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Laryngopedia

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

Laryngopedia By Bastian Medical Media

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Can’t Burp? Comprehensive Resources for R-CPD (in One Place)

Can't Burp?

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R-CPD

Inability to belch or “burp” (Also known as Retrograde Cricopharyngeus Dysfunction, or R-CPD for short) occurs when the upper esophageal sphincter (cricopharyngeus muscle) loses its ability to relax in order to release the “bubble” of air. 

Overview of R-CPD

Can't burp
Play Video

People who cannot release air upwards are miserable. They can feel the “bubble” sitting at the mid to low neck with nowhere to go. Or they experience gurgling when air comes up the esophagus only to find that the way of escape is blocked by a non-relaxing sphincter. It is as though the muscle of the esophagus continually churns and squeezes without success. Common symptoms include the inability to belch, gurgling noises, chest/abdominal pressure and bloating, and flatulence.

Symptoms of R-CPD

The Big Four Symptoms Of R-CPD That Provide Virtually 100% Accuracy In Diagnosis

Inability to burp

This is almost always, but not exclusively “lifelong,” though persons may not recognize this as a “problem” or “difference from others” until early childhood or teenage years.

Socially awkward gurgling noises

This is almost always, but not exclusively “lifelong,” though persons may not recognize this as a “problem” or “difference from others” until early childhood or teenage years. These noises can be mostly quiet and “internal,” but more often are loud enough to be embarrassing. Mouth opening makes them louder. Almost everyone says they are easily heard several feet away; not infrequently “all the way to the door.” They engender social anxiety in most persons with R-CPD, causing some to avoid eating or drinking for hours before social occasions and even during them. Carbonation makes them much worse and is to be avoided at all costs. Some more colorful patient descriptions:

  • Symphony of gurgles
  • Croaking frogs
  • Creaking floorboards
  • Dinosaur sounds
  • Strangled whale.

Bloating & Pressure

Most common location is high central abdomen. Distention is common, especially later in the day. Using pregnancy as an analogy even in men, the usual degree of distention is described as “3 or 4 months.” “Six months” is not rare, and one slender young man was “full term.” Almost as often as abdominal distress, patients describe chest pressure, and for some that is the worst symptom. Some have pressure in the low neck. While “pressure” is the frequent descriptor, some experience occasional sharp pain in abdomen, back, or between shoulder blades. Some have to lie down after eating to find some relief.

Flatulence

Routinely, this is described as “major,” or even “ridiculous.” Flatulence increases as the day progresses, and many experience it into the night. When around others, some scan their surroundings at all times for a place they can go briefly to pass gas. Understandably, the social ramifications of this problem can also be major.

Other Common Symptoms

Nausea

especially after eating larger than normal amounts or drinking carbonated beverages.

Hypersalivation

when symptoms of bloating are major.

Excessive Flatulence
Play Video

Inability to Vomit

A few simply cannot vomit; more often it is possible but only after strenuous retching. Vomiting (spontaneous or self-induced) always begins with a very loud noise and major release of air in a phenomenon we call “air vomiting.” Emetophobia can be major.

Play Video

Painful hiccups

again, more commonly after eating.

Descending colon dilates

(Still under evaluation): The question is whether this occurs over time if flatulence cannot be responded to, so that muscular effectiveness is diminished.

Shortness of breath

A person can be so full of air that athletics, or even ability to climb stairs, etc. are impaired.

Anxiety & social inhibition

This can be MAJOR due to gurgling, flatulence, and discomfort.

Where Do Patients Come From?

0
No-burpers turned burpers!

What Causes R-CPD?

Inability to burp or belch occurs when the upper esophageal sphincter (cricopharyngeus muscle) cannot relax in order to release the “bubble” of air. The sphincter is a muscular valve that encircles the upper end of the esophagus just below the lower end of the throat passage. If looking from the front at a person’s neck, it is just below the “Adam’s / Eve’s apple,” directly behind the cricoid cartilage.

If you care to see this on a model, look at the photo below. That sphincter muscle relaxes for about a second every time we swallow saliva, food, or drink. All of the rest of the time it is contracted. Whenever a person belches, the same sphincter needs to let go for a split second in order for the excess air to escape upwards. In other words, just as it is necessary that the sphincter “let go” to admit food and drink downwards in the normal act swallowing, it is also necessary that the sphincter be able to “let go” to release air upwards for belching.

People who cannot release air upwards are miserable. They can feel the “bubble” sitting at the mid to low neck with nowhere to go. Or they experience gurgling when air comes up the esophagus and is blocked by a non-relaxing sphincter. It is as though the muscle of the esophagus continually churns and squeezes without success. The person so wants and needs to burp, but can’t. Sometimes this can even be painful. Such people often experience abdominal bloating as the air must make its way through the intestines before finally being released as flatus.

For people who experience this problem to the point of discomfort and reduced quality of life, here is one approach: First, a videofluoroscopic swallow study, perhaps with effervescent granules. This establishes that the sphincter works normally in a forward (antegrade) swallowing direction, but not in a reverse (retrograde) burping or regurgitating fashion. Along with the symptoms described above, this establishes the diagnosis of retrograde-only cricopharyngeus dysfunction (non-relaxation).

 

Second, a treatment trial involving placement of Botox into the malfunctioning sphincter muscle. The desired effect of Botox in muscle is to weaken it for at least several months. The person thus has many weeks to verify that the problem is solved or at least minimized. The Botox injection could potentially be done in an office setting, but we recommend the first time (at least) placing it during a very brief general anesthetic in an outpatient operating room. That’s because the first time, it is important to answer the question definitively, that is, that the sphincter’s inability to relax when presented with a bubble of air from below, is the problem.

For a few months at least, patients should experience dramatic relief of their symptoms. And, early experience suggests that It may be that this single Botox injection allows the system to “reset” and the person may never lose his or her ability to belch. Of course, if the problem returns, the individual could elect to pursue additional Botox treatments, or in a truly severe case, might even elect to undergo endoscopic laser cricopharyngeus myotomy.

Photo Essays

Abdominal Distention of R-CPD

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Gastric Air Bubble (1 of 3)

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

Bloated Abdomen (2 of 3)

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

Non-bloated Abdomen (3 of 3)

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

Can’t Burp: Progression of Bloating and Abdominal Distention – a Daily Cycle for Many with R-CPD

This young woman has classic R-CPD symptoms—the can’t burp syndrome. Early in the day, her symptoms are least, and abdomen at “baseline” because she has “deflated” via flatulence through the night.  In this series you see the difference in her abdominal distention between early and late in the day.  The xray images show the remarkable amount of air retained that explains her bloating and distention.  Her progression is quite typical; some with R-CPD distend even more than shown here especially after eating a large meal or consuming anything carbonated.

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Side view of a bloated abdomen (1 of 6)

Early in the day, side view of the abdomen shows mild distention. The patient’s discomfort is minimal at this time of day as compared with later.

Mild distension (2 of 6)

Also early in the day, a front view, showing again mild distention.

Front view (3 of 6)

Late in the same day, another side view to compare with photo 1. Accumulation of air in stomach and intestines is distending the abdominal wall.

Another view (4 of 6)

Also late in the day, the front view to compare with photo 2, showing considerably more distention. The patient is quite uncomfortable, bloated, and feels ready to “pop.” Flatulence becomes more intense this time of day, and will continue through the night.

X-ray of trapped air (5 of 6)

Antero-posterior xray of the chest shows a very large stomach air bubble (at *) and the descending colon is filled with air (arrow).

Side view (6 of 6)

A lateral view chest xray shows again the large amount of excess air in the stomach and intestines that the patient must rid herself of via flatulence, typically including through the night, in order to begin the cycle again the next day.

A Rare “abdominal crisis” Due to R-CPD (inability to burp)

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X-Ray of Abdominal Bloating (1 of 2)

This young man had an abdominal crisis related to R-CPD. He has had lifelong symptoms of classic R-CPD: inability to burp, gurgling, bloating, and flatulence. During a time of particular discomfort, he unfortunately took a “remedy” that was carbonated. Here you see a massive stomach air bubble. A lot of his intestines are air-filled and pressed up and to his right (left of photo, at arrow). The internal pressure within his abdomen also shut off his ability to pass gas. Note arrow pointing to lack of gas in the descending colon/rectum. NG decompression of his stomach allowed him to resume passing gas, returning him to his baseline “daily misery” of R-CPD.

X-Ray of Abdominal Bloating (2 of 2)

X-Ray without markings

Shortness of Breath Caused by No-Burp (R-CPD)

Persons who can’t burp and have the full-blown R-CPD syndrome often say that when the bloating and distention are particularly bad—and especially when they have a sense of chest pressure, they also have a feeling of shortness of breath. They’ll say, for example, “I’m a [singer, or runner, or cyclist or _____], but my ability is so diminished by R-CPD.  If I’m competing or performing I can’t eat or drink for 6 hours beforehand.”  Some even say that they can’t complete a yawn when symptoms are particularly bad.  The xrays below explain how inability to burp can cause shortness of breath.

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X-ray of trapped air (1 of 2)

In this antero-posterior xray, one can see that there is so much air in the abdomen, that the diaphragm especially on the left (right of xray) is lifted up, effectively diminishing the volume of the chest cavity and with it, the size of a breath a person can take.

Side view (2 of 2)

The lateral view again shows the line of the thin diaphragmatic muscle above the enormous amount of air in the stomach. The diaphragm inserts on itself so that when it contracts it flattens. That action sucks air into the lungs and simultaneously pushes abdominal contents downward. But how can the diaphragm press down all the extra air? It can’t fully, and the inspiratory volume is thereby diminished. The person says “I can’t get a deep breath.”

Esophageal Findings

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Reperti esofagei (1 di 3)

A view of the mid-esophagus in a young person (early 30’s). The esophagus is kept open by the patient’s un-burped air. Note the “aortic shelf” at A, delineated by dotted lines.

Esophageal Findings (2 of 3)

A moment later, additional air is pushed upwards from the stomach to dilate the mid-esophagus even more. A bony “spur” in the spine is thrown into high relief by the stretched esophagus.

Esophageal Findings (3 of 3)

A view of the upper esophagus (from just below the cricopharyngeus muscle sphincter) shows what appears to be remarkable lateral dilation (arrows) caused over time by the patient’s unburpable air. Dilation can only occur laterally due to confinement of the esophagus by trachea (anteriorly) and spine (posteriorly), as marked.

More Interesting Esophageal Findings of R-CPD (Inability to Burp)

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Stretched Esophagus

Stretched Esophagus (1 of 4)

Using a 3.7mm ENT scope with no insufflated air, note the marked dilation of the esophagus by swallowed air the patient is unable to belch. T = trachea; A = aortic shelf; S = spine
posterior wall of the trachea

Tracheal Wall (2 of 4)

The posterior wall of the trachea (T) is better seen here from a little higher in the esophagus. A = aorta
stretched esophagus

Over-dilation (3 of 4)

The photo is rotated clockwise at a moment when air from below is pushed upward so as to transiently over-dilate the esophagus. Note that the esophagus is almost stretching around the left side of the trachea in the direction of the arrow.
left mainstem bronchus is made visible

Bronchus (4 of 4)

Now deeper in the esophagus (with it inflated throughout the entire examination by the patient’s own air), it even appears that the left mainstem bronchus (B) is made visible by esophageal dilation stretching around it.

R-CPD and Esophageal Dilation

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between posterior pharyngeal wall and arytenoid eminences

(1 of 3)

Here, in the panoramic view of the "bottom of the throat," between posterior pharyngeal wall (marked PPW) and arytenoid eminences (A). The airway is indicated by the short arrow, and the dotted line shows the waiting "entrance" to the upper esophagus just above the CPM. The "entrance" opens for a second to permit passage of food or liquid through the sphincter and into the upper esophagus. The * is for reference with photo 2.
entrance to the esophagus

(2 of 3)

At the entrance to the esophagus, at closer range. Notice that the mucosa is redundant, a common but not universal finding in R-CPD.
upper esophagus

(3 of 3)

Now the view is within the upper esophagus. It almost appears that the lumen is dilated, especially in a lateral direction (arrows). Purely speculatively, one wonders if constant forcing of air upwards again a barrier ( the non-relaxing cricopharynxgeus muscle, aka upper esophageal sphincter), dilates the esophagus over time. Certainly, many with R-CPD experience not only gurgling, but also chest pressure and even pain that may be from "stretching" of the esophagus.

What the Esophagus Can Look Like “Below A Burp”

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Mid-esophagus of a person with R-CPD

Baseline (1 of 3)

Mid-esophagus of a person with R-CPD who is now burping well after Botox injection into the cricopharyngeus muscle many months earlier. The esophagus remains somewhat open likely due to esophageal stretching from the years of being unable to burp and also a “coming burp.”
esophagus dilates abruptly

Pre-burp (2 of 3)

A split-second before a successful burp the esophagus dilates abruptly from baseline (photo 1) as the excess air briefly enlarges the esophagus. An audible burp occurs at this point.
burp in the esophagus

Post-burp (3 of 3)

The burp having just happened, the esophagus collapses to partially closed as the air that was “inflating it” has been released.

Additional Resources

Read this initial peer-reviewed article on this condition, written by Dr. Bastian and colleague.

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Community Created Content



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:

Laser surgery for Bilateral Vocal Cord Cancer

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squamous cell carcinoma

Squamous cell carcinoma (1 of 6)

This man developed hoarseness across a few months. Biopsy elsewhere revealed squamous cell carcinoma, seen here on both vocal cords. Based upon a friend’s experience, he rejected radiotherapy, opting for laser resection, knowing it could be very hard on voice.
Tumor on the vocal cords

Tumor on the vocal cords (2 of 6)

At closer range and under narrow band (blue-green) light to accentuate the vascular abnormalities associated with this tumor.
superficial laser cordectomy

Granuloma delays voice recovery (3 of 6)

Six weeks after superficial laser cordectomy, the larynx is almost healed with the exception of a small granuloma, left vocal cord (right of photo). When healing includes granulation, voice recovery is delayed as the granuloma resolves.
granuloma prevents vibratory closure

Closer view of granuloma (4 of 6)

He has hoarse but functional voice, but under strobe light, the granuloma prevents vibratory closure. Note the medial-to-lateral capillary reorientation so typical after laser cordectomy.
Granuloma on vocal cord

Granuloma is smaller (5 of 6)

Now 3 ½ months from surgery, voice has improved further and he considers it “75%” of original...One can see that the granuloma is smaller.
ranuloma no longer prevents vibratory closure

Granuloma doesn't impede voice (6 of 6)

Note that the granuloma no longer prevents vibratory closure and this explains further improvement of voice. Compare with photo 4.

Vocal cord cancer, before and after surgery

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Vocal cord cancer (1 of 4)

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

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

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

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

Approximately one month after excision, healing progressing.

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.

Laser Removal of Vocal Cord Cancer with Bilateral Disease

For treatment of early vocal cord cancer, both laser excision and radiotherapy are in competition as good treatment modalities. See also Early Vocal Cord Cancer: Remove with a Laser, or Radiate? Often, radiation is used when disease is bilateral, in the interest of preserving voice. This is an example of the ability to do fairly extensive laser surgery bilaterally, yet preserving good voice. This man had a friend who had severe difficulty with radiation, and he was therefore opposed to that option.

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Vocal cord cancer (1 of 10)

This 70-something man is a longterm smoker. Here you see an obvious cancer of his left vocal cord (biopsy-proven), but disease on the right side as well that is more superficial.

Stippling (2 of 10)

At higher magnification and using narrow band light, some of the vascular abnormality (stippling) is better seen (arrows).

Granulation (3 of 10)

A week after definitive excision of his cancer. Typical early wound appearance, with a suggestion of granulation on the left side (right of photo).

Reparative Granuloma emerges (4 of 10)

Six weeks later, healing is nearly complete other than a typical reparative granuloma on the left (right of photo).

Granuloma interferes with voicing (5 of 10)

During voicing, the granuloma interferes with closure, explaining in part his ongoing severe hoarseness. Note also the typical medial-to-lateral capillary reorientation.

Granuloma fades away (6 of 10)

Now 3 months postop, the granuloma is smaller. Classic capillary reorientation is again seen.

Closer view (7 of 10)

Under strobe light, closed phase of vibration. Voice is highly functional, since the granuloma no longer interferes with closure.

Granuloma cleft (8 of 10)

Open phase of vibration under strobe light shows the bilobed, clefted nature of the granuloma, where the right vocal fold “fits into” the granuloma (arrows at cleft).

Blood tattoo (9 of 10)

At nearly 5 months postop, the granulation tissue has auto-detached, leaving only a small “blood tattoo.” Here, under strobe light and closed phase of vibration.

Open phase of vibration (10 of 10)

Voice is somewhat hoarse but highly serviceable, and “better than it has been in years,” according to the patient.

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).

Glottic Cancer, After Surgery

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capillary reorientation

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.
matching of the cords at closed phase of vibration

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.
left cord oscillates, but the right doesn’t

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, before and after surgery

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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.

Vocal cord cancer, 7 weeks after surgery (8 of 8)

Vibration of the arytenoid apices (arrows) against the petiole of the epiglottis (line), providing a rough, voice serviceable for quiet conversation, but highly limited in noisy surroundings.

Breaking cancer “rules” intelligently with use of laser

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lesions shows persistent cancer

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.
tumor crosses the anterior commissure

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.
area of tumor removal

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.
removal of soft tissue from anterior commissure to the inner perichondrium

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.
Healing is complete 6 months after surgery

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).
Vessels have been stable for 2 months

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.
False cord phonation, open phase

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.
false cord vibratory closure

Closed phase of false vocal cord phonation (8 of 8)

True vocal cords are obscured by the false cord vibratory closure.

Glottic/vocal cord cancer

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Left vocal cord cancer

Glottic/vocal cord cancer (1 of 2)

Left vocal cord cancer, abducted breathing position, standard light.
left cord moves normally with tumor

Glottic/vocal cord cancer (2 of 2)

Phonation, standard light, shows that the left cord moves normally. Tumor is mostly exophytic (growing outward like broccoli, rather than inward, like an onion).

Supraglottic cancer

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circumscribed exophytic squamous cell carcinoma at the petiole

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.
aberrant tumor vessels

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.
tumor does not cross the plane of the ventricle

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.
tumor’s aberrant vessels under strobe light

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, before and after surgery

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new hypopharyngeal cancer

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.)
Trumpet maneuver

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.)
tumor in trumpet maneuver

Hypopharyngeal cancer (3 of 10)

Similar view to photo 2 (still with the trumpet maneuver), but now with the tumor outlined.
tumor in trumpet maneuver

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.
swollen arytenoid mounds

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.
surgical wound on vocal cord

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).
Maximum trumpet maneuver

Hypopharyngeal cancer: 1 week after surgery (7 of 10)

Maximum trumpet maneuver. Closer view of the surgical wound. Compare with photo 4.
left pyriform sinus

Hypopharyngeal cancer: 1 week after surgery (8 of 10)

View into the left pyriform sinus, where the tumor was most bulky.
swallowing crescent

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.
hypopharyngeal/ postcricoid stenosis

Hypopharyngeal cancer: several months after surgery (10 of 10)

With the trumpet maneuver, again splaying open the hypopharynx, as in photo 2. Notice the hypopharyngeal/ postcricoid stenosis; the dotted lines represent what would be a normal-sized opening.

Verrucous carcinoma, before and after laser treatment

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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.

Verrucous carcinoma, several weeks after laser treatment (5 of 5)

During voicing. Arytenoid moves, but much of membranous vocal cord has been ablated as intended.

Cancer, HPV Subtype 16, before and after radiation

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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.

Cancer: HPV Subtype 16, after radiation therapy (5 of 5)

Strobe light, closed phase of vibration. The more normal right cord (left of image) unsuccessfully attempts to reach the left cord’s residual upper surface mucosa. Voice is functional but hoarse.

Vocal cord cancer, before and after radiotherapy

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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 of 7)

During phonation.

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, 2 months after radiotherapy (7 of 7)

Phonation. Compare with photo 3 of this series.

Vocal cord cancer, before, during, and after radiation

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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.

Vocal cord cancer, 6 months after radiation (8 of 8)

Strobe illumination, nearly closed phase of vibration. Oscillatory flexibility is preserved, but the vocal cord margins are not perfectly straight.

Vocal cord cancer

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large lobule projecting upwards

Vocal cord cancer (1 of 1)

Carcinoma right vocal cord with a large lobule projecting upwards and medial to the false cord, too.

Radiation induced web

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Marked laryngeal swelling

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.
superficial ulceration

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.
ulceration and 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.
flexible scope is used to break cords apart

Flexible scope used to separate vocal cords​ (4 of 4)

Using only topical anesthesia with patient in chair and not in the O.R., the flexible scope has been used several times to break the cords apart. Voice is instantly restored. The dotted line helps to see the separation of the forming scar ban.

Larynx cancer managed like “skin cancer”

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mid-cord elevation and subtle haziness

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).
elevation and hazy leukoplakia

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.
thulium laser coagulation

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.
white area will slough off

After thulium laser coagulation (4 of 4)

Distant view at the conclusion of laser treatment. The white area will slough off over the next several days.

Vocal cord CA—a case for radiation instead of laser resection

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vocal cords of long term smoker

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

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.
Suspicion of submucosal fullness in the anterior subglottis

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.
hazy granularity of the anterior subglottis

Two months later (4 of 4)

Nearly 2 months after completion of radiotherapy, the tumor appears to have melted away; the hazy granularity of the anterior subglottis (arrow) bears careful surveillance.

Scarring after cancer treatment but with very good voice

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Post laser excision

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

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

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.
lateral capillary reorientation

Close-up view (4 of 4)

At very close range, medial-to-lateral capillary reorientation—typical of superficial cordectomy after healing.

Cancer beginning to block airway

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tumor

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.
Tumor

Closer view (2 of 2)

At closer range.

Breaking the rules in larynx cancer

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Cancer, recurrent after radiotherapy

Recurrent cancer (1 of 8)

Cancer, recurrent after radiotherapy. Cancer treatment 'rules' dictate a radical anterior commissure resection or more likely, total laryngectomy.
cancer that crosses the anterior commissure

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.
inner perichondrium of the thyroid cartilage

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.
vocal cords are scarred and will not vibrate

One year postop (4 of 8)

A year post-op. 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.)
rue cords approximate but do not vibrate

True cord phonation (5 of 8)

Making voice, the true cords approximate but do not vibrate.
False vocal cords

False vocal cords (6 of 8)

The false cords travel toward each other...
False vocal cord closure

False vocal cord closure (7 of 8)

Here, they have come into full vibratory approximation.
True cords

True cords (8 of 8)

False cords separate, again revealing the non-vibrating true cords.

Biopsy of early vocal cord cancer

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diffusely abnormal-looking tissue on his vocal cords

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.
biopsy

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 finds cancer

Cancer finding (3 of 3)

Cup forceps have now been closed to encompass a small fragment of tissue. The pathologist’s answer after looking at this sample under the microscope: cancer

Tumor in trachea

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Tumor growing through wall of trachea

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.
Biopsy of cell carcinoma

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 has melted away

Tumor gone (3 of 4)

Soon after radiation therapy, the tumor has melted away, leaving a depression in the tracheal wall.
slow return of tumor

Slow return (4 of 4)

Eighteen months later, the patient has experienced a fairly durable response, with very slow return of tumor.

HPV 31 cancer cure

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Carcinoma in situ

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

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.
severe dysplasia/ CIS

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.
no stippled or other abnormal vascular marks

Seven years later (4 of 4)

Seven years later, at an annual visit, there are no stippled or other abnormal vascular marks. Voice has been very acceptable to the patient, if occasionally faintly husky.

Before and after radiation for vocal cord cancer

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Bilateral vocal cord cancer

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.
tumor vessels

"Tumor vessels" (2 of 4)

Note the bulky disease on both sides, with "tumor vessels."
radiotherapy

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.
Aberrant vessels

Vascular pattern (4 of 4)

At very close range, under narrow band light, this vascular pattern can be carefully monitored for stability. Aberrant, "suspicious" vessels (none seen here) are often the earliest indication of recurrent cancer.

Small, but dangerous!

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abnormality below the vocal cords

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.
closure of the vocal cords is good

Normal voice (2 of 4)

Voice is normal, because closure of the vocal cords and their vibration is not impeded.
biopsy-proven persistent cancer

Persistent cancer (3 of 4)

Closer view. This is biopsy-proven persistent cancer. Note infiltrative appearance and submucosal component at arrow.
T4 tumor

T4 tumor (4 of 4)

Why so dangerous? Radiation resistance can indicate a more aggressive tumor. And in this location, infiltration and even cartilage invasion (direction white arrow) may be present, making this a T4 tumor.

Unusual posterior and transglottic epicenter for larynx cancer

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tumor is transglottic

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.
accentuation of the vascularity

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.
bulk of tumor involves the cartilaginous glottis

Posterior commissure (3 of 4)

Magnified posterior commissure view shows that the main bulk of tumor involves the cartilaginous glottis. This is highly unusual.
Laser excision

A year later (4 of 4)

Laser excision was satisfying except that the deep margin was the cricoid cartilage and therefore radiation therapy followed laser excision for added "safety." Laser excision and radiotherapy were 9 years prior to this posting, at which point he remained free of disease.

Nice try, but on to radiation

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eft vocal cord lesion

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.
large bulky tumor

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).
endophytic growth pattern

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.
Vocal cords

Nice try, but on to radiation (4 of 4)

If significantly more vocal cord were removed, voice might also have been excessively compromised.

Progressive cricoarytenoid joint fibrosis/ fixation as a late complication of radiation

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oice is deteriorating

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.
The left vocal cord lateralizes incompletely

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.
no sense of atrophy of either cord

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.
nly the left vocal cord mucosa is flexible

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.

Progressive radiation fibrosis effects on the larynx and a solution to some of it

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forty years after curative radiation for a vocal cord cancer

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.
mucosa indraws and vibrates

Involuntary inspiratory voice (2 of 8)

With sudden inspiration, the darker mucosa (at the arrows) indraws and vibrates, making an involuntary inspiratory voice.
small mucosa capable of vibration

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.
vibrating mucosa in open phase

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.
cookie bites taken from posterior cords

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.
posterior vocal cord divots

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).
Vocal cords Three months post-surgery

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.
divots are smaller

Closer view, post-surgery (8 of 8)

In a closer view, as is always the case after complete healing, the divots are smaller than just after surgery.

Evolution of the wound after laser removal of a vocal cord cancer: Not pretty at first, but voice result can be very good

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Vocal cord cancer (1 of 8)

Bulky but superficial right vocal cord cancer (arrow, left of photo).

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.

Voice-making, four months post-op (8 of 8)

Making voice, again that lateral deviation of the right vocal process (arrow, left of photo). Voice is very functional but a little weak. Vibratory blur is greater for left than right cord.

Laser can beat cancer and spare voice even after radiotherapy failure

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no vascular abnormality or leukoplakia is seen

Healing post-laser excision(4 of 4)

Now at 18 weeks after laser excision, healing is truly complete. Even under narrow band light and at close range, no vascular abnormality or leukoplakia is seen. Voice is remarkably good, without audible " effort," or syllable dropouts. Obviously, close follow up is required.
medial-to-lateral reorientation of capillaries

Post-laser excision (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).
areas of leukoplakia and stippled vascularity

Leukoplakia and Stippled Vascularity(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."
bilateral disease

Return of cancer (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.

How a vocal cord heals after laser removal of a cancer

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squamous cell carcinoma

squamous cell carcinoma (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.
1 week after laser excision

1 week after 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.
upper and lower lips with central depression

Difficulty speaking (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.
round granuloma

Natural granulation after laser excision (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.
abnormal post-laser capillary pattern

Abnormal capillary pattern (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.
Stiff right vocal cord

Stiff right vocal cord (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.

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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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, 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:

Candida can resolve quickly

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Steroid induced candida growth

Steroid-induced candida growth (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.
candida

Candida (2 of 4)

In this closer view, the “inflammatory surround” typical of candida (but not garden-variety leukoplakia) is better seen.
candida colonies and surrounding inflammation are nearly resolved

2 weeks after fluconazole treatment(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.
residual hazy white

Fluconazole (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, Before and After Treatment

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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, 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

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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

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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

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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.

Candida Before and After Fluconazole

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Chronic hoarseness

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

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

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.
Microvascularity

Microvascularity (4 of 4)

At closer range, the microvascularity is easily visible. No residual candida remains.

Laryngeal Candida in A Singer

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Candida colonies

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.
irregular margins and white lesions

Phonation, open phase (2 of 4)

Producing voice under strobe light, the irregular margins and white lesions are seen.
fluconazole treatment

Recovered voice (3 of 4)

After a course of fluconazole, voice has recovered fully. The white lesions are gone. Compare with photo 1.
Straight margins

Straight margins (4 of 4)

Again producing voice under strobe light, the margins are straight and no lesions are seen. Compare with photo 2.

Candida Infection with Cheesy Residue Before and After Fluconazole

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white lesions on residual epiglottis and posterior pharyngeal wall

white lesion (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.
cheesy residue clinging in large areas

Inside the laryngeal vestibule (2 of 4)

Now viewing inside the laryngeal vestibule, notice the cheesy residue clinging in large areas, representing large amounts of candida overgrowth.
white residue on esophageal remnant and posterior pharyngeal wall is gone

White Residue Is Gone (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.
inside the laryngeal vestibule

After treatment with fluconazole (4 of 4)

Again viewing inside the laryngeal vestibule, after treatment with fluconazole, the copious cheesy residue is also gone. Compare with photo 2.


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:

Capillary Ectasia, before and after Laser Coagulation

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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 (2 of 7)

Pre-phonatory instant, standard light.

Capillary ectasia (3 of 7)

Strobe light, open phase of vibration. Mucus is consistent with the patient’s known acid reflux laryngitis.

Closed phase (4 of 7)

Strobe light, closed phase of vibration.

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, after laser coagulation (6 of 7)

Same view, but under narrow-band illumination.

After laser coagulation (7 of 7)

Prephonatory instant, narrow-band illumination.

Capillary Ectasia and Hemorrhagic Polyp, before and after Treatment

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Capillary ectasia and hemorrhagic polyp (1 of 4)

Open phase of vibration, strobe light.

Capillary ectasia and hemorrhagic polyp (2 of 4)

Partially closed phase of vibration, strobe light.

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 and hemorrhagic polyp, after treatment (4 of 4)

Pre-phonatory instant, standard light, showing excellent match. Oscillatory ability entirely normal into extreme upper range in this professional singer.

Capillary Ectasia with Vocal Nodules

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Capillary ectasia with vocal nodules

Breathing position, note insignificant micro-web at anterior commissure.

Capillary ectasia with vocal nodules (2 of 2)

Phonatory position, with poor match of vocal margins.

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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 with vocal nodules (3 of 3)

Same patient, during voicing (phonation), shows how capillary ectasia can be less easily seen.

Capillary Ectasia, Before and After Laser Coagulation

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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, 6 weeks after laser coagulation (3 of 3)

Six weeks later; the capillaries have vanished, as expected.

Capillary Ectasia and Hemorrhagic Polyp

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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).

Capillary ectasia and hemorrhagic polyp (2 of 2)

Strobe illumination better reveals the polypoid component of the swellings. Some mucus accumulation, especially posteriorly.

Vocal Nodules, Leukoplakia, and Capillary Ectasia

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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 (2 of 4)

Prephonatory instant, standard light.

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.

Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (4 of 4)

Strobe light, moving towards closed phase of vibration.

Capillary Ectasia and Hemorrhagic Polyp, Treated by Thulium Laser

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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.