When, during the oral preparatory phase of swallowing (chewing, mixing with saliva), some of the liquid or food material escapes and begins to drain down into the hypopharynx. A tendency toward early spillover can accompany a poor ability to “organize” the food material within the mouth. Individuals with this tendency can include those who have had a partial glossectomy, have a neurological disease like ALS, or have suffered a stroke. The finding of early spillover is often seen as well with a delayed swallow reflex.
Effortful swallow technique
To perform the action of swallowing with greater conscious effort and vigor than comes naturally or seems necessary to the person. Normally, a person swallows without much conscious effort. However, individuals who suffer from weaker or less organized swallowing function (e.g., presbyphagia) can benefit from a superimposition of volitional effort. Just before swallowing any food or liquid, the person is told by the swallowing therapist, a family member, or him or herself: “Now, swallow hard!”
A technology that detects the degree of closure or opening of the vocal cords by measuring the electrical resistance between two electrodes placed on either side of the neck. Electroglottography, or EGG, can give good information about degree of compression of one vocal cord against the other. It provides a waveform that represents the closed and open phases of vocal cord movement.
At present, the value of EGG and the measures generated from this technology may be viewed differently in different institutions or clinics. At our practice, we believe that these measures offer little to the typical clinical needs of the diagnostic process, but may be of interest to those doing voice research and of help in voice therapy.
Electromyogram (EMG) is a diagnostic study that provides information about the integrity of the muscles and the nerves in the body. Laryngeal electromyogram (LEMG), of course, limits the study to muscles and nerves of the larynx. Intense visual analysis of the larynx can clearly show the neurological status of three major muscles of the larynx.
Our physicians are proficient in LEMG and used it much more often before discovering the visual correlates of various laryngeal neuropathies. They continue to use LEMG frequently, however, to perform Botox™ injections for spasmodic dysphonia. In this procedure, a very small, sterile disposable needle is inserted into various muscles of the larynx. Then, using an amplifier, loudspeaker, microprocessor, and other high tech equipment, the examiner may see and/or hear how the laryngeal muscles and nerves are working and/or determine the best location for Botox™ injection.
Elicitation means to draw or bring forth something that is latent or otherwise hidden. At our practice, where the integrative diagnostic model is used, during the vocal capability battery the examiner elicits the patient’s vocal phenomenology to uncover a working diagnosis, by asking the individual to perform a variety of vocal tasks designed to uncover the deficit or abnormal phenomenology. For example, weakness that is not very evident during quiet conversation may become obvious when the individual is asked to yell or project the voice.
Endoscopic surgery refers to surgery done “inside” using a special scope that goes through the mouth or nose, rather than, for example, through an incision on the neck. Laryngoscopy means to look inside the larynx, esophagoscopy means to look into the esophagus, and bronchoscopy means to look inside the tracheobronchial tree of the lungs.
Also known as a breathing tube, an endotracheal tube is placed during surgery to deliver oxygen and anesthetic gases in a controlled fashion. It may also be used in gravely ill persons who need the assistance of a ventilator. Rarely, it may cause injury to the posterior part of the larynx, especially when the tube remains in place for many weeks.
A cyst that has a wall lined by squamous epithelium and therefore accumulates keratin. An epidermoid cyst may also be called an epidermal cyst, an epidermal inclusion cyst, or a keratin cyst. In the larynx, an epidermoid cyst typically occurs in one or both of the vocal cords. These epidermoid cysts are usually white in color, and are often seen in vocal overdoers.
How an epidermoid cyst forms:
Epithelium is the tissue that makes up the outermost layer of skin, and is also the top layer of tissue that lines the interior of the body. Epithelial tissue produces a protein called keratin. If any of this epithelial tissue somehow becomes buried in the subepithelial layer, then the keratin it produces may become trapped and accumulate within the subepithelial layer, leading to an epidermoid cyst.
In the vocal cords, an epidermoid cyst may sometimes occur simply due to a congenital defect: keratin-producing epithelial cells were buried in the subepithelial layer from birth. Some believe this is the explanation even when the initial manifestation of hoarseness doesn’t occur until adulthood. In these cases, however, it is more logical to see vocal overuse as the key factor, perhaps because epithelial cells can get buried in the subepithelial layer as the vocal cord mucosa heals in response to a vocal overuse injury.
Vocal symptoms of an epidermoid cyst:
An epidermoid cyst may cause vocal limitations similar to that of vocal nodules. However, patients with epidermoid cysts are more likely to experience diplophonia in the upper voice, and as the voice ascends in pitch, its impairment may manifest itself much more abruptly and severely at a particular frequency, as compared to most patients with nodules, who experience a more gradual transition to increasing impairment as they ascend in pitch.
Appearance of an epidermoid cyst:
An epidermoid cyst of the vocal cord is generally most visible on the cord’s upper surface, and is whitish in color. In comparison with mucus retention cysts, epidermoid cysts project less from the cord, and when smaller, they can be quite subtle and easy to miss. Sometimes an epidermoid cyst will have spontaneously ruptured but still retain some of the accumulated keratin (an open cyst); in this case, the cyst’s outline may be more subtle, and usually assumes an oval shape with the long axis oriented anteriorly and posteriorly. An open cyst may also produce a mottled appearance.
Treatment for an epidermoid cyst:
Speech therapy is important for patients who are vocal overdoers, to help prevent the future occurrence of this or other vocal overuse-related lesions and injuries, but it will not resolve the cyst. Surgery can be performed to remove the cyst. This requires an incision and then dissection of the entire intact sphere of the cyst. The surgery is technically far more difficult than is removal of nodules or polyps, and is more likely to cause chronic stiffness of the disturbed mucosa. Still, results can be very good, especially if the overlying mucosa is relatively thick.
Epidermoid cyst (1 of 3)
Epidermoid cyst, right vocal cord. Note white submucosal mass predominately on upper surface of the cord, but with bilateral free margin elevation as well.
Teacher with longstanding hoarseness (1 of 4)
Elementary school teacher with longstanding hoarseness, told that she had a “nodule” on one vocal cord .
Epidermoid cyst and polypoid nodule seen (2 of 4)
Closer inspection, under narrow band light, shows that she has an epidermoid cyst of the left cord (right of photo) and a polypoid nodule with what looks like a small sulcus (arrows) of the right cord (left of photo).
Six days post-surgery, voice improved (3 of 4)
Six days after vocal cord microsurgery to address both lesions seen in photo 2, voice is already dramatically improved. This is a distant view under standard light.
Expected early postsurgical swelling (4 of 4)
Also six days postop, at close range under strobe light. As the cords approach phonation position, note the expected very early postsurgical swelling of the right cord (left of photo), and linear incision (tiny dots) through which the cyst was removed from the left cord (right of photo). No later postoperative photos are available.
Capillary ectasia and white submucosal abnormality (1 of 3)
Left vocal cord (right of photo) has not only overlying capillary ectasia, but a white submucosal abnormality.
Hoarse voice (1 of 4)
A young woman with a history of repeated loud cheering during athletic activities, to the point of hoarseness. She has a sulcus of the right cord (left of photo), and an open cyst of the left (right of photo). Openings from sulcus and cyst are indicated by dotted lines.
Cyst + sulcus (2 of 4)
Narrow band light. The lateral lip of a sulcus is often bordered by a prominent capillary as seen here. An open cyst assumes an elliptical shape in the anteroposterior direction. It fails to empty completely because the opening draining it is smaller than the diameter of the cyst.
Epidermoid cyst (1 of 4)
A large and somewhat bi-lobed epidermoid cyst of the right vocal cord (left of photo). The cyst is white due to retained keratin. A mucus retention cyst tends instead to be either clear, or yellowish.
Post microsurgery (3 of 4)
A week after microsurgical removal. The mucosa has been preserved, but capillaries are congested. The incision line on the upper surface of the cord is indicated by the subtle dotted line. Voice is already much improved.
4 months post surgery (4 of 4)
4 months after surgery, expected inflammatory change remains evident, but the incision line is no longer seen. The small white dot at the margin is mucus. Under strobe light, the right cord (left of photo) has regained partial ability to vibrate. Because its match with the left fold (right of photo) is precise, voice is surprisingly good, even at high pitch.
Distant view (1 of 6)
This middle-aged coach has been grossly hoarse for many months. In this distant view, you can see a white submucosal mass of her left vocal cord (right of photo). It already appears to be an epidermoid cyst.
Closer view, narrow band light (2 of 6)
At close range under narrow band light one can observe a kind of bi-lobularity.
Closure under strobe light (3 of 6)
Under strobe light at the low pitch of B-flat 3 (233 Hz), closure is complete.
Open phase (4 of 6)
Open phase of vibration at the same pitch. Both cords open and the larynx creates just one pitch.
An octave above (5 of 6)
At an octave above, B-flat 4 (466 Hz), the left vocal cord (right of photo) no longer vibrates. The open phase of vibration includes only the anterior segment here.
The epiglottis is the flexible, leaf-like cartilaginous structure that sits upright in the pharynx, between the base of the tongue and the larynx. The root or petiole of the epiglottis is inside the upper part of the thyroid cartilage just above the anterior insertion of the vocal cords. During swallowing, the epiglottis bends backward to cover the entrance of the larynx, helping to divert food into the esophagus.
Esophageal manometry is a test that measures the resting pressures and dynamic pressure waves within the esophagus. Esophageal manometry may be performed when a barium esophagram shows dysmotility, stasis of material, failure of lower esophageal sphincter relaxation (achalasia), etc.
Narrowing in the esophagus. This narrowing can be congenital, or can result from causes such as trauma, surgery, chronic inflammation, cancer, and radiation. Esophageal stenosis can create swallowing difficulty, especially with solids. A common treatment approach is to begin with dilation (if a malignancy is not present) or a series of dilations, using a balloon dilator. If this measure fails, sometimes a stent is placed endoscopically.
Post radiation therapy (1 of 3)
This man finished chemotherapy + radiation therapy elsewhere for base of tongue cancer with neck disease, finishing a year prior to this examination. Despite swallowing therapy and VitalStim treatments, he was unable to swallow even his own saliva.The actual diagnosis is seen in the next photo. Panoramic view of hypopharynx.
Small stricture (2 of 3)
During “trumpet maneuver,” the larynx pulls anteriorly and reveals a stricture of very small size, at arrow. This would normally allow passage of saliva, but in this case it does not. View photo 3 for explanation.
Esophageal stenosis (3 of 3)
The stricture ends as a virtually blind pouch. Here, the scope has been inserted to a distance of nearly an inch into the stricture seen in prior photo, at which point a near-total stenosis is found. The arrow shows a pinhole opening less than a millimeter in diameter. The dotted line shows the expected size of opening at this level.
Esophagoscopy is a procedure by which the examiner looks inside the full length of the esophagus, as well as the stomach if desired, in order to diagnose an abnormality or to take a biopsy of an abnormal lesion.
Dramatic dilation of the esophagus in a person with R-CPD due to buildup of swallowed air that he cannot belch to get rid of. : Series of 2 photos
Esophagus, after total laryngectomy (1 of 4)
After total laryngectomy. At the level where larynx was, there is no airway seen. The small air collection (at arrow) is within the reconstructed esophagus, at the level of the neck.
Esophagus, after total laryngectomy (2 of 4)
At the base of neck, the trachea has been sutured forward to neck skin. In this view, the tracheoesophageal prosthesis (TEP) can be seen traversing the shared tracheoesophageal party wall. In this view, the esophagus is very dilated with air.
Esophagus, after total laryngectomy (3 of 4)
Below the tracheostome, the entire trachea is again seen. The horseshoe-shaped anterior segment of the trachea’s wall, two-thirds of the total circumference, is the trachea’s cartilaginous component. The posterior one-third is the membranous trachea, which also constitutes the anterior one-third of the esophagus, and is also called the tracheoesophageal party wall. The esophagus is again dilated with air here.
(1 of 3)
During swallowing, the “the swallowing crescent” -- outlined by the dotted line -- receives swallowed food or liquid in order to funnel it into the esophagus (not open in this view). The asterisks are reference points to compare all three photos. One does not want any material to enter the laryngeal vestibule (hashed lines).
(2 of 3)
A closer view. The esophagus is still not open in this view. Compare asterisk with prior and following photo.
Liquid in the lower esophagus (1 of 2)
After swallowing blue food-colored water, it sits momentarily in the lower esophagus waiting to enter the stomach. The saliva bubbles indicated by arrow and dotted lines are for reference with the next photo.
Acid Reflux int he lower esophagus (2 of 2)
A moment later, without effort or gag, the blue water refluxes (zooms upwards from the lower esophagus and stomach) towards the stationary camera chip. If this occurred with acidic stomach contents, the esophagus would suffer chemical irritation and the patient might experience “heartburn.”
View of the mid-esophagus (1 of 2)
This view in the mid-esophagus was obtained with a 3.6mm scope without an air channel. The dilation is from the patient’s own unbelchable air. Note quite major lateral dilation of the esophagus, indicated by concentric dotted lines and arrows. Dilation is not possible in the direction of unyielding spine (S) and trachea (T).
View of the mid-esophagus (2 of 2)
A view that shows more clearly the indentation of trachea (T). Persons with this much dilation of esophagus often complain as much of chest pressure as they do abdominal bloating. This man has experienced “large” reduction of R-CPD symptoms after botulinum toxin injection into his upper esophageal sphincter (cricopharyngeus muscle).
Essential Voice Tremor
Essential voice tremor is a neurological disorder that causes a regular wavering of the voice, not unlike an exaggerated singer’s vibrato, except that it occurs during speech as well as during singing. This disorder is one subtype of a neurological disorder called essential tremor, and it should be distinguished from another neurological disorder that sometimes includes a tremor component and consequent wavering in the voice: laryngeal dystonia. Essential tremor and dystonia are two separate neurological disorders. The tremor caused by essential tremor tends to be more consistent and steadily rhythmic than the tremor sometimes caused by dystonia. For more on how to distinguish the tremor manifestations of these two classes of disorders, see dystonic tremor of the voice or larynx.
Exercise intolerance is an inability to participate in any significant level of aerobic activity without becoming unacceptably short of breath. When this is the result of airway disturbance (as opposed to heart or lung disease), the individual may make involuntary breathing noises, such as stridor, or involuntary inspiratory phonation.
The act of returning air from the expanded (filled) air sacs (alveoli) of the lungs upwards through the tracheobronchial tree, between the vocal cords, and then out the nose or mouth. Also known as exhalation.
Exhaled air is important for producing voice. In order to produce voice, the vocal cords will close together as exhaled air is moving up between them, causing the cords to vibrate and thereby transducing this air into sound.