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
Glottic Cancer, Laser Removal
Glottic cancer, after surgery (1 of 3)
After superficial cordectomy, right cord, for early vocal cord cancer, standard light. Note capillary reorientation from normal mostly anteroposterior direction to medial-lateral.
Glottic cancer, after surgery (2 of 3)
Strobe light. Notice excellent matching of the cords at closed phase of vibration, correlating with the patient’s excellent voice quality.
Glottic cancer, after surgery (3 of 3)
Strobe light, open phase of vibration. This view reveals that the left cord oscillates, but the right doesn’t. As long as match is good, and there is no vibratory abnormality of the left cord (e.g. flaccidity, or mucosal abnormality), then voice can be essentially normal.
Vocal cord cancer (1 of 8)
Patient from elsewhere, first seen 9 months after radiotherapy, with obvious persistent right vocal cord cancer.
Vocal cord cancer (2 of 8)
Closer view, during phonation, showing deep ulceration and rolled upper and lower border of cancer.
Vocal cord cancer, 1 week after surgery (3 of 8)
One week after aggressive cordectomy, right, including down to inner perichondrium of thyroid cartilage.
Vocal cord cancer, 1 week after surgery (4 of 8)
Phonation, showing that the left vocal cord now has no “partner” against which to vibrate, and this explains the marked breathiness.
Vocal cord cancer, 7 weeks after surgery (5 of 8)
Nearly complete healing after complete cordectomy right vocal cord. Only residual granulation.
Vocal cord cancer, 7 weeks after surgery (6 of 8)
Closer view of defect. Thin mucosa covers inner surface of thyroid cartilage, and residual exposed cartilage, not yet healed over with mucosa, at arrow.
Vocal cord cancer, 7 weeks after surgery (7 of 8)
At maximum phonatory adduction. Note that the left vocal process is turned medially (arrow), signifying maximum adductory “effort” of that side. There is no right vocal cord, and hence there is no possibility of glottic voice.
Post radiotherapy stage (1 of 8)
This woman had completed radiotherapy elsewhere many months ago for early vocal cord cancer. Recent biopsy of these lesions shows persistent cancer. At the same time, she is under treatment for unrelated stage IV lung cancer. Standard treatment here would be total laryngectomy.
Laser surgery typically not acceptable (2 of 8)
Under narrow band light and at closer range. Not only due to failure of radiation to cure, but also because this tumor crosses the anterior commissure (where the two vocal cords meet at the bottom of the photo), the widely accepted "rule" is that she should undergo total laryngectomy. The blue lines are located in the same place in the following photo.
Laser removal of tumor with careful followup (3 of 8)
In light of the patient’s uncertain future due to advanced lung cancer, her near-refusal of total laryngectomy, and with detailed inclusion of patient in “breaking the rules” thinking, the tumor was removed with the laser. Tissue margins were negative. Still, tumor behavior is not as predictable as it would be in a previously-untreated patient. Careful followup is therefore critical. Hashmarks show area of removal, to include everything even faintly abnormal-looking and the blue lines are located in the same place in the previous photo.
Second view post laser surgery (4 of 8)
Better view of the anterior commissure, where soft tissue was removed all the way to the inner perichondrium of the thyroid cartilage at the arrow.
Six months post laser surgery (5 of 8)
Nearly 6 months after laser surgery. Healing is complete. No obvious tumor is seen. The patient has developed very serviceable false cord voice (see photos 7 and 8).
Blood vessels stable two months post surgery (6 of 8)
Narrow band light allows more intense monitoring for aberrant blood vessels that might indicate tumor regrowth before there is any visible bulk. Vessels in the area of arrows have been stable for 2 months but require careful comparison with future examination photos.
Open phase of false vocal cord phonation (7 of 8)
False cord phonation, open phase. The true cords cannot oscillate at all due to dense scarring.
Glottic/vocal cord cancer (1 of 2)
Left vocal cord cancer, abducted breathing position, standard light.
Supraglottic cancer (1 of 4)
Middle-aged woman with sore throat, discovered to have a circumscribed exophytic squamous cell carcinoma at the petiole and anterior false cords.
Supraglottic cancer (2 of 4)
Closer view, showing the aberrant tumor vessels especially in the inferior half of the tumor, with less “white-out” from light overexposure.
Supraglottic cancer (3 of 4)
As is often the case, this tumor “respects” the ventricle, meaning it does not cross the plane of the ventricle (entrance at dotted line) to invade the true cords. An instrument could lift the inferior border of the tumor to show that the true cords aren’t invaded; the tumor is simply overlapping them.
Supraglottic cancer (4 of 4)
Under narrow-band lighting, the tumor’s aberrant vessels and its relationship to both the true and false cords are clearer. This is a supraglottic (not transglottic) tumor, likely amenable to outpatient endoscopic laser resection, and management of lymphatic compartments of the neck, depending on individual circumstances, via observation, radiotherapy, or selective neck dissection.
Hypopharyngeal cancer (1 of 10)
Years after successful radiotherapy for glottic cancer, during a routine, yearly follow-up examination, a new hypopharyngeal cancer (invasive squamous cell carcinoma) is barely seen, at arrow. (For reference, X marks the same location in the larynx throughout this series.)
Hypopharyngeal cancer (2 of 10)
Trumpet maneuver begins, to splay open the post-arytenoid part of the posterior pharyngeal wall (arrows and dotted lines), as well as the pyriform sinuses on each side. The tumor is now seen clearly. (Note the change of perspective from photo 1, using X as a reference point.)
Hypopharyngeal cancer (3 of 10)
Similar view to photo 2 (still with the trumpet maneuver), but now with the tumor outlined.
Hypopharyngeal cancer (4 of 10)
Closer view than photos 2 and 3 (again, still with the trumpet maneuver), with the tumor still outlined. Radiation is not an option for this tumor because of prior larynx irradiation; an attempt at laser surgery was selected.
Hypopharyngeal cancer: 1 week after surgery (5 of 10)
One week after laser excision of the tumor. Note the widespread redness, and the swollen arytenoid mounds, especially on the right side of the image. Compare with photo 1.
Hypopharyngeal cancer: 1 week after surgery (6 of 10)
Panoramic view, with the patient beginning the trumpet maneuver. The surgical wound is coming into view. Compare with photo 2 (again, using X as a reference point).
Hypopharyngeal cancer: 1 week after surgery (7 of 10)
Maximum trumpet maneuver. Closer view of the surgical wound. Compare with photo 4.
Hypopharyngeal cancer: 1 week after surgery (8 of 10)
View into the left pyriform sinus, where the tumor was most bulky.
Hypopharyngeal cancer: several months after surgery (9 of 10)
Months after laser resection, panoramic view, showing the swallowing “crescent” (within dotted lines), at the upper limit of where the laser resection occurred. There is surgical stenosis at the entrance to the esophagus (shown in the next photo). This stenosis affects swallowing of solid food, but the patient says this is no problem for him, if he eats a little more slowly and chews well.
Verrucous carcinoma (1 of 5)
Verrucous carcinoma, left vocal cord, persistent after radiotherapy elsewhere, in a patient unable to undergo general anesthesia due to severe lung disease.
Verrucous carcinoma, after laser treatment (3 of 5)
After several Thulium Laser ablations, using topical and injected local anesthesia, with patient sitting in examination chair, thereby avoiding general anesthesia.
Verrucous carcinoma, several weeks after laser treatment (4 of 5)
Approximately six weeks later, durable resolution of tumor. Yellow material is mucus.
Cancer: HPV Subtype 16 (1 of 5)
Cancer, in a patient with HPV subtype 16. The divot and blood seen on the left vocal cord (right of image) are the result of a biopsy performed elsewhere (not by BVI physician) earlier the same day as this examination.
Cancer: HPV Subtype 16, after radiation therapy (3 of 5)
Six weeks after the end of radiation therapy, the tumor is no longer seen. However, part of the left cord (right of image) is missing, due to sloughing of the tumor that had eaten away part of the cord’s normal tissue.
Cancer: HPV Subtype 16, after radiation therapy (4 of 5)
Phonation. Strobe light, open phase of vibration, shows that the margin of the left cord (right of image) is at a lower level than the right’s, due to loss of some of the bulk of the cord where the tumor died and sloughed away.
Vocal cord cancer (1 of 7)
A 66-year-old man who complains of hoarseness. He smoked a pack a day for 50 years but quit five years ago. Note here the fullness and irregular contour especially of the left vocal cord (right of photo). A biopsy confirmed this was cancer.
Vocal cord cancer (2 of 7)
At closer range, scattered leukoplakia and stippled vascular markings (suggestive of HPV effect, but HPV tested negative).
Vocal cord cancer, 3 weeks after radiotherapy (4 of 7)
Same patient, three weeks after the end of full-course radiotherapy. Distant view shows radiation-induced mucositis on the false and true cords, seen as areas of white, superficial ulceration. General redness is also a radiation effect.
Vocal cord cancer, 3 weeks after radiotherapy (5 of 7)
Closer view, showing that the main tumor of the left vocal cord (again, right of photo) has melted away. Note that the mucositis is generalized, and not necessarily focal to the area of tumor sloughing.
Vocal cord cancer, 2 months after radiotherapy (6 of 7)
Same patient, now two months after the end of radiotherapy. All of the visible tumor is gone, and voice is very good. Small anterior web. Compare with photo 1 of this series.
Vocal cord cancer (1 of 8)
Superficial cancer involving both vocal cords. This is stage 1 disease (T1B). The greatest bulk is on the right posterior cord (left of image), but the majority of both cords is involved with at least superficial disease. A faint dotted rectangle indicates the zoomed-in area seen in photo 2.
Vocal cord cancer (2 of 8)
Close-up view of only the anterior half of the cords. Notice the irregular surface, and areas of leukoplakia within this squamous cell carcinoma.
Vocal cord cancer, during radiation (3 of 8)
Just over midway through radiation treatment. One can see that the tumor is melting away.
Vocal cord cancer, during radiation (4 of 8)
Postcricoid / hypopharyngeal mucositis. In this view, the patient is performing a so-called trumpet maneuver to splay open the lower throat. The radiation delivered to the vocal cords (which inhabit the airway but are hidden here due to the momentary constriction of the laryngeal vestibule, at arrows) also causes superficial ulceration of the swallowing passage (upper half of the photo), directly behind the vocal cords. On occasion, if tissue reaction and mucositis are much more severe than seen here, a stricture can form, requiring dilation.
Vocal cord cancer, 2 months after radiation (5 of 8)
Two months after radiation is complete, showing that the tumor is gone, and the mucositis has resolved. There is a small anterior commissure web (at arrow) just below the free margin of the cords. The patient’s voice can nevertheless pass for normal.
Vocal cord cancer, 4 months after radiation (6 of 8)
Now four months after the end of radiation. Close-up view of the postcricoid / hypopharynx regions (compare with photo 4 in this series). Mucositis here is resolved as well, and there is no stricture.
Vocal cord cancer, 6 months after radiation (7 of 8)
Now six months after the end of radiation. Strobe illumination, open phase of vibration. Note that the contours of the vocal cords are not perfectly normal, even though voice is very good.
Post radiation therapy (1 of 4)
Marked laryngeal swelling and inflammation in a woman undergoing radiation therapy to the neck for recurrent thyroid cancer. The larynx is unavoidably in the radiation field. Note swelling of the left arytenoid (right of photo) as compared with right (left of photo). The X's indicate the location of the arytenoids. In the distance, surrounded by the dotted line, is the web between the vocal cords.
Web formation (2 of 4)
At closer range, the superficial ulceration is indicated by the dotted line. Dashed line indicates where the cords should remain separated but are not, due to formation of a web.
Closer view of ulceration and web (3 of 4)
Closer view. The dotted line is yet again seen around the ulceration and web. Dashed line shows where the cords should remain separate.
Two years after excision (1 of 4)
Two years after successful laser excision of a right vocal cord cancer, preserving a good voice, despite stiffness of the right cord (left of photo). During this routine followup, slight mid-cord elevation, and subtle haziness catch the eye (within dotted line).
Narrow-band lighting (2 of 4)
Under narrow band light, the elevation and hazy leukoplakia are seen more clearly. Medial-to-lateral capillary reorientation is due to the prior superficial cordectomy.
During thulium laser coagulation (3 of 4)
At the conclusion of thulium laser coagulation. This turns the tissue even whiter, much like when one puts a thin layer of white icing on an already-white cake.
Long term smoker (1 of 4)
Distant view of vocal cords of long term smoker who is chronically hoarse. The tumor is at arrow.
Tumor (2 of 4)
Close-up shows obvious tumor is mostly involving immediate undersurface of the cord. The free margin of both cords is indicated by dotted lines.
Radiation therapy suggested (3 of 4)
Suspicion of submucosal fullness in the anterior subglottis. Laser is generally preferred to radiation for non-bulky tumors but undersurface and anterior subglottic suspicion suggests radiation therapy instead.
Post laser excision (1 of 4)
Ten years after laser excision of a left vocal cord (right of photo) cancer, viewed from a distance. Voice has been extremely serviceable, if slightly husky.
Prephonatory instant (2 of 4)
Closer visualization at the prephonatory instant. Now the pseudobowing of the left cord (from tissue loss is easily seen.
Phonation (3 of 4)
Making voice, the faint blurring of the right cord margin (left of photo), but non-vibrating left cord (right of photo) can be more easily appreciated.
Formerly heavy smoker (1 of 2)
Formerly heavy smoker with several months of deteriorating voice. Note that the dark chink where air must pass to enter the trachea is obstructed by an estimated 50% by the tumor. The remaining space remains sufficient for all normal activities without any sense of airway restriction.
Recurrent cancer (1 of 8)
Cancer, recurrent after radiotherapy. Cancer treatment 'rules' dictate a radical anterior commissure resection or more likely, total laryngectomy.
Closer view (2 of 8)
Closer view. The rules just invoked came about because cancer that crosses the anterior commissure is not to be trusted and especially after radiotherapy; cartilage involvement is far more likely; furthermore, laser resection might trigger radionecrosis. With careful patient involvement, an exception to these 'rules' was made here due to concomitant Stage 4 lung cancer of highly uncertain prognosis.
One week post laser resection (3 of 8)
A week after radical laser resection, including to the inner perichondrium of the thyroid cartilage. Wound healing/ radionecrosis is a concern, as is the risk of recurrence when rules are bent.
One year postop (4 of 8)
A year postop. There is no sign of recurrence. As expected, the vocal cords are scarred and will not vibrate. The patient has developed highly functional false vocal cord voice. (See the next four photos.)
Chronic hoarseness (1 of 3)
Examination of this man for chronic hoarseness reveals diffusely abnormal-looking tissue on his vocal cords. The area on the upper surface of the right vocal cord (enclosed in dotted circle) appears to be most likely to be diagnostic. Note the bulk, and aberrant blood vessels.
Just before biopsy (2 of 3)
A 2 millimeter cup forceps has been passed through a channel scope and is planted on this area in open position, just before the biopsy.
Biopsy (1 of 4)
Tumor growing through wall of trachea, from a paratracheal lymph node. Biopsy forceps are about to close to take a tissue fragment for study.
After biopsy (2 of 4)
After biopsy was taken at arrow. The result: squamous cell carcinoma thought to be an unusual metastasis from unusually aggressive larynx cancer.
Tumor gone (3 of 4)
Soon after radiation therapy, the tumor has melted away, leaving a depression in the tracheal wall.
Carcinoma in situ (1 of 4)
This man developed hoarseness spontaneously a year before this visit. He had accumulated 30 pack-years as a smoker, but had quit 7 years earlier. Removal of “polyps” elsewhere returned a diagnosis of carcinoma in situ (CIS), the earliest stage in the development of cancer.
HPV subtype 31 (2 of 4)
Under narrow band light, note some unusual “suspicious” capillaries, and the stippled “HPV effect” at the arrow. These findings triggered HPV subtyping and identification of high-risk subtype 31.
Excisions (3 of 4)
After 2 prior excisions elsewhere with positive margins, somewhat aggressive excision was performed in the operating room, attempting to avoid the need for radiotherapy in this fairly young man. The specimen showed severe dysplasia/ CIS, but with negative margins. After some months, voice became very functional.
Bilateral vocal cord cancer (1 of 4)
Bilateral vocal cord cancer in an elderly man. Laser excision is preferred for early cancer, except when, as seen in this larynx, the abnormality is bilateral and diffuse, lacking in obvious boundaries.
After radiotherapy (3 of 4)
After radiotherapy, more normal contours are restored to the vocal cords. Voice is also much improved. The arrow points to tiny capillaries to serve as reference for the next photo.
Post radiotherapy (1 of 4)
After radiotherapy for reported early bilateral vocal cord cancer. No photos are available of the original tumor. Distant view here, showing abnormality below the vocal cords, anteriorly.
Normal voice (2 of 4)
Voice is normal, because closure of the vocal cords and their vibration is not impeded.
Persistent cancer (3 of 4)
Closer view. This is biopsy-proven persistent cancer. Note infiltrative appearance and submucosal component at arrow.
Tumor (1 of 4)
View under standard light shows normal left vocal cord (right of photo) and tumor on right (left of photo). Main bulk is posterior; the cord is mobile, yet (unusually) the tumor is transglottic.
Narrow band light (2 of 4)
Slightly more distant view under narrow band light; accentuation of the vascularity makes the tumor even more easily seen.
Posterior commissure (3 of 4)
Magnified posterior commissure view shows that the main bulk of tumor involves the cartilaginous glottis. This is highly unusual.
Vocal cord lesion (1 of 4)
Middle aged man with hoarseness and a left vocal cord lesion (right of photo) suspicious for cancer. After extensively educating the patient about options he would have if this were proven to be cancer, a single trip to the O.R. was planned for both frozen section, and possible definitive laser excision.
Closer view (2 of 4)
Though this looks bulky, some "large" tumors can be removed definitively with the laser, if they are mostly exophytic (growing outwards) rather than endophytic (deeply infiltrating).
Removal of tumor (3 of 4)
Frozen section was positive for squamous cell cancer, and much of the tumor was removed, but an endophytic (infiltrative) growth pattern diverted the plan to radiation therapy.
25 years post radiotherapy (1 of 4)
During 25 years since radiotherapy for vocal cord cancer, voice had been “80%” and breathing normal. In recent years, voice is deteriorating; breathing also seems restricted during exertion. During “quiet breathing,” the vocal cords are in only partial abduction, due to fixation/ partial fixation of the crico-arytenoid joints. This glottic chink for breathing is likely less at night during sleep, explaining noisy breathing and the need for CPAP.
Fibrosis (2 of 4)
Here, the patient is sniffing, in order to reveal maximum possible abduction. Note that the right vocal cord (left of photo) seems “frozen” but not paralyzed (no atrophy) due to fibrosis of the right cricoarytenoid joint. The left vocal cord (right of photo) lateralizes incompletely. Note as well, post-radiation capillary ectasia.
Closed phase (3 of 4)
Under strobe light, closed phase of vibration. The left cord can move to the midline, and there is no sense of atrophy of either cord.
Open phase (4 of 4)
Open phase of vibration shows that only the left vocal cord mucosa (right of photo) is flexible, and is the source of all of the patient’s voice. The right cord mucosa (left of photo) is stiff and non-vibrating at all pitches. Without an examination from 25 years earlier, it is unknown where this represents early post-treatment stiffness (scarring from biopsy, etc.) or whether it is also the result of progressive fibrosis.
Forty years post-radiation (1 of 8)
This photo is taken forty years after curative radiation for a vocal cord cancer. Four decades of progressive radiation fibrosis (“leatherization”) has taken away arytenoid movement so that this is the maximum opening. The patient is exercise-intolerant and makes loud inspiratory breathing noises while sleeping. Her voice is also very poor.
Involuntary inspiratory voice (2 of 8)
With sudden inspiration, the darker mucosa (at the arrows) indraws and vibrates, making an involuntary inspiratory voice.
Only capable of high pitch (3 of 8)
Other than a stage whisper, she can only make a very high pitch, because the only mucosa capable of vibration is the small segment indicated by the arrows.
Open phase vibration (4 of 8)
Again under strobe light, this is the open phase of vibration, with arrows again indicating the short segment of mucosa that can oscillate.
One week post-commissuroplasty (5 of 8)
A week after posterior commissuroplasty, the patient’s breathing is much improved. Despite the distant view, the “cookie bites” taken from the posterior cords are visible.
Rapid inhalation, closer view (6 of 8)
In a much closer view, the posterior vocal cord divots are seen well. The segment of flexible mucosa is indrawing here as the patient inhales rapidly (at arrows).
Three months post-surgery (7 of 8)
Three months after the laser surgery, the patient continues to say the improvement of breathing is “large.” In this distant view the full reason why is not seen.
Voice-making with tumor (2 of 8)
Voice-making position. Notice the more lateral turning of the right vocal process (left of photo) as compared with the left (right of photo). As the remaining series shows, it is impossible to know if this is compensation for the bulk of tumor, or weakness of the LCA muscle.
One week post-removal (3 of 8)
A week after definitive removal, swelling, early granulation, and a division of the wound into upper and lower “lips” that must bind together with healing.
Voice-making, post-removal (4 of 8)
Note again the lateral turning of right vocal process (arrow, left of photo).
Six weeks post-op (5 of 8)
Six weeks after surgery, the wound is “bound together,” and there is a residual granuloma on the upper surface anteriorly (arrow).
Voice-making, post-op (6 of 8)
Making voice, there is still that peculiar lateral turning of the vocal process on the right (left of photo).
Four months post-op (7 of 8)
Now a full 4 months since laser excision, the cord is fully healed though still pink as expected. The anterior upper surface is coated with mucus.
(1 of 4)
Eight years after radiotherapy for early vocal cord cancer, cancer has returned in a man who never stopped smoking. Radiotherapy is no longer an option. Here, we have bilateral disease.
(2 of 4)
At closer range under narrow band light, areas of leukoplakia and stippled vascularity are seen more clearly; all of this must be removed. The options are laser excision, partial laryngectomy, and total laryngectomy. Laser excision was selected as the "next step."
(3 of 4)
10 weeks after laser excision, healing is nearly complete. Stippled vascularity is no longer seen; the medial-to-lateral reorientation of capillaries often seen after laser excision is seen especially on the right vocal cord (left of photo).
(1 of 6)
After biopsy performed elsewhere revealed squamous cell carcinoma, this right vocal cord cancer (left of photo) is scheduled to be treated for cure via laser excision.
(2 of 6)
A week after laser excision, the typical upper and lower "lips" swell at the margins of resection will need to heal back together to re-establish a normal vocal cord contour.
(3 of 6)
As the vocal cords approach each other in preparation for producing voice, the upper and lower lips with central depression are seen more clearly.
(4 of 6)
At approximately 2 months after laser excision, healing is nearly complete and voice very functional. There is a round granuloma (exuberant healing response) that will soon fall off spontaneously. Every patient is told about possible granulation of this sort, so that they do not worry that this is a tumor recurrence.
(5 of 6)
A year after surgery, the patient's voice can pass for normal. Under strobe light, this closed phase of vibration shows the good match of the vocal cord margins. The regenerated mucosa of the right (upper part of photo) vocal cord has a typically abnormal (but healthy) post-laser capillary pattern.
(6 of 6)
Here during the open phase of vibration, one can see that the right vocal cord is stiff (as expected after laser surgery of any depth) and does not vibrate well. Voice sounds virtually normal, however, due to the precise match of the margins and normal left vocal cord vibration (see again, photo 5). At the time of this posting, this person has remained free of disease for 8 years, and has no sense of vocal limitation.
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.
Candida laryngitis, before and after treatment
Candida laryngitis, before and after treatment: Series of 4 photos
Candida pharyngitis: Series of 2 photos
Candida laryngitis, before and after treatment: Series of 3 photos
Hazy candida under 2 kinds of light
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.
(1 of 4)
The additive effects of high-dose systemic steroids, inhaled steroids for asthma, and multiple courses of antibiotics have precipitated this severe case of vocal cord candida growth.
(2 of 4)
In this closer view, the “inflammatory surround” typical of candida (but not garden-variety leukoplakia) is better seen.
(3 of 4)
After just 2 weeks of fluconazole, 100mg per day, the candida colonies and surrounding inflammation are nearly resolved. Only faint haziness remains, along with subtle pinkness.
(4 of 4)
Narrow band light shows the residual hazy white especially on the left vocal cord. The patient’s heavy steroid / antibiotic treatment had to continue for several more weeks, and during this time, she remained on fluconazole 100 mg twice a week, which was sufficient to keep candida from regrowing.
Candida laryngitis (1 of 4)
Severe laryngeal candidiasis, in a person using inhaled steroids at high dose. Standard light.
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 (3 of 4)
After 15 days of oral fluconazole. Obvious improvement, but incomplete resolution of tissue changes.
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).
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 (3 of 4)
After treatment with fluconazole, the colonies have virtually disappeared.
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 (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).
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.
Candida colonies (2 of 3)
Candida colonies are routinely surrounded by a zone of erythema (see other photo series). No redness is seen here.
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.
Patient with chronic hoarseness (1 of 4)
Chronic hoarseness across many months in the context of long term steroid inhaler use for asthma. Note the irregular margins and “leukoplakia” which is actually candida overgrowth.
Candida colonies (2 of 4)
Narrow band light at closer range accentuates the abnormalities. Candida colonies on the vocal cords do not usually have as discrete boundaries as they do elsewhere, because of the “smearing” effect of vibration.
Fluconazole treatment (3 of 4)
The voice was noticeably improved by about day 4 of fluconazole treatment. Here we see the result after a month of treatment of this longterm, deep-seated infection.
Candida colonies (1 of 4)
A voice performance major just through a siege of bronchitis with wheezing requiring use of antibiotics, inhaled steroid, and a brief burst of systemic steroids. This is the classic triad that can produce the (presumed) candida colonies shown here.
Phonation, open phase (2 of 4)
Producing voice under strobe light, the irregular margins and white lesions are seen.
Recovered voice (3 of 4)
After a course of fluconazole, voice has recovered fully. The white lesions are gone. Compare with photo 1.
(1 of 4)
This patient was treated years earlier with radiotherapy for larynx cancer. The esophageal defect is chronic. The main finding here is white lesions on residual epiglottis and posterior pharyngeal wall. Arrows point to some examples of the countless candida colonies.
(2 of 4)
Now viewing inside the laryngeal vestibule, notice the cheesy residue clinging in large areas, representing large amounts of candida overgrowth.
(3 of 4)
After 15 days of fluconazole, notice the white residue on esophageal remnant and posterior pharyngeal wall is gone. Compare with photo 1.
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:
Capillary ectasia (1 of 7)
Abducted, breathing position, standard light. This is a vascular abnormality and not a polyp. We use the term “capillary lake.”
Capillary ectasia (3 of 7)
Strobe light, open phase of vibration. Mucus is consistent with the patient’s known acid reflux laryngitis.
Capillary ectasia, after laser coagulation (5 of 7)
Abducted breathing position, standard light, some weeks after pulsed-KTP laser coagulation of the dilated capillaries, which are no longer visible.
Capillary ectasia and hemorrhagic polyp, after treatment (3 of 4)
Abducted breathing position after vocal cord microsurgery, standard light. Note that the right cord is normalized, the capillary ectasia on the left is smaller, but persists in spite of spot-coagulation. A simple pulsed-KTP laser procedure in the videoendoscopy procedure room abolished this residual lesion.
Capillary ectasia with vocal nodules (1 of 2)
Breathing position, note insignificant micro-web at anterior commissure.
Capillary ectasia with vocal nodules (1 of 3)
Standard light reveals dilated capillaries, especially left vocal cord (right of image), as well as bilateral vocal nodules.
Capillary ectasia with vocal nodules (2 of 3)
Narrow-band light makes the dilated capillaries stand out more clearly.
Capillary ectasia (1 of 3)
Bilateral capillary ectasia, made to stand out with the help of narrow-band illumination.
Capillary ectasia, right after laser coagulation (2 of 3)
At the conclusion of pulsed-KTP laser coagulation, performed in a videoendoscopy procedure room with patient awake and sitting in a chair.
Capillary ectasia and hemorrhagic polyp (1 of 2)
Note the differing patterns of capillary ectasia—fine “stream;” meandering “river,” and “pond.” Brilliant white areas are reflection of light; more indistinct submucosal white area right cord raises question of possible cyst (arrow).
Vocal nodules, leukoplakia, and capillary ectasia (1 of 4)
Abducted breathing position, standard light. Notice not only the margin swellings (nodules) but also the ectatic capillaries and the roughened leukoplakia. This person illustrates well the idea that vibratory injury can be manifested differently. Many express the injury more in the form of sub-epithelial edema and other changes; this person also has considerable epithelial change.
Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (3 of 4)
Partial resolution of mucosal injury as a result of behavioral changes directed by a speech pathologist. Strobe light, open phase of vibration.
Capillary ectasia and hemorrhagic polyp (1 of 7)
Open position for breathing, standard light. There is capillary ectasia on both vocal cords, and there is also a hemorrhagic polyp of the left vocal cord margin (right of photo).
Capillary ectasia and hemorrhagic polyp (2 of 7)
During voicing, the polyp interferes with accurate approximation of the vocal cords, which explains this man's chronic hoarseness.
Capillary ectasia and hemorrhagic polyp, thulium laser treatment (3 of 7)
Using the thulium laser to spot-coagulate and interrupt the flow in dilated capillaries.
Capillary ectasia and hemorrhagic polyp, thulium laser treatment (4 of 7)
Coagulation of the polyp, with fiber tangential to the vocal cord and sometimes lifting medially during contact mode. A second, similar procedure was needed a few weeks later, only for residual polyp.
Capillary ectasia and hemorrhagic polyp, after treatment (5 of 7)
Several weeks later, capillary areas are blanched, but the vocal cord mucosa is fully mobile.
Capillary ectasia and hemorrhagic polyp, after treatment (6 of 7)
Vocal cord margin match and mucosal flexibility are best tested in high voice. This is strobe light, closed phase of vibration, at F4 (~349 Hz).
Capillary lake (1 of 6)
This teacher struggles with reduced mucosal endurance: the sense of slight laryngitis after extensive talking. This is likely due to the increased mucosal vulnerability to either swelling or hemorrhage caused by this capillary lake. This is a stable finding, whereas a hemorrhage resolves at least intermittently over time. Note that there was a recent surgical procedure performed elsewhere on the left cord (right of photo); the nature of the prior lesion is unknown to the patient.
Mucosal fatigue (2 of 6)
At D4 (294 Hz) under strobe light, the capillary lake and bilateral translucent swelling is seen, verifying in another way that “mucosal fatigue” is the likely cause of his reduced vocal endurance.
Prep for laser coagulation (3 of 6)
The same capillary lake seen with the smaller-chip channel scope, in preparation for pulsed-KTP laser coagulation. Note the red color and compare with post-KTP images that follow.
KTP laser coagulation (4 of 6)
The glass fiber is delivering KTP laser energy that is preferentially coagulating the red hemoglobin.
Post laser ablation (5 of 6)
Immediately after laser ablation, the red lake has changed color due to denaturation/ coagulation.
Post laser ablation, distant view (6 of 6)
More distant view after ablation is complete. Compare with photos 1 and 3.
After a weekend of vocal overuse (7 of 8)
Several months later, after a brutal weekend of coaching. Strobe view, closed phase of vibration. No evidence of residual ectasia that had been causing such reduced ability of the mucosa to “endure” vibratory trauma. Note the margin swellings and slight pinkness from vibratory trauma.
Hoarse choral singer (1 of 4)
Older amateur but experienced and committed choral singer is grossly hoarse due to this chronic vascular lesion, left vocal cord (right of photo).
2 months post-surgery (3 of 4)
Nearly 2 months after surgery, only a bit of ectasia (non-threatening as it is upper surface e of the cord) is seen. The patient says voice is fully restored.
Ectatic capillary (1 of 4)
This young performer has a sense of a weakened voice and loss of vocal stamina. Here, we see an ectatic capillary of the left vocal cord (right of photo). Is the problem intermittent vocal hemorrhage from this vulnerable capillary? Is there increased susceptibility to edema due to this margin capillary?
Ectatic capillary, narrow band light (2 of 4)
Under narrow band light, the capillary is even more evident. The additional network of prominent capillaries prompt the same questions as in caption 1.
Margin swelling (3 of 4)
Under strobe light at B-flat 4 (494 Hz), we see subtle margin swelling (arrows), here of only “indicator lesion” magnitude.
Bowing, atrophy, and flaccidity (4 of 4)
The large amplitude of the open phase of vibration at the same pitch, along with the lack of closure in photo 3, reveals the actual problem to be bowing, atrophy, and flaccidity. These findings fit with the “bowing” symptom complex: loss of edge to voice quality and the tendency of voice quality and strength to “fade” as the day progresses.
Obvious mucosal injury (1 of 3)
This young woman is hoarse, but two examinations elsewhere returned no significant findings. Her upper voice limitations during vocal capability testing already tell us “for certain” that there is mucosal injury, even before we look at the larynx. In this mid-range view, we can see early contact at the mid-cords, but the full extent and nature of the injuries are seen in the closer views that follow.
Vocal nodules (2 of 3)
At a more appropriate level of magnification, the vocal nodules are seen. But we want to know more…
Margin swelling and bruising (1 of 2)
This professional woman is extraordinarily dynamic and intense, and must talk all day to do her work. Here, the right vocal cord (left of photo) is bruised due to vibratory trauma. The margin swelling on the right causes her hoarseness more than the bruising, however.
Six weeks later (2 of 2)
Six weeks later, the bruise is mostly resolved. The capillary that “leaked” blood to form the bruise is now seen more clearly (long arrow). This ectatic capillary can be seen easily now when looking back at photo 1. The short arrows indicate the residual “smudges” of discoloration caused by breakdown products of the bruise. The last evidence of widespread vocal cord bruising is always in these two locations.
(1 of 7)
In this musical theater singer, under narrow band (blue-green) light, we see an ectatic (dilated) capillary leading to a small hemorrhagic polyp on the left vocal cord (right of photo).
(2 of 7)
Now under strobe light, at E5 (660 Hz), there is also a projecting component that interferes with margin approximation.
(3 of 7)
Just prior to pulsed-KTP ablation, again under narrow band light. The arrows point out the feeding capillary, for comparison with photo 5.
(4 of 7)
Under standard light, the glass fiber is seen. The "white" spot is only the aiming beam; no laser energy is being delivered at this moment.
(5 of 7)
At the conclusion of the laser procedure. You can see that not only is the blood in the polyp coagulated but the flow of blood in the feeding capillary has also been (note discontinuity at the arrows, where the capillary has "disappeared." Compare with photo 3.)
(6 of 7)
Three weeks later, voice is restored to "original equipment" capabilities. The area of treatment (surrounded by tiny dots) is arguably "blanched" with fewer capillaries in general, but with no loss of mucosal flexibility under strobe light. Compare with Photo 1.
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.”
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.
Cartilaginous glottis (1 of 1)
Vocal cords approaching adducted (phonatory) position. Note that the posterior 1/3 of the vocal cord is “inhabited” by the arytenoid cartilage, with vocal process turned slightly medially. The cartilaginous glottis appears to make up more than the posterior 1/3 of the cord due to optical distortion from the wide-angle lens used in the tip of the endoscope.
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.
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.
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.
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.
After sipping water (3 of 7)
After three sips of blue-stained water, much of the applesauce has been washed away.
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.
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.)
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.
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 is a term that, as used popularly, can describe at least a few distinct scenarios or disorders:
- Minor aspiration. A person swallows and food or liquid “goes down the wrong tube” (down the airway), which provokes aggressive coughing.
- Life-threatening aspiration. A person swallows food (a piece of meat, for instance) that enters the airway and plugs it, requiring a Heimlich maneuver.
- Sensory neuropathic cough. A person uses the term “choking” to describe a severe episode of coughing, but without any aspiration of liquid or food.
- 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.
A benign growth composed of cartilage cells.
Chondroma of thyroid cartilage: Series of 4 photos
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 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
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.
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 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).
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.
“Tattoo” of blood after detachment of intubation granuloma
Intubation Granuloma (1 of 3)
Six months after a long intubation due to grave illness. When the patient exhales as shown here, his contact granulomas “blow” upwards from the level of the vocal cords. These granulomas are quite “mature” as can be seen in the next photo.
Intubation Granuloma (3 of 3)
Here, dotted lines are added to show where the granuloma will likely detach. Occasionally a patient will cough out a small piece of tissue with a small amount of blood. More often, the granuloma detaches outside of patient awareness.
Intubation Granuloma (2 of 3)
With the patient now breathing in, the granulomas are drawn downwards toward the trachea, and the pedicle or “stalk” to which it is attached becomes visible on the left side (right of photo). These particular granulomas are well along in the process of pedunculation, and typically detach spontaneously. It can take patience to wait this process out. If symptoms at any time during this wait are unacceptable (not usually the case), then the granuloma can be treated with laser ablation in a videoendoscopy laboratory or steroid injection into the abnormal tissue.
Contact granuloma (1 of 2)
Contact granuloma right posterior vocal cord. Note bi-lobularity and surrounding inflammation (erythema).
Contact granuloma (1 of 11)
Breathing position shows classic large bi-lobed granuloma. Note the deep cleft (arrows), into which the right (left of image) vocal process (dotted line) will fit during voicing, which will leave one lobe above and one below the level of the cords.
Contact granuloma (2 of 11)
When the patient is asked to exhale rapidly, the granuloma displaces upwards (toward the camera), indicating that this granuloma is pedunculating (narrowing at its base) as a part of the process of maturation.
Contact granuloma (3 of 11)
The instant before full closure for phonation. The inferior lobule will descend slightly and the granuloma as a whole will rotate anteriorly so that the right vocal process can fit into the cleft between the two lobes. (That is, A will match A, and B match B; note that the B points here are further apart than they appear to be.)
Contact granuloma (4 of 11)
Phonation. Full adduction is still possible, but only the granuloma’s upper lobe is seen. This voice sounds virtually normal, due to how deep the granuloma’s cleft is, which allows the cords to fully meet each other, and also the fact that this granuloma doesn’t interfere with the vibrating part of the vocal cords (the anterior two-thirds, in clear view here).
Contact granuloma, 2 months later (5 of 11)
Same patient, two months later. Without any intervention, the inferior lobule has spontaneously detached. In this inspiratory (breathing in) view, the remaining lobule is drawn inward and slightly downward. The dotted lines indicate where the stalk will continue to pinch inward and narrow before spontaneous detachment.
Contact granuloma, 2 months later (6 of 11)
With exhalation, the lobule is blown slightly upwards on its stalk.
Contact granuloma, 2 months later (7 of 11)
Phonation. This looks similar to image 4, but the second lobule hidden from view below the cords in image 4 is now not there at all.
Contact granuloma, 5 months later (8 of 11)
Same patient, another three months later. The upper lobule has now also detached, leaving only a bruise. This bruise can be surprisingly durable, almost like a “tattoo.”
Contact granuloma, one year later (10 of 11)
Another seven months later. The bruise is smaller but still visible.
Contact granuloma (1 of 3)
Contact granuloma, with a typical bi-lobed shape divided by a deep central cleft. Note also the inflammatory appearance of the granuloma.
Contact granuloma (2 of 3)
As the vocal cords approach each other for phonation, the right medial arytenoid (at dotted line) is poised to fit into the cleft of the opposing contact granuloma (at arrows).
Large tumor, before removal (1 of 8)
Large tumor posterior right true cord (left of photo) with abnormality extending up onto posterior false cord (indicated by the black dotted line).
After tumor removal (2 of 8)
A week after surgical excision, revealing the lesion to be a benign verruca. The wound exposes some of the arytenoid cartilage (indicated by smaller dotted circle). The circumference of the entire excision is shown within the larger circle of black dots.
2 months after surgery (3 of 8)
2 months after surgical removal of the verrucous hyperplasia, granulation formation is well underway.
5 Months after surgery, a granuloma is seen (4 of 8)
Five months later, a granuloma is seen, but voice is normal because no vibratory tissue was removed from the anterior 2/3 of the cord, and the left vocal cord (right of photo) can fit into the deep cleft between the two lobes of the granuloma so that the granuloma does not keep the cords separated, as seen in the next two photos.
7 months after surgery (5 of 8)
Two months later, 7 months after surgery, the inferior lobule of the granuloma has begun to fall off.
Pedunculation (6 of 8)
Asking the patient to inspire suddenly draws the granuloma into the airway, and shows that there is significant pedunculation (pinching in at the base to a stalk rather than remaining a broad attachment)
One year after surgery (7 of 8)
Now one year after removal (photo 2), the lower lobe is gone, and the upper lobe nearly resolved.
15 months after surgery (8 of 8)
Now 15 months after surgical removal of the verrucous hyperplasia, the granulation tissue has gone through the pedunculation process and has detached, leaving behind a tell-tale “bruise” at its base. Note that there are flecks of presumed hyperplasia seen, and these will be addressed with a thulium laser in the videoendoscopy room.
Intubation injury (1 of 4)
Gross hoarseness was immediately evident after a surgical procedure involving endotracheal intubation. After a few months, this granuloma is evident. It appears to be pedunculated and attached only where indicated by the dotted line. The small "X" is for reference with photos 2 and 4.
Granuloma drawn into glottis (2 of 4)
Here, the granuloma is drawn downward into the glottis by the inspiratory airstream. The "X" is for reference with photos 1 and 4.
Phonation (3 of 4)
During phonation, seen at closer range, the granuloma rides upward and nearly fills the laryngeal vestibule.
Anterior commissure (4 of 4)
Closeup at the anterior commissure. Dotted line indicates anterior edge of the granuloma. The "X" is for reference with photos 1 and 2.
Granuloma detached (5 of 8)
A few months later, voice has improved. The granuloma has spontaneously detached. Pinkness remains.
Vocal cord blurring
During voicing under standard light, note that there is vocal cord blurring on the right cord (left of photo) far more than on the left (blurring is indicated by thin, black lines). This suggests that the left side (right of photo) is not vibrating well.
Panoramic view (1 of 6)
Panoramic view of larynx, showing left contact granuloma (right of photo). Elsewhere, this has been removed twice, with prompt recurrence.
Upper and middle lobule, Cleft 1 (2 of 6)
Close-up of posterior commissure. Deep 'cleft 1' here separates upper (U) and middle (M) lobules of the granuloma.
Phonation (3 of 6)
During phonation, the right vocal process is settled deeply into 'cleft 1' and only the upper lobule (U) rides above the plane of the cords.
Lower lobule (4 of 6)
Here the patient is blowing out and rotating the granuloma upward to expose 'cleft 2' and the lower lobule (L).
Upper and middle lobule, Cleft 2 (5 of 6)
Again during phonation, but with right vocal process now settled deeply into 'cleft 2,' and now both upper and middle lobules (U, M) ride above the plane of the cords.
Contact granuloma (1 of 4)
This man was diagnosed elsewhere with a stubbornly persistent lesion of his right vocal cord (left of photo). It almost appears that the left cord (right of photo) may have had a similar lesion in the past, but is now healed.
Narrow band light (2 of 4)
Under narrow band light, the rolled border of the right-sided lesion (left of photo is better seen, as is the healed nature of the left vocal cord (right of photo).
Phonation (3 of 4)
During voicing, the left cord (right of photo) clearly fits into the cleft of the right sided lesion (left of photo).
Two weeks post-op (1 of 4)
Two weeks after removal of totally stenosed cricotracheal segment that and circular reanastomosis. Looking downward from the level of the vocal cords, the circular suture line is indicated with a dashed line. The point of origin of the granuloma is seen is at the *.
Six weeks post-op (2 of 4)
Six weeks after the crico-tracheal resection and reanastomosis, the patient’s breathing seems normal to him, including during vigorous workouts. Here on exhalation, note that there is a granuloma attached to the “scar” line anteriorly. As seen in the next photo, this granuloma is highly pedunculated and ready to spontaneously detach.
Inhaling (3 of 4)
The patient is inhaling here, and this has drawn the granuloma below the suture line. The pedicle (point of attachment) is indicated by the dotted line.
"Third" granuloma (1 of 6)
This man has had a granuloma removed twice elsewhere. As expected it recurred both times, so that in a sense, this is the “third” granuloma. It has the typical bi-lobularity (U = upper; L = lower).
Injection into lower lobe (2 of 6)
Occasionally a steroid injection is used for the small percentage of persons with granuloma who are symptomatic. Here, note the needle inserted into the lower lobe (L, right of photo) to infiltrate triamcinolone.
Injection into upper lobe (3 of 6)
Now the needle has been redirected into the upper lobe (U). This procedure is done under topical anesthesia in the voice laboratory.
Five weeks later (4 of 6)
About 5 weeks later, the patient’s symptoms have gone away. The granuloma has shrunk by as much as 50% comparing with photo 1.
Six months post-injection (5 of 6)
Now six months after the steroid injection, not only steroid, but also maturation of the granuloma continues. Compare with photos 1 and 4.
Tethered vocal cords (1 of 5)
This man has right vocal cord paralysis and a history decades ago of Teflon injection into the right vocal cord, resulting in posterior commissure synechiae. He is short of breath, partly due to the tissue band and partly because it tethers the vocal cords closer together than they would otherwise need to be as seen in photo 4 after the band is removed. See also photo 5.
Before laser removal (3 of 5)
The thulium laser fiber (F) is touching the synechiae, with laser energy about to be delivered.
Immediately after laser (4 of 5)
This is just after the thulium laser division of the band using topical anesthesia only, with patient sitting in a chair.
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 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.
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.
Secretions (1 of 4)
This person has cricopharyngeus dysfunction--the "catcher" problem described in the teaching video "Swallowing Trouble 101." One small indication in the first glimpse of the throat area is the pooling of secretions (here, mucus) in an "organized" fashion in the swallowing crescent right behind the larynx.
Contracted pharynx (2 of 4)
As part of VESS part 1, assessment of the patient's swallowing "equipment," pharyngeal squeeze elicitation is always performed. Here the patient produces the highest pitch she can make on "EEEE!" Note the major contraction of the pharynx as it "hugs" the larynx and closes the pyriform sinuses.
Cracker residue (3 of 4)
After chewing and swallowing a cheese cracker, some residue remains in the vallecula and also in the swallowing crescent.
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.
Cricopharyngeal dysfunction, with incipient Zenker’s (1 of 1)
This patient with cricopharyngeal dysfunction is just beginning to form a Zenker’s pouch. Note that the cricopharyngeus muscle (light grey “thumb” at asterisk) is beginning to turn upwards and become more slender. The volume of barium below the dotted line is inside the incipient Zenker’s pouch. Over months or years, this pouch would stretch and develop into a true Zenker’s pouch.
Reflux into hypopharynx (1 of 3)
The patient has swallowing problems typical of cricopharyngeal dysfunction. This swallow study reinforces that impression as well as the likely presence of a Zenker's diverticulum. In this photo, blue-stained water has just been swallowed, and the vocal cords are beginning to open. At this point, the hypopharynx contains no residue.
Reflux into hypopharynx (2 of 3)
One second later, the blue-stained water begins to emerge from just above the cricopharyngeus muscle into the "swallowing crescent".
Immediately after swallow (1 of 4)
During VESS, after administration of several boluses of blue-stained applesauce. Trace applesauce on pharyngeal walls, immediately after a completed swallow. The postcricoid area is “clean” in this view, at *.
One second later (2 of 4)
Approximately a half second later, applesauce appears at the *, having been ejected upwards from a presumed Zenker’s diverticulum.
Un-relaxed cricopharyngeus muscle (3 of 4)
During water administration, a glimpse of the un-relaxed cricopharyngeus muscle is seen (concentric dotted lines). Esophageal entrance at ‘E’ and Zenker’s pouch, still containing some previously-administered blue applesauce, at ‘Z'.
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.
Cricopharyngeal myotomy: Series of 7 photos
Cricopharyngeal dysfunction, before and after myotomy: Series of 2 photos
Cricopharyngeal dysfunction, before and after myotomy: Series of 2 photos
Cricopharyngeal dysfunction, before and after myotomy: Series of 2 photos
Cricopharyngeus myotomy for recreational eating and management of saliva: Series of 4 photos
98 year-old before and after myotomy: Series of 10 photos
Great view of fresh cricopharyngeus myotomy surgical wound: Series of 4 photos
Bolus stream before and after cricopharyngeus myotomy: Series of 2 photos
VESS (videoendoscopic swallow study) findings after radiotherapy: Series of 7 photos
The evolution of a cricopharyngeus myotomy wound: Series of 8 photos
Zenker’s diverticulum a week after cricopharyngeus myotomy: Series of 3 photos
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:
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.
Cricopharyngeus muscle (1 of 4)
Close-up view of the cricopharyngeus muscle. When contracted like this, the muscle squeezes shut the entrance to the esophagus. When a person swallows, the muscle relaxes, and the entrance to the esophagus opens dramatically to let food or liquid enter.
Cricopharyngeus muscle (2 of 4)
Same image as photo 1, but a small solid oval marks the center-point of the muscle’s grip, when contracted, and a larger dotted oval shows roughly how large the opening becomes when the muscle relaxes. Also, a yellow dotted line indicates the line of incision used when performing a cricopharyngeal myotomy (not needed in this patient).
Cricopharyngeus muscle (3 of 4)
More distant view of the cricopharyngeus muscle, as the camera has retracted upward and is now sitting in the postcricoid part of the hypopharynx, looking downward.
Cricopharyngeus muscle (4 of 4)
Much more distant view yet of the cricopharyngeus muscle, now framed within the hypopharyngeal inlet to the esophagus, at the top-center of the photo. Also now in view are the arytenoid mounds, at the bottom of the photo. Incidentally, this patient’s hypopharyngeal inlet to the esophagus is abnormally narrowed, due to post-surgery scarring; black dotted lines indicates the normal size of this inlet.
Trumpet maneuver (1 of 4)
This man is performing a trumpet maneuver in order to open the post-arytenoid and post-cricoid area of the hypopharynx. He is able to reveal the opening to the esophagus (dark oval). A = arytenoid mound apices.
The "shelf" (2 of 4)
At closer range, the "shelf" of the cricopharyngeus muscle is seen posteriorly (upper photo). The radial lines on the slightly relaxed / open muscle should be compared with photo 4, where the sphincter is completely closed.
Cervical esophagus (3 of 4)
After passing through the sphincter, a view of the open cervical esophagus.
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.
Croup, aka laryngotracheitis (1 of 4)
Though croup is most often seen in children, this woman developed a barking cough and mild, non-anxiety provoking stridor in the context of an upper respiratory infection. In this panoramic view note in particular the prominence and redness of the conus part of the vocal cords (indicated by white lines).
Croup, aka laryngotracheitis (3 of 4)
Even closer view showing redness and narrowing of the posterior subglottic airway.
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 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
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.