankylosis. The individual with this problem may note that he or she cannot access a part of the upper voice, be that a few notes or an octave or more. As the individual approaches the ceiling of the voice, whether normal or lowered, one begins to hear muscular effort, and often a tendency for the pitch to flat against the person’s will.




Cervical osteophyte

Also called bone spurs, osteophytes are usually seen at joints where inflammation or injury causes new bone cells and calcium to be deposited; in other words, new bone is formed. Osteophytes of the cervical spine occur with the passage of time and, when large, can project anteriorly into the swallowing passage. Only rarely do cervical osteophytes alone interfere with a person’s swallowing or voice capabilities.


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Chin tuck maneuver

A maneuver in which, just before swallowing, a person drops the chin to or toward the chest. This maneuver has the effect of narrowing the pharynx so that the propulsive forces of swallowing have a smaller passageway in which to work, which can help to counteract some individuals’ tendency toward hypopharyngeal pooling, laryngeal penetration, or even aspiration. The chin tuck maneuver can be “tested” for its efficacy during both the videoendoscopic swallowing study and videofluoroscopic swallowing study, in order to determine whether this maneuver should become a formal part of the patient’s swallowing strategy.



Choking

Choking is a term that, as used popularly, can describe at least a few distinct scenarios or disorders:

  1. Minor aspiration. A person swallows and food or liquid “goes down the wrong tube” (down the airway), which provokes aggressive coughing.
  2. Life-threatening aspiration. A person swallows food (a piece of meat, for instance) that enters the airway and plugs it, requiring a Heimlich maneuver.
  3. Sensory neuropathic cough. A person uses the term “choking” to describe a severe episode of coughing, but without any aspiration of liquid or food.
  4. Laryngospasm. A person uses the term “choking” to describe the sudden inability to breathe and the noisy inspiration of a laryngospasm attack.

When a patient uses the term “choke,” the clinician must ask a series of questions to verify whether the fundamental issue is dysphagia with aspiration, coughing unrelated to dysphagia or aspiration, or laryngospasm. View this article for more information.



Chondroma

A benign growth composed of cartilage cells.


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Cidofovir

Cidofovir, also known as Vistide™, is a newer anti-viral drug originally developed for a different indication and now appearing to have value in the treatment of laryngeal papillomatosis. It is increasingly used as an adjunctive, off-label treatment for human papillomavirus infection in the larynx – that is, recurrent respiratory papillomatosis (RRP) or laryngeal papillomatosis.



Classic variant spasmodic dysphonia

The typical variant of spasmodic dysphonia in which the spasms (and their effect on the voice) are intermittent rather than sustained. Classic variant spasmodic dysphonia is much more common and more easily diagnosed than tonic variant spasmodic dysphonia.

Classic variant spasmodic dysphonia is easier to diagnose because its intermittent spasms cause noticeable phonatory arrests: in the case of adductor spasmodic dysphonia, words or syllables are momentarily choked off; in the case of abductor spasmodic dysphonia, words or syllables momentarily drop out to a whisper.




Combined modality treatment

Combined modality treatment is used particularly in reference to cancer treatment, where there are two or more treatment options. For example, a patient may undergo combined modality treatment, where the tumor is first removed with the laser (primary treatment is surgery) and then the tumor bed and neck are irradiated. In this case, combined modality treatment would mean surgery + radiation therapy.



Commensal

Commensal refers to an organism that lives within a host and derives benefit from so doing without either harming or helping the host – in a sense, an organism that is a harmless freeloader. An example is candida albicans, which can cause candida laryngitis.



Complete voice rest

Complete voice rest is avoidance of any voice use at all. This measure (more extreme than relative voice rest) is rarely needed, but might be requested of a person for a few days after vocal cord microsurgery, immediately following a vocal cord hemorrhage, or when suffering from acute laryngitis.



Composite food

A food material that includes more than one consistency. The classic example is chicken noodle soup, because it contains a thin liquid (broth), a soft consistency (noodles), and a solid (chicken). With some individuals who have presbyphagia, for example, the broth component of chicken noodle soup might “get away” while the person is chewing the chicken and noodles, so that the broth spills over into the hypopharynx and even larynx, causing coughing or aspiration. Even a home-made ice cream can do this, as it melts quickly to a thin liquid while the mouth is still busy with the remaining semi-frozen component.



Conservation surgery

Conservation surgery is a strategy and philosophy of larynx cancer surgery that focuses not only on radicality with respect to removal of cancer, but also on being conservative concerning sparing of normal laryngeal structures, so as to preserve voice, swallowing, and breathing, and to avoid total laryngectomy and/or chemotherapy and radiation. Special training and experience are required especially for advanced conservation operations, both laser (through the mouth) and non-laser (through an incision on the neck).



Contact granuloma

A contact granuloma is a benign tissue reaction or growth, typically on the posterior third of the vocal cord, that occurs in response to injury. Contact granulomas are also known as contact ulcers, intubation granulomas, or “proud flesh.” This kind of chronically irritated tissue may be viewed as an exuberant healing response that “didn’t know when to quit.”

Sources of injury:

One type of injury that may lead to a contact granuloma is injury from an endotracheal tube, as the inserted tube presses and rubs against the posterior ends of the vocal cords. Another potential source of injury is chronic, aggressive coughing or throat-clearing. Yet another potential source is undergoing surgical procedures such as laser excision of a cancer. Some also believe that irritation from acid reflux can lead to a contact granuloma. In many cases, there is no obvious cause for the original injury.

The typical location of a contact granuloma:

Contact granulomas typically occur on the posterior third of the vocal cord, also known as the cartilaginous glottis. Unlike the other two-thirds of the vocal cord, this segment is inhabited by cartilage (namely, the arytenoid cartilage), and that cartilage is covered only by a relatively thin layer of perichondrium and a layer of mucosa. This thinly cushioned cartilage or perichondrium interface is particularly prone to being irritated and then responding with the exaggerated healing that produces a contact granuloma. Hence, most granulomas occur in this location.

Symptoms of a contact granuloma:

Some individuals with contact granulomas have no symptoms whatsoever and only discover they have a granuloma while being examined for some other reason. Others notice a sticking or pinprick sensation, or have some sense of vague discomfort in the area of the neck radiating upward towards the angle of the jaw. Occasionally, a person may develop a “catch” in the voice, such that it takes a second to begin speaking clearly. Very occasionally, when a bit of the granuloma detaches (see below), a person may cough up blood or a tiny piece of tissue. In general, symptoms are mild.

Treatment for a contact granuloma:

Some clinicians prefer to treat contact granulomas by removing them. However, the tiny injury or wound that results often produces a recurrent granuloma.

A better approach is simply to wait for the granuloma to detach of its own accord. This process of self-detachment, which may take several months, is like an apple maturing and then dropping from the tree: the granuloma continues to grow in size, and once it becomes big enough, the back-and-forth movement of air and the displacement caused by contact with the opposite arytenoid cartilage cause the granuloma to slowly pinch inward at its base and become more and more pedunculated; eventually, the connecting stalk can no longer support the granuloma, and the granuloma breaks free. For an example, see the photos below.

If, however, a person’s symptoms are too troublesome to wait for months, then the granuloma can be surgically removed, but while still leaving part of the stalk or base projecting from the surface, so as to avoid re-injuring the cartilage and perichondrium, which would provoke the formation of another granuloma.


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Videos:

Contact Granuloma
In this video, Dr. Bastian provides an introduction to contact granulomas.


Cough

An explosion of air from the lungs, sent up between suddenly opened vocal cords, in order to clear the airway of mucus or foreign particles, or in response to certain sensations in the airway, such as a tickle.



Creaky voice

Creaky voice is the quality of a voice that sounds like a door creaking on its hinges. Creaky voice is normally produced in the mid to upper part of the range, and not typically at high levels of loudness. It also tends to be a low glottal airflow condition of phonation. Contrast with the related phenomenon of vocal fry.




Cricopharyngeal dysfunction (CPD)

Failure of the tonically contracted upper esophageal sphincter to relax and open when one swallows. Cricopharyngeal dysfunction is also known as cricopharyngeal achalasia. The cause is usually unknown.

The upper esophageal sphincter is also known as the cricopharyngeus muscle and is located at the lower level of the voicebox or larynx. This muscle is always contracted except at the moment of swallowing, when it relaxes briefly to let food or liquid pass through.

Symptoms and treatment for cricopharyngeal dysfunction:

Typically, individuals with cricopharyngeal dysfunction first notice that pills or solid food begin to lodge at the level of the lower part of the larynx. The problem tends to progress inexorably, though often slowly, as the years pass, until the individual must limit himself or herself to liquid and soft foods. Cricopharyngeal dysfunction is fully resolved through a straightforward surgical procedure (cricopharyngeal myotomy), performed through the mouth with the laser or, only occasionally, through a neck incision. See also: Zenker’s diverticulum.


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Videos:

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Cricopharyngeal Dysfunction: Difficulty Swallowing, Especially Solid Foods
Dr. Bastian explains this progressive swallowing problem and presents options for treatment.
Cricopharyngeal Dysfunction: Before and After Cricopharyngeal Myotomy
This video shows x-rays of barium passing through the throat, first with a narrowed area caused by a non-relaxing upper esophageal sphincter (cricopharyngeus muscle), and then after laser division of this muscle. Preoperatively, food and pills were getting stuck at the level of the mid-neck, and the person was eating mostly soft foods. After the myotomy (division of the muscle), the patient could again swallow meat, pizza, pills, etc. without difficulty.


Cricopharyngeal myotomy (CPM)

A procedure in which the cricopharyngeus muscle, which makes a “ring” around the upper esophagus, is divided or cut across in order to break its grip. A cricopharyngeal myotomy is done in cases where this cricopharyngeus muscle (i.e., the upper esophageal sphincter) fails to relax when one swallows (cricopharyngeal dysfunction), resulting in a functional obstruction.

Cricopharyngeal dysfunction can be seen alone, or, as illustrated below, in combination with a Zenker’s diverticulum. Symptoms of cricopharyngeal dysfunction include dysphagia, with solids more so than with liquids. If a Zenker’s diverticulum is present, the patient may also experience late “regurgitation” of undigested food retained for hours or longer in the sac.


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Cricopharyngeal spasm

Cricopharyngeus Spasm and What to Do About It – Article by Dr. Bastian

Hyper-contraction of the cricopharyngeus muscle, which causes a constricted or lump-in-the-throat sensation. Cricopharyngeal spasm is a harmless disorder, but it can cause great anxiety for somebody who is experiencing it and has not received a clear diagnosis for the symptoms.

The physiology of cricopharyngeal spasm:

The cricopharyngeus muscle, or upper esophageal sphincter, is a ring of muscle that encircles the upper end of the esophagus. This muscle is constantly contracted, closing off the entrance to the esophagus, except when a person swallows, at which point the muscle relaxes momentarily to let the food or liquid pass through.

In a person with cricopharyngeal spasm, the problem is that the cricopharyngeus muscle is overly contracted when in its state of habitual contraction. This hyper-contraction or hyper-tonic state may be felt by the person. However, the muscle will still relax properly during swallowing, and thus does not impede swallowing.

Symptoms of cricopharyngeal spasm:

Individuals with cricopharyngeal spasm may describe a persistent sensation—usually felt precisely at the level of the cricoid cartilage—of something stuck in the throat, like a “wad of phlegm” or a “golf ball,” which the person cannot swallow or spit out. Or, similarly, they might say that they feel a sensation of choking or constriction in the throat. These kinds of symptoms may become worse as the day goes on, or in stressful situations.

However, a key indicator of cricopharyngeal spasm is that the person can still eat and drink without trouble, and that the troubling sensations described above actually tend to diminish or disappear when the person is eating. This happens because the cricopharyngeus muscle relaxes during swallowing (as it should), which temporarily relieves the hyper-contraction sensations. Very infrequent swallows of small amounts of saliva are not sufficient to be “therapy” for the hyper-contracted muscle, but swallowing one bite of food after another (as during a meal) is.

Treatment for cricopharyngeal spasm:

For many patients with cricopharyngeal spasm, receiving a clear diagnosis is the start of the resolution of the problem. Once they understand the nature of their problem, and that it does not pose any risk to them, they can “throw their worry over the shoulder.” In many cases, the symptoms subsequently go away within a few weeks.

If the problem persists and continues to trouble the patient, a clinician might provide a few doses of valium, not as treatment, but so that each dose can serve as a diagnostic test to further prove the diagnosis to the patient, that it is a muscle-contraction issue. Also, if need be, some clinicians may try therapy such as neck relaxation exercises under the care of a speech pathologist or physical therapist.


Photos of Cricopharyngeal spasm:




Videos:

Cricopharyngeal Spasm: A Troubling Feeling of a Lump in the Throat
Cricopharyngeal spasm is caused by over-contraction of the upper esophageal sphincter, or cricopharyngeus muscle, and causes an annoying, preoccupying, even anxiety-provoking sensation of something stuck in the throat, like a “wad of phlegm.” A common description is “There is something in my throat that I can’t swallow or spit out.”


Cricopharyngeus muscle

A sphincter muscle encircling the upper end of the esophagus. The cricopharyngeus muscle, also called the upper esophageal sphincter or UES, is almost always in a contracted state, even during sleep. Its action is like a continually clenched fist. This contraction closes off the entrance to the esophagus.

Whenever a person swallows, the cricopharyngeus muscle momentarily relaxes, opening its grip and allowing food or liquid to pass through and enter the esophagus.

The cricopharyngeus muscle is subject to one of two disorders. Cricopharyngeal dysfunction is the failure of the muscle to relax, which causes swallowing difficulty. Cricopharyngeal spasm is hyper-contraction of the muscle, which causes a sensation of a lump in the throat but without interfering with swallowing.


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Croup

Also known as laryngotracheitis or laryngotracheobronchitis, croup ((Meyer, Anna. “197. Pediatric Infectious Disease” Cummings Otolaryngology Head and Neck Surgery. Ed. Paul Flint. 6th ed. Vol. 3. Philadelphia, PA: Elsevier, 2015. 3045-3054.)) is a primarily pediatric viral disease affecting the larynx and trachea. Though it may resemble a simple cold at first, the infection causes a loud barking cough and stridor (unusual, high-pitched breathing noises indicating partial airway obstruction). The majority of croup cases are caused by parainfluenza viruses (types 1, 2, and 3) but a variety of other viruses can lead to croup symptoms.

The central problem for patients with croup is the swelling of the subglottic region of the larynx, which is the narrowest part of the airway in children. Croup varies in its severity and can last anywhere from three days to two weeks. Most patients do not require hospitalization, as home treatment or prescribed antibiotics or steroids are typically sufficient.


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Cryptococcus neoformans

Cryptococcus neoformans laryngitis is a rare fungal infection of the larynx. The infection usually occurs as a primary pulmonary infection but can spread to other regions of the body. Common characteristics of cryptococcus neoformans include longstanding hoarseness, sore throat, or edema of the vocal cords. Cryptococcus neoformans laryngitis is treated with oral anti-fungal medications such as fluconazole.


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Cymetra™

Cymetra™ is a human collagen product. The collagen is micronized (ground into tiny particles, and treated to remove any possibility of contamination with bacteria or viruses). It is then made into a dry powder. Before use, it is reconstituted to create a paste consistency that can be injected through a relatively fine needle. Commonest use is to fatten and firm up a paralyzed vocal cord . Duration of benefit varies between six weeks and six months. Consequently, this procedure is used when only temporary assistance is needed – as when it is believed that the vocal cord’s function will recover.



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