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.

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.

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.

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 (1 of 2)
Left vocal cord cancer, abducted breathing position, standard light.

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 (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.

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 (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 (2 of 5)
During voicing.

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 (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 (2 of 5)
Closer view.

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 (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 (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 (1 of 1)
Carcinoma right vocal cord with a large lobule projecting upwards and medial to the false cord, too.

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.

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.

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.

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.

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.

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.

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.

Close-up view (4 of 4)
At very close range, medial-to-lateral capillary reorientation -- typical of superficial cordectomy after healing.

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.

Closer view (2 of 2)
At closer range.

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.)

True cord phonation (5 of 8)
Making voice, the true cords approximate but do not vibrate.

False vocal cords (6 of 8)
The false cords travel toward each other...

False vocal cord closure (7 of 8)
Here, they have come into full vibratory approximation.

True cords (8 of 8)
False cords separate, again revealing the non-vibrating true 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.

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.

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

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.

Slow return (4 of 4)
Eighteen months later, the patient has experienced a fairly durable response, with very slow return of tumor.

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.

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.

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" (2 of 4)
Note the bulky disease on both sides, with "tumor vessels."

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.

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.

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.

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.

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.

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.

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.

Nice try, but on to radiation (4 of 4)
If significantly more vocal cord were removed, voice might also have been excessively compromised.

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.

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.

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.

(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).

(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.

(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.

(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, 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 (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 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 (2 of 2)
An even more dramatic case of candidiasis, in a different patient. Here, the colonies are more obvious and nearly confluent.

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.

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 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 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.

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.

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.

Microvascularity (4 of 4)
At closer range, the microvascularity is easily visible. No residual candida remains.

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.

Straight margins (4 of 4)
Again producing voice under strobe light, the margins are straight and no lesions are seen. Compare with photo 2.

(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.

(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 (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.

Capillary ectasia (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.

Capillary ectasia, after laser coagulation (7 of 7)
Prephonatory instant, narrow-band illumination.

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 (1 of 2)
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.

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 (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 (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 (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 (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 ectasia and hemorrhagic polyp, after treatment (7 of 7)
Also at F4 (~349 Hz). The mucosa of both cords is completely supple. The patient considers his voice to be perfectly normal—"original equipment."

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.

Capillary
Open phase of vibration shows that the longstanding capillary “lake” has been abolished.

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).

Residual bruising (2 of 4)
Less than a week after surgical removal, residual bruising is seen.

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.

Margins match (4 of 4)
Under strobe light, the margins match perfectly at D5 (587 Hz) and vibratory flexibility is equal to the unoperated side.

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…

Capillary ectasia (3 of 3)
Slightly greater magnification and narrow band light point out more clearly the capillary ectasia. Now we know that for complete restoration of voice and of mucosal endurance, surgery will likely be needed, assuming this fits with the patient’s goals.

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.

(7 of 7)
Under standard light at F5 (698Hz), the projecting polyp is also virtually gone. Compare with Photo 2.

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.

Cervical osteophyte (1 of 1)
Panorama of the hypopharynx and larynx. The posterior pharyngeal wall protrudes forward and seems to contact the posterior surface of the arytenoid cartilages.

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.

Gravity aiding again in swallowing (7 of 7)
Blue-stained water flowing into the esophagus mostly by gravity.

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 (2 of 2)
Same patient, as cords are arriving at phonatory contact. The medial surface of the left arytenoid cartilage will fit into the cleft between the two lobes of the contact granuloma.

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, 5 months later (9 of 11)
Phonation.

Contact granuloma, one year later (10 of 11)
Another seven months later. The bruise is smaller but still visible.

Contact granuloma, one year later (11 of 11)
Phonation.

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).

Contact granuloma (3 of 3)
As the vocal cords now almost meet, the arytenoid fits into the granuloma cleft like a key in a lock. This contact of the arytenoid show clearly the reason for the cleft and bilobularity.

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.

Closed phase (7 of 8)
Low in the female range, at A3 (220 Hz), closed phase of vibration.

Open phase (8 of 8)
Open phase of vibration at the same pitch, showing that only the right cord (left of photo) vibrates.

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.

Tri-lobed (6 of 6)
Another view, now showing clefts 1 and 2, as well as all three lobes of the granuloma. The plan is to allow granuloma maturation and spontaneous detachment.

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).

One year later (4 of 4)
Nearly a year later, the granuloma is healed. Lesions like this usually eventually heal, but can take many months and even a year or more.

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.

Rapid inhalation (4 of 4)
With rapid inspiration, the granuloma flutters, causing its blurring. Detachment within weeks is expected.

"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.

One year post-injection (6 of 6)
Now a year after the steroid injection, the granuloma has finished its maturation process and is gone. Only a subtle residual elevation is visible.

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.

At closer range (2 of 5)
At closer range.

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.

One month post-op (5 of 5)
A month later, no residue of the synechiae is seen, and the vocal cords can spring farther apart than in photo 1.

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.

Cricopharyngeal dysfunction: after myotomy, resolved (2 of 2)
After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

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.

Pharyngeal walls (4 of 4)
As the patient swallows, the pharyngeal walls come to near-approximation from lateral to medial, just before the view is lost during the upheaval of the swallow.

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: after myotomy, resolved (1 of 2)
After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

Cricopharyngeal dysfunction, 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".

Reflux into hypopharynx (3 of 3)
Another two seconds later, the larynx has fully opened post-swallow. The post-swallow hypopharyngeal re-emergence of the blue-stained water is apparent.

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'.

More water (4 of 4)
After several more boluses of blue-stained water, the applesauce has mostly washed away, and the same findings of photo 3 are seen more clearly.

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.

Closed position (4 of 4)
Back again above the sphincter, now in closed (contracted) position.

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 (2 of 4)
Closer view. Dotted lines signify normal airway diameter.

Croup, aka laryngotracheitis (3 of 4)
Even closer view showing redness and narrowing of the posterior subglottic airway.

Croup, aka laryngotracheitis (4 of 4)
View within the posterior subglottic narrowing.