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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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Cancer

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


Photos of cancer:

Vocal cord cancer, before and after surgery

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Squamous cell carcinoma

Vocal cord cancer (1 of 4)

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

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

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

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

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

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

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

Glottic Cancer, Laser Removal

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Glottic cancer, laser removal (1 of 3)

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

Glottic cancer, laser removal (2 of 3)

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

Glottic cancer, laser removal (3 of 3)

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









 




















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.


Photos:

Candida laryngitis, before and after treatment

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laryngeal candidiasis

Candida laryngitis (1 of 4)

Severe laryngeal candidiasis, in a person using inhaled steroids at high dose. Standard light.
surrounding inflammation on vocal cords

Candida laryngitis (2 of 4)

Closer view shows more clearly not only the white areas, but also surrounding inflammation. Standard light.
Candida laryngitis, 15 days after starting treatment

Candida laryngitis, 15 days after starting treatment (3 of 4)

After 15 days of oral fluconazole. Obvious improvement, but incomplete resolution of tissue changes.
Candida laryngitis, several months later

Candida laryngitis, several months later (4 of 4)

After longer-term fluconazole, along with reduction of inhaled steroid dose, complete resolution. Strobe light, closed phase of vibration at high vocal pitch.

Candida laryngitis, before and after treatment: Series of 4 photos

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lesions are vague, hazy, and best seen anteriorly on the right cord

Candida laryngitis (1 of 4)

Candidiasis in patient using inhaled steroids for asthma. Under standard light, the lesions are vague, hazy, and best seen anteriorly on the right cord (left of image).
vascularity

Candida laryngitis (2 of 4)

Same patient, narrow-band illumination. This not only emphasizes vascularity, but brings out the candida colonies.
Candida laryngitis after treatment

Candida laryngitis, after treatment (3 of 4)

After treatment with fluconazole, the colonies have virtually disappeared.
post-treatment examination

Candida laryngitis, after treatment (4 of 4)

Same post-treatment examination, under narrow-band illumination. Note that there are normal specks of mucus (such as at the arrows) in the view.

Candida pharyngitis: Series of 2 photos

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Countless candida colonies in the hypopharynx

Candida pharyngitis (1 of 2)

Countless candida colonies in the hypopharynx (lower throat) of a patient who, for treatment of an auto-immune disorder, is not only inhaling steroids but also taking high-dose steroids orally. Each tiny white dot represents a colony of the fungus.
dramatic case of candidiasis

Candida pharyngitis (2 of 2)

An even more dramatic case of candidiasis, in a different patient. Here, the colonies are more obvious and nearly confluent.

Candida laryngitis, before and after treatment: Series of 3 photos

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whitish discoloration on the left vocal cord

Candida laryngitis (1 of 3)

Elderly woman with a history of laryngeal amyloidosis requiring laser sculpting several years earlier. Now using high-dose inhaled steroids, antibiotics, and oral steroids for unrelated pulmonary problem. Marked increase of hoarseness, and whitish discoloration, especially of the left vocal cord (right of image).
hazy white areas and irregular right cord margin

Candida laryngitis (2 of 3)

Closer view of hazy white areas and irregular right cord margin (left of image), presumed to be candida overgrowth. Empiric treatment with fluconazole is justified, given history and findings.
white areas are completely resolved

Candida laryngitis, after starting treatment (3 of 3)

Two weeks after starting fluconazole; the white areas are completely resolved. The patient’s voice had improved markedly within three or four days of starting the treatment.

Candida masquerader!

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white lesions were seen in the larynx

White lesions (1 of 3)

This man uses a steroid inhaler for his asthma. During esophagoscopy, white lesions were seen in the larynx and his GI Doctor sent him for evaluation of probable candida overgrowth. In all routine views, such as this one, white lesions are seen.

Candida colonies (2 of 3)

Candida colonies are routinely surrounded by a zone of erythema (see other photo series). No redness is seen here.
pattern of white lesions has changed after aggressive throat clearing

After throat clearing (3 of 3)

After aggressive throat clearing, the pattern of white lesions has changed, and this is of course another indication that we are not dealing with candida colonies here, but simple adherent mucus.

Hazy candida under 2 kinds of light

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haziness (Candida) and redness

Haziness and redness (1 of 3)

This patient uses inhaled steroids and takes oral steroids as well. She has had prior episodes of documented Candida infection in prior years and has developed new laryngitis. Under standard light, both haziness (Candida) and redness (inflammatory response) are seen.
leukoplakia

Leukoplakia (2 of 3)

Narrow band light shows the leukoplakia much more clearly. Candida on the vocal cords is often hazy and diffuse, presumably because the shearing effects of vibration do not allow the discrete, demarcated colonies often seen in other locations.
swelling of the left vocal cord

Swelling (3 of 3)

This individual is also highly talkative, and also has a swelling of the left vocal cord (right of photo) from vibratory injury. The inflammation present here may have facilitated this injury.


Candida Laryngitis and Pharyngitis

Infection with candida albicans, an ubiquitous commensal organism in the upper aerodigestive tract, usually on the vocal cord mucosa. 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 (e.g. asthma).

(3) When the individual is immunosuppressed by disease (e.g. diabetes) 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.


Photos:












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.
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.


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.


Photos:




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.


Photos:





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.


Photos:

Chondroma of thyroid cartilage: Series of 4 photos

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CT scan of the larynx, showing the thyroid cartilage

Chondroma of thyroid cartilage (1 of 4)

CT scan of the larynx, showing the thyroid cartilage (outlined by gray dotted lines) and an abnormality deforming the thyroid cartilage on one side (between the white arrows). Note how the thyroid cartilage bulges on that side, as compared with the opposite side, and the black speck which indicates varying densities in the cartilage.
Chondroma of thyroid cartilage

Chondroma of thyroid cartilage (2 of 4)

Same patient, endoscopic view of the larynx, again showing the abnormality (at arrows). Here the abnormality looks similar to a saccular cyst, but the scan (and subsequent biopsy) shows that it is cartilaginous and a chondroma, not chondrosarcoma.
Closer view of the chondroma

Chondroma of thyroid cartilage (3 of 4)

Closer view of the chondroma, showing an almost bi-lobed appearance.
Chondroma of thyroid cartilage

Chondroma of thyroid cartilage (4 of 4)

Under strobe lighting, which shows that the left vocal cord (right of photo) is apparently at a lower level than the opposite cord.


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.

Candida laryngitis, before and after treatment

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laryngeal candidiasis

Candida laryngitis (1 of 4)

Severe laryngeal candidiasis, in a person using inhaled steroids at high dose. Standard light.
surrounding inflammation on vocal cords

Candida laryngitis (2 of 4)

Closer view shows more clearly not only the white areas, but also surrounding inflammation. Standard light.
Candida laryngitis, 15 days after starting treatment

Candida laryngitis, 15 days after starting treatment (3 of 4)

After 15 days of oral fluconazole. Obvious improvement, but incomplete resolution of tissue changes.
Candida laryngitis, several months later

Candida laryngitis, several months later (4 of 4)

After longer-term fluconazole, along with reduction of inhaled steroid dose, complete resolution. Strobe light, closed phase of vibration at high vocal pitch.

 



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.


Photos:

“Tattoo” of blood after detachment of intubation granuloma

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intubation granuloma on vocal cords

Intubation granuloma (1 of 5)

This woman was intubated for 5 days due to severe illness. Afterwards, she had no voice for several weeks. It has recovered nearly fully, but she was told elsewhere that there was a “growth” that needed to be removed.
granuloma becoming pedunculate

Intubation granuloma (2 of 5)

In this closer view with forced inspiration, one can see that this is a granuloma, with point of attachment at arrows becoming pedunculated. Since granulomas typically mature, pedunculate (become attached by a progressively thinner stalk), and fall off on their own, she was advised to return in 4 months, at which point it would likely be gone.
granuloma has detached

Granuloma is gone (3 of 5)

4 months later: In this distant view, it appears that the granuloma has indeed detached. (Typically patients do not know when this happened; rarely, they cough out a pink piece of tissue and a bit of blood at the time of detachement.)
Blood tattoo left from granduloma

Blood tattoo (4 of 5)

In this mid-range view, a “blood tattoo” is seen where the pedicle detached from the granuloma (arrow). This “blood spot” often persists for months or years.
Blood tattoo on vocal cord

Blood Tattoo (5 of 5)

A closer view of the “blood tattoo.”

Contact granuloma

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right fold fitting into the groove between the two lobes of the contact granuloma

Contact granuloma (2 of 2)

Same patient, as vocal folds begin to come together for phonation, showing right fold fitting into the groove between the two lobes of the granuloma (Lab).
residual haziness

Contact granuloma (1 of 2)

Same patient, after treatment with antifungal agent. Note residual haziness (Lab).













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.


Photos:








Videos:

Cricopharyngeal Dysfunction: Difficulty Swallowing, Especially Solid Foods
Dr. Bastian explains this progressive swallowing problem and presents options for treatment. Cricopharyngeal dysfunction is caused by failure of relaxation of the upper esophageal sphincter—cricopharyngeus muscle—during eating. Typically it is solid foods that tend to lodge in the mid-neck area where this muscle is located.

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.
https://youtu.be/_dBPKBg8jXM
Swallowing Trouble 101
This video gives an overview of how swallowing works, how it can sometimes go wrong (presbyphagia or cricopharyngeal dysfunction), and possible ways to treat those problems (swallowing therapy or cricopharyngeal myotomy).


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.


Photos:

Cricopharyngeal myotomy: Series of 7 photos

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small dark opening in the center is the entrance to the Zenker’s diverticulum

Cricopharyngeal myotomy (1 of 7)

Upon initial approach to the upper esophagus. The small dark opening in the center is the entrance to the Zenker’s diverticulum or pouch. The point of entry to the esophagus is at the dotted line. The cricopharyngeus muscle lies between the entrances to the Zenker’s pouch and the esophagus.
Zenker’s pouch is opened further

Cricopharyngeal myotomy (2 of 7)

When the scope is inserted and lifted additionally, the Zenker’s pouch is opened further, and retained food material is seen within. The cricopharyngeus muscle’s contour is seen more clearly (faint dotted line), and the actual opening of the esophagus can be seen at the arrow.
suction cannula is now inserted into the esophageal opening

Cricopharyngeal myotomy (3 of 7)

Similar view to photo 2, except that the suction cannula is now inserted into the esophageal opening, further accentuating the contour of the cricopharyngeus muscle.
suction cannula is placed within the esophagus

Cricopharyngeal myotomy (4 of 7)

The food material has been removed from the Zenker’s pouch, and the suction cannula is placed within the esophagus.
Division of the cricopharyngeus muscle is underway

Cricopharyngeal myotomy (5 of 7)

Division of the cricopharyngeus muscle is underway, using the CO2 laser. The red aiming beam is visible at the lower end of the incision.
muscle is now approximately half-divided

Cricopharyngeal myotomy (6 of 7)

The muscle is now approximately half-divided, along with mucosa lining the anterior wall of the sac (arrow).
muscle is entirely divided, and the sac marsupialized

Cricopharyngeal myotomy (7 of 7)

The muscle is entirely divided, and the sac marsupialized. The suction cannula (blurry here, but marked by a faint dotted line) now lies within the trough created by the laser. The esophagus is now gaping open; compare with photos 1 through 4 of this series.

Cricopharyngeal dysfunction, before and after myotomy: Series of 2 photos

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Lateral x-ray of the neck while swallowing barium

Cricopharyngeal dysfunction: before myotomy (1 of 2)

Lateral x-ray of the neck while swallowing barium (seen as a dark column). The non-relaxing cricopharyngeus muscle (light-grey bulge outlined by a dotted line) is causing narrowing of the upper esophageal passageway, as highlighted by the narrowed stream of dark barium at that point (arrow). Liquids and very soft foods can squeak through this narrow opening, but solid foods tend to get stuck.
X-ray after myotomy

Cricopharyngeal dysfunction: after myotomy, resolved (2 of 2)

After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

Cricopharyngeal dysfunction, before and after myotomy: Series of 2 photos

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VFSS of the neck while swallowing barium

Cricopharyngeal dysfunction: before myotomy (1 of 2)

Lateral x-ray of the neck while swallowing barium (the dark material seen here in the throat). The non-relaxing cricopharyngeus muscle (light-grey bulge outlined by a dotted line) is causing narrowing of the upper esophageal passageway, as highlighted by the narrowed stream of dark barium at that point (arrow). Liquids and very soft foods can squeak through this narrow opening, but solid foods tend to get stuck.
urgically divided muscle can no longer narrow the upper esophageal passageway

Cricopharyngeal dysfunction: after myotomy, resolved (1 of 2)

After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

Cricopharyngeal dysfunction, before and after myotomy: Series of 2 photos

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X-ray of cricopharyngeus muscle which narrows the swallowed barium stream

Cricopharyngeal dysfunction: before myotomy (1 of 2)

Elderly patient with nearly a year’s duration of frequent lodgment of solid food at the level of the cricoid cartilage (at the mid-neck level). Note here the cricopharyngeus muscle “bar” which narrows the barium stream (indicated by green dotted line). This narrowing is due to incomplete relaxation of the muscle (aka upper esophageal sphincter) causing a smaller entrance to the esophagus. Liquids and very soft foods can still get through, but solid foods tend to get stuck or to require repeated swallows.
x-ray of a month after endoscopic cricopharyngeus myotomy

Cricopharyngeal dysfunction: after myotomy (2 of 2)

A month after endoscopic (through the mouth) cricopharyngeus myotomy (division of the muscle with a laser). The patient’s initial swallowing symptoms are completely resolved and the barium stream no longer shows narrowing and the cricopharyngeus bar is no longer seen (see green arrows).

Cricopharyngeus myotomy for recreational eating and management of saliva: Series of 4 photos

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patient has just completed a swallow of her own saliva

Immediately after swallowing (1 of 10)

This 98 year-old woman experiences dysphagia that is most noticeable for solids. She is also aware of constant “phlegm” in her throat. In this photo, she has just completed a swallow of her own saliva. See what happens a moment later in the next photo.
hypopharynx

Trumpet maneuver (2 of 4)

Trumpet maneuver opens the hypopharynx including at the level of the divided cricopharyngeus muscle. The curved line and 'X' are to orient this photo in comparison with the next (photo 3).
myotomized and therefore non-functional cricopharyngeus muscle

Closer view (3 of 4)

Closer view of myotomized and therefore non-functional cricopharyngeus muscle, again during trumpet maneuver. Gravity alone could take secretions and small amounts of food down into the esophagus (arrow).
laryngeal vestibule

Well-managed saliva (4 of 4)

After 6 boluses of blue-stained applesauce, intentionally given in rapid-pressured fashion to test limits, laryngeal vestibule remains very clean, and pooling does not tend to be deep enough to easily spill over into the laryngeal vestibule. Still g-tube dependent, this man enjoys some food, and manages saliva better than before myotomy.

98 year-old before and after myotomy: Series of 10 photos

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Immediately after swallowing (1 of 10)

This 98 year-old woman experiences dysphagia that is most noticeable for solids. She is also aware of constant “phlegm” in her throat. In this photo, she has just completed a swallow of her own saliva. See what happens a moment later in the next photo.

Zenker's (2 of 10)

A second later, saliva emerges from below, as her known Zenker’s diverticulum discharges some of its contents upwards into the hypopharynx rather than downwards into the esophagus.

Dysphagia (3 of 10)

During VESS, part 2, she has just completed a swallow of blue-stained applesauce without leaving any immediate post-swallow residue.

Residue from Zenker's (4 of 10)

A second later, the applesauce and saliva retained in her Zenker’s diverticulum is pushed upwards from below.

X-ray showing Zenker's (5 of 10)

An x-ray image showing the Zenker’s diverticulum immediately following her swallow.

Moments later (6 of 10)

A moment later, some swallowed barium has discharged upwards into the hypopharynx.

After myotomy (7 of 10)

A week after endoscopic cricopharyngeus myotomy. The patient says her swallowing has become normal. This view verifies her observation. Here, she has just completed a swallow and after waiting considerable time, no saliva reappears. Compare with photo 2.

No residue (8 of 10)

After not only blue-stained applesauce, but also a cheese cracker, there is no return of material and only a fleck of cracker in the left pyriform sinus (arrow). Compare with photo 4.

Zenker's gone (9 of 10)

After myotomy, note that the Zenker’s sac only puddles at its apex, because the rest of the sac has been marsupialized into the esophagus. Patients with this finding have no swallowing symptoms. Compare with photo 5.

No barium in hypopharynx (10 of 10)

While watching throughout the study, no barium ever emerges upwards into the hypopharynx, in constrast to pre-operatively. Compare with photo 6.

Great view of fresh cricopharyngeus myotomy surgical wound: Series of 4 photos

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small and organized residue in the post-arytenoid

CPM dysfunction (1 of 4)

After administration of blue-stained applesauce during VESS, small and organized residue in the post-arytenoid area suggests possible cricopharyngeus muscle dysfunction. At this time, the patient noted only occasional pill lodgement.
FSS shows narrowing of the barium stream

VFSS six years later (2 of 4)

Six years later, the patient returned saying that swallowing had gradually become extremely difficult. Swallowing pills and eating food were nearly impossible. A VFSS shows narrowing of the barium stream at the arrow, due to a cricopharyngeus bar or “thumb” at *.
post-arytenoid area

Five days post-op (3 of 4)

Five days after endoscopic laser cricopharyngeus myotomy, the patient says that while surgical pain is still significant, she can already swallow pills and solid food easily, a dramatic change from 5 days earlier. The area of surgery is not seen in this resting view. The * is for orientation with the following photo.
cervical esophagus

Cervical esopagus (4 of 4)

The patient is puffing her cheeks and this is enough to open the cervical esophagus (E). This allows visualization of the raw surface where the muscle was divided with the laser. It is stained by recently administered blue applesauce. The * is for orientation with the prior photo.

Bolus stream before and after cricopharyngeus myotomy: Series of 2 photos

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x-ray of broad bolus stream at the level of the hypopharynx becomes a thin pencil line in the cervical esophagus

Pre-myotomy (1 of 2)

...
bolus width is the same

Post-myotomy (2 of 2)

...

VESS (videoendoscopic swallow study) findings after radiotherapy: Series of 7 photos

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narrowing of the pharyngeal wall from radiation scarring

Narrowed pharyngeal wall (1 of 7)

After radiation and chemotherapy for larynx cancer several years earlier. Note the dry secretions. There is narrowing of the pharyngeal wall (dotted line) due to radiation scarring.
post-swallow residue

Swallowing applesauce (2 of 7)

After the second bolus of blue-stained applesauce. The propulsive ability ("pitcher of swallowing") is inadequate, leaving a lot of post-swallow residue.
cleaned esophagus with bits of blue applesauce

After sipping water (3 of 7)

After three sips of blue-stained water, much of the applesauce has been washed away.
swallowing crescent

Gravity aiding in swallowing (4 of 7)

Additional water washes nearly all of the residue in the "swallowing crescent" away--mostly by gravity as seen in the next photo.
wallowing crescent opens down to the cricopharyngeus muscle

Lifting larynx (5 of 7)

Each swallow looks like this. The pharynx "bird swallow" mechanism lifts larynx forward so that the swallowing crescent opens down to the cricopharyngeus muscle, indicated by double dotted lines. (PC = post-cricoid.)
cricopharyngeus muscle bulge

A closer look (6 of 7)

At closer range, the cricopharyngeus muscle bulge is seen more clearly, along with the small opening into the esophagus.
Blue-stained water flowing into the esophagus

Gravity aiding again in swallowing (7 of 7)

Blue-stained water flowing into the esophagus mostly by gravity.

The evolution of a cricopharyngeus myotomy wound: Series of 8 photos

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saliva is noted in the swallowing crescent

Difficulty swallowing solid foods (1 of 8)

This ~80 year old man is having considerable trouble swallowing, particularly for solid foods. In this panoramic view at the start of VESS, saliva is noted in the swallowing crescent (outlined) and clinging to the posterior pharyngeal wall (arrows).
saliva within the laryngeal vestibule

Pooled saliva (2 of 8)

At closer range, the pooled saliva in the swallowing crescent is more clearly seen, as is some saliva within the laryngeal vestibule (arrows). Organized pooling of saliva or food / liquid can indicate cricopharyngeus dysfunction (non-relaxation).
lit of opening into the esophagus

Muscle bulge (3 of 8)

The patient has swallowed some water to clear away the saliva, and the pre-myotomy cricopharyngeus muscle bulge (between dotted lines) is seen with only a slit of opening into the esophagus at the arrow.
swallowing crescent remains full of residue

Residue in swallow crescent (4 of 8)

After many boluses of blue-stained applesauce, the swallowing crescent remains full of residue, but laryngeal vestibule is not soiled. Both propulsive and receptive functions of swallowing are impaired but a significant part is outlet obstruction caused by incomplete cricopharyngeus muscle relaxation.
less salivary pooling in swallowing crescent

Three weeks later (5 of 8)

About 3 weeks after cricopharyngeus myotomy, note that the salivary pooling in the swallowing "crescent" is less than pre-operation.
residual "wound" from the myotomy is stained blue

Residual "wound" (6 of 8)

After administering blue-stained applesauce and water, the residual "wound" from the myotomy is stained blue. After myotomy, the cut ends of the muscle retracts laterally as suggested by the curved lines. Compare with the muscle bulge in Photo 3.
deep "notch" in the cricopharyngeus muscle bulge

Three months post-op (7 of 8)

Nearly 3 months after myotomy, both the patient and his wife say swallowing is much improved. Note the deep "notch" in the muscle bulge as compared with photo 3.
cricopharyngeus muscle

At close range (8 of 8)

At very close range with some clockwise rotation of the view. The muscle can no longer impede passage of food or liquid into the esophagus.

Zenker’s diverticulum a week after cricopharyngeus myotomy: Series of 3 photos

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Zenker's diverticulum

Zenker's Sac (1 of 3)

Shown in operating position, E = esophageal opening; PPW = posterior pharyngeal wall at the level of hypopharynx; S= residual Zenker's sac, now marsupialized into the esophagus; CPM = lateral bulges of completely divided cricopharyngeus muscle. The actual wound (W) is stained by the blue applesauce this elderly patient just swallowed.
mucosal "septum" between sac and esophagus

Zenker's Sac (2 of 3)

Not only the muscle, but also the elongated mucosal "septum" between sac and esophagus must be divided on both esophageal (anterior) and sac (posterior) surfaces. This view is mostly on the esophageal side. Note the large caliber of the esophageal opening, explaining dramatic resolution of this 90-something year-old woman's difficulty swallowing.
enlarged esophageal opening

Zenker's Sac (3 of 3)

Looking here more directly into the esophagus, one can see that the enlarged esophageal opening as compared with pre-myotomy explains why swallowing pills and solid food is already no longer a problem for this person.

 

Videos:

https://youtu.be/_dBPKBg8jXM
Swallowing Trouble 101
This video gives an overview of how swallowing works, how it can sometimes go wrong (presbyphagia or cricopharyngeal dysfunction), and possible ways to treat those problems (swallowing therapy or cricopharyngeal myotomy).


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:

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tracheal stenosis

Tracheal stenosis? (1 of 4)

During a grave illness, this woman eventually underwent tracheotomy. Though she wore the tube for several months, it was removed 3 years ago. Only six months prior to this examination, due to a feeling of choking, she underwent a CT scan that revealed tracheal stenosis. The patient does have mildly noisy breathing but has no sense of exercise intolerance.
Inside the trachea

No significant change in breathing (4 of 4)

Now with the scope through the area of greatest narrowing, the patient doesn’t experience any significant change in her breathing. Her symptoms are those of cricopharyngeus spasm, not tracheal stenosis.
Closer view of trachea

Closer view (3 of 4)

A closer view shows normal trachea beyond.
Narrowing at trachea

Narrowing at trachea (2 of 4)

Viewing from just below the vocal cords, there is narrowing and deformity of the trachea at the site of prior tracheotomy.

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.


Photos:





Croup

Also known as laryngotracheitis or laryngotracheobronchitis, croup1 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.


Photos:



  1. 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. 



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.


Photos of cryptococcus neoformans:

Cryptococcus infection of the larynx: Series of 4 photos

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laryngeal vestibule

Panoramic view (1 of 4)

Panoramic view of laryngeal vestibule in a man with very longstanding hoarseness and sore throat. Note intense redness and bumpy mucosal surface. Biopsy revealed Cryptococcus neoformans.
rough surfaced vocal cords

Closer view (2 of 4)

Closer view of the vocal cords shows similar intense inflammation and rough surface.
smooth mucosal surface

One year later (3 of 4)

After a one-year course of fluconazole, an oral anti-fungal medication. Symptoms are gone. The larynx is no longer inflamed, and the mucosal surface is smooth. White area of scarring (dotted surround), and scar band (parallel dotted lines).
healthy vocal cords

One year later, close-up (4 of 4)

Close-up of the vocal cords shows similar resolution of redness and cobblestoned surface.


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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