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.
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).
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
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.
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.
Possible Open Epidermoid Cyst
Open Cyst and Sulcus in Same Patient
Epidermoid Cyst, Before and After Removal
Bilobed Epidermoid Cyst and Shimmying Vibration
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.
Esophageal Stenosis from Radiation
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.
More Interesting Esophageal Findings of R-CPD (Inability to Burp)
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
Three Views of the Entrance to the Esophagus From Far Away to Close-up
Endoscopic View of Esophageal (Acid) Reflux
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
The Esophagus Doesn’t Like Being Stretched for Years Due to Untreated R-CPD
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.