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Laryngopedia

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

Laryngopedia By Bastian Medical Media

Multimedia Encyclopedia


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Early Spillover

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!”



Electroglottography (EGG)

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)

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

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

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. 



Endotracheal Tube

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.

Nuances of Endotracheal Tube Injury Distinguished from Paralysis

This woman with high-risk comorbidities of diabetes and obesity, was in ventilated in ICU more than a month for pulmonary complications of Covid-19 infection. She had an orotracheal tube in place for 3.5 weeks, and then a tracheotomy tube was placed. Now at her first visit a year later, she remains tracheotomy-dependent, and is told she has bilateral vocal cord paralysis (disproven in the above photo series).

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Maximum glottic opening (1 of 8)

Is it paralysis, as diagnosed elsewhere? At a fairly distant view, the maximum opening between the vocal cords at any phase of breathing appears to be approximately a 4mm glottic opening.

Undersurface mucosa indraws (2 of 8)

When the patient inspires rapidly with tracheotomy tube plugged, the vocal cord undersurface mucosa indraws (grey bands at dotted lines), further narrowing the glottic chink. One sees a faint suggestion of breathing tube injury (divot) at the arrow. Notably, there is a very low pitched rumbling sound heard that does not come from the glottis.

Phonation (3 of 8)

During phonation, the cords approximate fully, and in fact the voice is remarkably normal-sounding and she even has an excellent upper range.

Posterior commissure divot (4 of 8)

At close range while breathing with trach plugged, the posterior commissure divot subtly visible in Photo 2 is confirmed. A divot in the right posterior cord “always” indicates that the tube was taped to the left corner of the mouth. The patient’s mother confirmed that this was so.

Further evidence of scarring (5 of 8)

Angling farther posteriorly, additional evidence of inter-arytenoid and possible joint capsule injury is seen. Faint dotted lines outline this area. The problem is not bilateral vocal cord paralysis but posterior commissure scarring, tethering the arytenoids together.

View into trachea (6 of 8)

Looking now into the subglottis and trachea, there is narrowing only at trach entry site, accentuated functionally because the membranous trachea (MT) moves in and out with respiratory phase.

Vibration of trachea (7 of 8)

When the patient plugs the trach tube and inspires rapidly, the deep rumbling sound is again heard, and comes from vibration of the membranous trachea indrawing (arrows) and vibrating (zigzag line).

Open trachea beyond the tube (8 of 8)

A view past the tip of the trach tube shows no secondary area of tracheal stenosis.

The plan here is posterior commissuroplasty, followed by placement of a smaller trach tube and a trial of plugging. If plugging is tolerated during the day, she will need a sleep study with it plugged at night, given the tracheomalacia and her obesity.

Breathing Tube Injury—A Rare Complication of Intubation for General Anesthesia

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Inflamed vocal cord (1 of 5)

This patient had severe voice change after intubation for a 2-hour surgical procedure. She says voice was 100% before surgery and she awakened at 15%, a whisper with a bit of voice mixed in. Fortunately, across six weeks she has recovered partially to “70%.” The right cord (left of photo) looks “inflamed.”

Closer view (2 of 5)

At closer range, a little more detail is seen.

Scarring from intubation tube (3 of 5)

Under narrow band light, it appears that there is scarring of that fold likely from a laceration upon insertion of the tube. (She was told intubation was difficult.) A key finding, however: the right vocal process is turned slightly laterally, suggesting weakness of the LCA muscle.

Mucosal Injury (4 of 5)

Under strobe light, closed phase of vibration, it is almost as if there is loss of mucosa upper surface of right cord.

Flaccidity of right vocal cord (5 of 5)

Open phase of vibration shows flaccidity of the right cord, with a much larger lateral excursion / amplitude of open phase on the right (left of photo).

Conclusion: While we try to explain abnormality due to one cause, here, the patient has a mucosal injury and paresis of right TA and LCA muscles, which can also follow intubation. This explains why the initial postop voice was so weak and whispery, and also the rapid partial improvement. This voice will likely continue to improve and be very functional as a speaking voice. Fortunately, this person is not a singer, as clarity especially in upper notes, will likely be remain impaired even after full recovery.



Epidermoid Cyst

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.


Photos:

Cyst Removal

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Cyst removal (1 of 7)

Initial view with white sphere (cyst) shining through upper surface of left vocal fold.

Cyst removal (2 of 7)

After injection of lidocaine for hydrodissection (Bouchayer).

Cyst removal (3 of 7)

This incision must be ~75% longer than the diameter of the cyst. The most difficult parts of the dissection are typically adherence to the vocal ligament, and to the diaphanous overlying mucosal flap (held here in micro-alligator forceps).

Cyst removal (4 of 7)

As is occasionally the case, the cyst has leaked some of its contents, but its outline is still clearly visible, allowing complete and precise removal.

Cyst removal (5 of 7)

Scissors are used to release the cyst from filmy attachments, precisely at its margin.

Cyst removal (6 of 7)

The flap is released and returned to its original position; the incipient sulcus is still seen.

Cyst removal (7 of 7)

Retraction of the flap reveals the gossamer nature of the still-intact overlying mucosa.

Epidermoid cyst

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Right epidermoid cyst during breathing

Epidermoid cyst (1 of 2)

Right epidermoid cyst during breathing (Lab). Note whitish sphere not as prominent due to thicker overlying mucosa, vascularity and mucus, suggesting concurrent acid reflux.
mismatch of vocal cords

Epidermoid cyst (2 of 2)

Same patient, during phonation, showing mismatch. In addition, right side very stiff and non-vibratile (Lab).
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Teacher with longstanding hoarseness

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

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).
Vocal cords six days post surgery

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.
early postsurgical swelling

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.

Possible Open Epidermoid Cyst

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Capillary ectasia and white submucosal abnormality

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.
Prephonatory view, mtd

Prephonatory view, mtd (2 of 3)

Prephonatory instant shows some muscular tension dysphonia as well.
Open cyst

Open cyst (3 of 3)

Closer view. While an intact epidermoid cyst has a distinct outline, an open cyst develops a more mottled appearance. It may leak intermittently from a tiny dimple or sulcus which is sometimes seen at very close range.

Open Cyst and Sulcus in Same Patient

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Openings from sulcus and cyst on vocal cords

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.
ateral lip of a sulcus is bordered by a prominent capillary

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.
Closed phase

Closed phase (3 of 4)

Closed phase of vibration, strobe light.
Open phase

Open phase (4 of 4)

Open phase of vibration.

Epidermoid Cyst, Before and After Removal

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bi-lobed epidermoid 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.
Phonatory view

Phonatory view (2 of 4)

While making voice, the affected side does not vibrate.
Post microsurgery

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 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.

Bilobed Epidermoid Cyst and Shimmying Vibration

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white submucosal mass on left vocal cord

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.
bi-lobularity

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

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

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

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.
Shimmying vocal cord

"Shimmying" vocal cord (6 of 6)

The open phase a few frames later includes only the posterior segment. Clear sound is produced with this "shimmying" right vocal cord (left of photo) vibration. At other pitches the cord vibrates chaotically with two pitches.

Videos:

Nodules and Other Vocal Cord Injuries: How They Occur and Can Be Treated
This video explains how nodules and other vocal cord injuries occur: by excessive vibration of the vocal cords, which happens with vocal overuse. Having laid that foundational understanding, the video goes on to explore the roles of treatment options like voice therapy and vocal cord microsurgery.


Epiglottis

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

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.



Esophageal Stenosis

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.


Photos:

Esophageal Stenosis from Radiation

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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

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.


Photos:

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left pyriform sinus

Esophagoscopy (1 of 4)

View into left pyriform sinus and post-arytenoid area.
initiation of swallow

Esophagoscopy (2 of 4)

Similar view at initiation of swallow, with opening of the upper esophageal sphincter (cricopharyngeus muscle) to allow admission of the tip of the scope.
Esophagoscopy

Esophagoscopy (3 of 4)

View within esophagus, using mild air insufflation.
Within hiatal hernia

Esophagoscopy (4 of 4)

Within hiatal hernia.

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.

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

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mid-esophagus

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).
mid-esophagus

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).


Esophagus

The esophagus is the passageway that connects the throat or pharynx to the stomach. Technically, the esophagus begins at the upper esophageal sphincter and ends at the lower esophageal sphincter.


Photos:

Esophagus, After Total Laryngectomy

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X-Ray of Post Laryngectomy

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.
X-ray of TEP

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.
X-ray of Esophagus

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.
x-ray of dilated esophagus

Esophagus, after total laryngectomy (4 of 4)

At the mid-thoracic level, the trachea is splitting into the two mainstem bronchi, and the esophagus is still seen due to dilation with swallowed air.

Three Views of the Entrance to the Esophagus From Far Away to Close-up

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Swallowing Crescent (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).

Closed esophagus (2 of 3)

A closer view. The esophagus is still not open in this view. Compare asterisk with prior and following photo.

Open Esophagus (3 of 3)

At the moment of a dry swallow, the esophagus opens as shown here. Again, the asterisks allow comparison with photos 1 and 2.

Endoscopic View of Esophageal (Acid) Reflux

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Liquid in the lower esophagus

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 in the lower esophagus

Acid reflux in the 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.”

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

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mid-esophagus

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).
mid-esophagus

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).

The Esophagus Doesn’t Like Being Stretched for Years Due to Untreated R-CPD

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Lateral dilation from R-CPD

Lateral dilation from R-CPD (1 of 3)

In this middle-aged patient with R-CPD (inability to burp), now fully resolved (burping well for more than a year) after botox therapy. This view is pre-treatment, at mid-esophagus using an ENT scope. No air was insufflated to get this photo; the patient “has her own.” The aortic shelf is prominent, but observe the dramatic lateral dilation (arrows). S = spine; T = trachea.
Lateral dilation in the upper esophagus

Lateral dilation in the upper esophagus (2 of 3)

Now in the upper esophagus, arrows again depict the remarkable lateral dilation.
Medial-lateral stretch

Medial-lateral stretch (3 of 3)

Opening of the esophagus is constant, due to the patient’s retained air, but as air goes downward transiently, the lumen size is reduced, almost accentuating the medial-lateral “stretch” of the esophagus. * denotes the same place in photos 2 and 3, for reference.

Videos:

What Burping Actually Looks Like
In this video, Dr. Bastian takes us into the esophagus to see what happens when you burp!


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

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.



Expiration

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.



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