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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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False Cord Phonation

False cord phonation is making voice by vibrating the false vocal cords. This kind of phonation is unlike normal phonation or voice-making, which uses the true vocal cords.

This produces a much deeper, rougher voice quality than normal phonation. It is purposefully used in certain kinds of vocal performance, such as Tibetan chant or heavy metal screaming. It can also occasionally serve as an alternate voice for a person whose true cords are unable to vibrate—due, for example, to their surgical removal or to scarring. It can also be produced concurrently with true cord phonation to produce a “Louis Armstrong” effect.


Photos:

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False cord phonation due to flaccid true cords (1 of 5): before false cords begin to vibrate

An elderly man, quiet by nature who uses the voice little, complains of weak, gravelly voice quality. This view of phonation, standard light, shows a slightly wider dark line of phonatory blurring. Also, the false vocal cords are overly approximated, but not yet participating in vibration (for that, see images 4 and 5).

False cord phonation due to flaccid true cords (2 of 5): before false cords begin to vibrate

Strobe light reveals an unusually wide amplitude of vibration, denoting flaccidity of the true vocal cords.

False cord phonation due to flaccid true cords (3 of 5): before false cords begin to vibrate

Maximum closed phase shows the telltale residual opening at the anterior commissure (from this perspective, the lowermost end of the true cords), also a potent indicator of flaccidity.

False cord phonation due to flaccid true cords (4 of 5): after false cords begin to vibrate

When asked to produce louder voice, the false cords begin to participate in vibration, and a rough, gravelly superimposed “ godfather” quality arrives. Notice that the true cords are in at least partial open phase of vibration.

False cord phonation due to flaccid true cords (4 of 5): after false cords begin to vibrate

When asked to produce louder voice, the false cords begin to participate in vibration, and a rough, gravelly superimposed “ godfather” quality arrives. Notice that the true cords are in at least partial open phase of vibration.

True and False Cord Voice

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Thin and weak voice

Thin and weak voice (1 of 4)

This man has a thin and weak voice, often with a superimposed gravelly, rough quality. In this view, false cords, marked with dotted lines, obscure the true cords and their vibration is indicated by blurred margins.
True cords during closed phase

True cords during closed phase (2 of 4)

At much closer range under strobe light, the true cords are approximated during the closed phase of vibration. The false cords should remain lateralized throughout voice production (but don’t).
Flase cords during open phase

Flase cords during open phase (3 of 4)

From same viewing position, but during open phase of vibration, showing very “wide” amplitude of vibration caused by flaccidity. The false cords are beginning to come together.
False cords during phonation

False cords during phonation (4 of 4)

Withdrawing the scope slightly, one can now see the false cords have completed their vibratory closure, explaining the superimposed rough quality. The arrow points to where true cords are, hidden in darkness below the false cords.

True and False Cord ‘Godfather’ Voice

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Bowing

Bowing (1 of 4)

The true cords are together posteriorly but with major bowing seen at the pre-phonatory instant, to explain the husky, weak quality of voice.
Closed phase

Closed phase (2 of 4)

As a result of the need to compress together the weak true cords, false cords also overcompress. This is closed phase of true cords; false cords have not yet reached midline as they are vibrating more slowly than the true cords.
False cord phonation

False cord phonation (3 of 4)

Now the false cords have come into contact but below them the true cords have begun their open phase of vibration. We hear the husky, weak true voice with the superimposed rough, gravelly false cord phonation.
True and False cords in open phase

True and False cords in open phase (4 of 4)

The true cords are at maximum open phase with enormous lateral excursions typical of flaccid cords. False cords are also at open phase, but as shown in photos 2 and 3, they are vibrating at a lower frequency and out of phase with the true cords.

True and False Cords Vibrate Mostly in Tandem (in phase)

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True cords vibrate

True cords vibrate (1 of 4)

At relatively high pitch, only the true cords vibrate. This is closed phase, under strobe light.
Open phase of vibration

Open phase of vibration (2 of 4)

Open phase, same pitch.
True and false cords, closed phase

True and false cords, closed phase (3 of 4)

At low pitch, where false cord phonation is facilitated. Both true and false cords are in closed phase of vibration (though the true cords are obscured by the false cords).
True and false cords, open phase

True and false cords, open phase (4 of 4)

Both true and false cords are simultaneously in open phase of vibration.

Another Voice Without Vocal Cords

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Hemilaryngectomy

Hemilaryngectomy (1 of 4)

After removal of the anterior larynx (hemilaryngectomy) for cancer that recurred after radiation therapy. Though not well seen here, the vocal cords are surgically absent. The black dot seen is for orientation to the next photo. A = arytenoid; E = epiglottis.
Within the larynx

Within the larynx (2 of 4)

A view within the larynx. Note again that vocal cords are surgically absent, with only the arytenoid cartilages remaining at the level of the cords. The black dot, on the left arytenoid cartilage, orients to the prior photo. The dot is on the right vocal process.
arytenoid mounds

"Wolfman Jack" voice (3 of 4)

The patient is about to produce his rough, “Wolfman Jack” voice but the arytenoid mounds have not yet started to vibrate.
Arytenoid vibration

Arytenoid vibration (4 of 4)

Aggressive voice use brings arytenoid mounds into vibration (notice blurring). With time and practice, this kind of supraglottic voice can serve moderately well, but it is always difficult to be heard in competition with background noise.

Audio:

True cord phonation

False cord phonation

True and false cord phonation



False Vocal Cord

A cord of tissue separated from the true vocal cord by the laryngeal ventricle. The false vocal cord serves as a secondary sphincter to help close the larynx when swallowing. While not “intended” for voicing, the false cords can be brought into vibration, but create a deep, rough voice quality.



Falsetto register

Falsetto register is a term that is applied especially to men to the high “feminine” quality sound available to most above the chest (normal speaking) register. Some call this head register. Falsetto is used in some countertenor voices and, in other cases, for comic effect. Some use “falsetto” as a term to denote the voice quality above the first break, whether in the male or female voice. This is the quality used by female classical singers, as compared with a more intense chest voice phonation used in most popular styles. The language and concepts used to describe vocal registers vary widely; hence, care is warranted so as to not take any single definition, such as ours, too seriously!



Flaccidity of the Vocal Cords

Vocal cord flaccidity correlates to some degree with atrophy of the muscle comprising them. Bowing also accompanies flaccidity most of the time. It is possible to have bowed/slender vocal cords that are not particularly flaccid—they still vibrate with good firmness and resilience. Similarly, vocal cords that appear to have good bulk (and are not atrophied) can nevertheless have a flaccid vibratory pattern. Photos below show the visual findings of flaccidity as distinct from bowing and atrophy. Voice manifestations of flaccid vocal cords are similar to bowing in cases such as:

  • Loss of “edge”
  • Reduced ability to be heard in noisy places
  • Reduced vocal endurance (The voice becomes fuzzier or raspier and more air-wasting as the day progresses and the atrophied muscles tire).

Vocal Cord Flaccidity at Two Pitches

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Vocal Cord flaccidity

Vocal Cords (1 of 5)

This woman in her sixties is experiencing loss of vocal strength. Her voice becomes raspier as the day progresses. Under standard light during voicing at her average pitch for speech, F3 (175 Hz), vibrating cords have blurred margins. Notice that the gap at the anterior vocal cords is wider (arrow) than between the rest of the cords. This anterior gap is a typical finding of flaccidity.
the gap is wider anteriorly

Wide anterior gap (2 of 5)

Still at her habitual pitch for speech, F3 (175 Hz), the closed phase is not closed at all! And again, the gap is wider anteriorly. This incomplete closure explains her air wasting, fuzzy voice quality.
Vocal Cords

Vocal Cords (3 of 5)

Still at her habitual pitch for speech, F3 (175 Hz), the closed phase is not closed at all! And again, the gap is wider anteriorly. This incomplete closure explains her air wasting, fuzzy voice quality.
telltale small gap

Telltale small gap (4 of 5)

Higher pitch lengthens the vocal cords (stretches them longitudinally, making them less flaccid: think “rubber band”) Yet under strobe light at C4 (252 Hz), that telltale small gap is still seen anteriorly during closed phase of vibration.
vocal folds fly less far laterally

Vocal Cords (5 of 5)

At the same pitch, the vocal folds fly less far laterally, but definitely farther than would normally be seen at moderate loudness at this pitch.

Flaccid Vocal Cords

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Flaccid vocal cords

Flaccid vocal cords (1 of 4)

Pre-phonatory instant, standard light.
Flaccid vocal cords

Flaccid vocal cords (2 of 4)

Vibratory blur with standard light. Note relatively wide "gray" zone of blur.

Flaccid and bowing (3 of 4)

Dramatic lateral excursions due not only to bowing, but also flaccidity.
Flaccid vocal cords

Flaccid vocal cords (4 of 4)

Eventual recoil towards midline, but cords never come into full contact before they are again thrown to their maximum lateral vibratory excursion, as in photo 3.
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Flaccid vocal cords (1 of 3)

Open phase of vibration showing large amplitude in middle voice.

Flaccid vocal cords (2 of 3)

Maximum closed phase, but with persistent open area anteriorly (at arrow) If this area of exaggerated flaccidity oscillates independently, a rough quality is added to the voice.

Flaccid vocal cords (3 of 3)

Between open and closed phase, showing vibratory contact is aberrant.

Vocal Cord Bowing

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Vocal cord bowing

Vocal cord bowing (1 of 4)

Open phase vibration, strobe light. Notice the large amplitude of vibration. The wide lateral excursions suggest flaccidity, especially when this is seen in middle voice.
Vocal cord bowing

Cause of a gravely voice (2 of 4)

Partially closed phase, strobe light. Notice that the anterior cords are more flaccid, with delayed return to midline contact. When this is seen, that anterior segment may vibrate independently and cause a rough, gravelly voice quality. The capillary ectasia, left vocal cord is an incidental finding an not related to the patient’s rough voice quality.
persistent anterior open segment

Vocal cords do not close completely (3 of 4)

Coming to closed phase, but with persistent anterior open segment.
Vocal cord bowing

Vocal cord bowing (4 of 4)

Closed phase of vibration, strobe light.

Flaccidity Without Bowing

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Flaccidity without bowing

Flaccidity without bowing (1 of 4)

The patient exhibits typical symptoms of bowing/atrophy/flaccidity, but in this case there is little bowing or atrophy—primarily flaccidity is seen. In this view, the abducted vocal cords appear full, with no exaggeration of the ventricles. (The apparent asymmetry between the vocal cords is due to the viewing angle; both cords are the the same.)
Flaccidity without bowing

Flaccidity without bowing (2 of 4)

Now seen under the strobe light, the amplitude of vibration of the vocal cords is excessive. These flaccid vocal cords lack the firmness to "recoil" back to the mid-line, until maximal separation of the cords is reached.
Flaccidity without bowing

Flaccidity without bowing (3 of 4)

As the patient is reaching the closed phase of the vibratory cycle, the anterior cords are arriving late to closure, a typical finding with flaccid vocal cords.
Flaccidity without bowing

Flaccidity without bowing (4 of 4)

Now at the maximum closed phase of vibration, a pinhole of incomplete closure is seen. In this case, there is no independent oscillatory vibration of the anterior segment of the vocal cord.

False Cord Phonation

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False cord phonation due to flaccid true cords (1 of 5): before false cords begin to vibrate

An elderly man, quiet by nature who uses the voice little, complains of weak, gravelly voice quality. This view of phonation, standard light, shows a slightly wider dark line of phonatory blurring. Also, the false vocal cords are overly approximated, but not yet participating in vibration (for that, see images 4 and 5).

False cord phonation due to flaccid true cords (2 of 5): before false cords begin to vibrate

Strobe light reveals an unusually wide amplitude of vibration, denoting flaccidity of the true vocal cords.

False cord phonation due to flaccid true cords (3 of 5): before false cords begin to vibrate

Maximum closed phase shows the telltale residual opening at the anterior commissure (from this perspective, the lowermost end of the true cords), also a potent indicator of flaccidity.

False cord phonation due to flaccid true cords (4 of 5): after false cords begin to vibrate

When asked to produce louder voice, the false cords begin to participate in vibration, and a rough, gravelly superimposed “ godfather” quality arrives. Notice that the true cords are in at least partial open phase of vibration.

False cord phonation due to flaccid true cords (4 of 5): after false cords begin to vibrate

When asked to produce louder voice, the false cords begin to participate in vibration, and a rough, gravelly superimposed “ godfather” quality arrives. Notice that the true cords are in at least partial open phase of vibration.

Flaccidity

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Flaccidity

Flaccidity (1 of 5)

Under strobe light, the vocal cords begin opening at the area of flaccidity anteriorly. The patient has a husky and gravelly voice quality (view here rotated 90 degrees counterclockwise).
Vibratory separation

Flaccidity (2 of 5)

Vibratory separation continues and is still greatest anteriorly.
Distance of lateral excursions is large

Flaccidity (3 of 5)

Open phase of vibration now complete. Distance of lateral excursions is large, indicating the flaccidity of cords.
Flaccidity

Flaccidity (4 of 5)

The cords are returning to closed vibratory position, but anterior cords close late due to flaccidity. Sometimes this anterior segment vibrates independently and this causes a rough voice quality.
Flaccidity

Flaccidity (5 of 5)

At maximum closed phase, there is still a tiny incomplete closure anteriorly.

Voice Building:

Voice Building (shorter version):



Food lodgment

Refers to when food gets stuck somewhere along its path from lips to stomach. Lodgment is more of a “full stop” of the food’s digestive journey, as compared with pooling. Lodgment usually occurs at one of these points: in the vallecula (usually in cases of presbyphagia); at the level of the cricopharyngeus muscle (in cases of cricopharyngeal dysfunction, which is one kind of achalasia); somewhere in the esophagus (in cases of esophageal stenosis); or at the lower esophageal sphincter (in cases of lower esophageal sphincter achalasia).



Foreign Content in the Throat

Photos:

Closeup, magnified examination finds barbecue brush bristle base of tongue: Series of 4 photos

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Pain in throat

Pain in throat (1 of 4)

While eating barbecued steak, this person felt a sharp pain deep in her throat. At this visit the next day, she continued to feel a sharp sensation, especially when swallowing. Note the faint dark line at the arrow.
abnormality in the throat

Closer view (2 of 4)

From a slightly closer vantage, the abnormality is seen better.
bristle in the throat

Bristle identified (3 of 4)

At even closer range, the bristle is identified.
bristle stuck in the esophagus

Bristle to be removed (4 of 4)

At this final view, the metallic nature of the foreign body and stuck-on carbonaceous debris can be appreciated. This bristle was removed with cup forceps through a channel scope in an office setting.


Formant

A formant is any of several regions of increased intensity within the sound spectrum. The formant frequencies and their intensity relate not only to quality of the sound but also to vowel and consonant sounds.



Forme Fruste Wegener’s Granulomatosis

An incomplete or frustrated form (forme fruste) of Wegener’s granulomatosis,* which we believe to be the cause behind some cases of inflammatory subglottic or tracheal stenosis. Unlike full-fledged Wegener’s, this forme fruste variant may or may not necessarily involve the sinus and nasal cavities, and in the author’s caseload of about 60 patients, it has not ever progressed to involve the lungs and kidneys. Such patients can go for years with only the need for intermittent dilation of the subglottic or tracheal narrowing. This disorder may be the same as what some call “idiopathic subglottic stenosis,” for which some have recommended cricotracheal resection and reanastomosis as treatment.

*Newer terminology is granulomatosis with polyangiitis (GPA)


Photos:

Subglottic / Tracheal Stenosis

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Wegener's granulomatosis (1 of 4)

Inflammatory subglottic/tracheal stenosis, thought to be the result of an incomplete expression of Wegener's granulomatosis (no history of trauma).

Subglottic / Tracheal stenosis (2 of 4)

Close view, from vocal cord level.

Subglottic / Tracheal stenosis (3 of 4)

Close view, from just above vocal cords.

Inflammed Stenosis (4 of 4)

Close view, showing the inflammatory nature of the stenosis.

Tracheal Stenosis, Due to Forme Fruste Wegener’s Granulomatosis

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Tracheal stenosis (1 of 3)

View from level of vocal cords shows residual lumen of airway at only ~35% of normal. The dotted circle shows how big the lumen should be.

Tracheal stenosis (2 of 3)

Closer view shows the characteristic appearance of mucosa and the inflammatory nature of the stenosis (pinkness).

Just below the tracheal stenosis (3 of 3)

After just passing through the stenotic area, distal trachea is normal in caliber and color.

Subglottic Stenosis, Before and After Dilation

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Subglottic stenosis, before dilation (1 of 2)

This individual has undergone at least a dozen prior dilations, each of which provides dramatic relief from noisy breathing and exercise intolerance. Here the patient is halfway to needing re-dilation, due to the typical inflammatory stenosis that is seen. Compare with photo 2.

Subglottic stenosis, after dilation (2 of 2)

One week after one of this patient's dilations (with Kenalog injection and topical Mitomycin C), showing a dramatic widening of her airway; compare with photo 1. After a number of years, inflammatory lesions such as this sometimes "burn out," and the interval between dilations increases.

Subglottic Stenosis, Before and After Dilation

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Subglottic stenosis (1 of 5)

Middle-aged woman with unexplained shortness of breath and noisy breathing, due to this idiopathic inflammatory and very high subglottic stenosis. The patient initially declined dilation due to her anxiety. She also had granularity of the nasal septum and a positive ANCA profile for Wegener’s granulomatosis.

Subglottic stenosis, worsened (2 of 5)

Five months later, the symptoms became intolerable, and the stenosis was noted to be slightly narrower and with a greater posterior component. The patient agreed to dilation.

Subglottic stenosis, worsened (3 of 5)

Same exam as photo 2; this close-up view shows more clearly the inflammatory nature of this stenosis.

Subglottic stenosis, after dilation (4 of 5)

Five days after outpatient dilation, triamcinolone injection, and topical mitomycin C application. The patient’s symptoms have vanished, the harsh inspiratory noise is no longer heard, and the size of the airway, though still not normal, is more than doubled. Compare with photo 2 of this series.

Subglottic stenosis, after dilation (5 of 5)

Same exam as photo 4, close-up view. Intensification of the inflammatory changes of this stenosis are expected so early after dilation. Compare size of the stenosis with photo 3 of this series.

A Soft Finding to Support a Diagnosis of Forme Fruste Wegener’s Granulomatosis

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Inflammatory subglottic stenosis

Inflammatory subglottic stenosis ( 1 of 4)

Middle-aged woman with chronic difficulty breathing for about two years. Initially treated unsuccessfully for asthma, and recently found to have this clearly inflammatory subglottic stenosis. No prior history of trauma or endotracheal intubation. Workup for Wegener’s granulomatosis was technically negative, and biopsy showed the usual “acute and chronic inflammation.”
Closer view indicates a forme fruste of Wegener's granulomatosis

Closer view indicates a forme fruste of Wegener's granulomatosis (2 of 4)

Closer view, showing the clearly demarcated (dotted line) area of inflammation and narrowing. Normal tracheal rings are seen in the shadow, below the stenosis. Negative ANCA notwithstanding, we believe this is a forme fruste of Wegener’s granulomatosis.
Inflammation on septum

Inflammation on septum (3 of 4)

As is often the case in persons with inflammatory subglottic stenosis of unknown cause, there are some signs of inflammation in the nose, too, usually on the septum, denoted here with “S. ” Right side of the septum is subtly abnormal.
Closer view of septum

Closer view of septum (4 of 4)

Here, under narrow-band (blue) light, the mottled, inflammatory appearance of the right side of the septum (S) is more clearly seen.

Stenosis Before and After Dilation for Forme Fruste Wegener’s

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Subglottic stenosis

Subglottic stenosis (1 of 5)

High-grade subglottic stenosis in a woman diagnosed syndromically with forme fruste Wegener's granulomatosis-related subglottic stenosis. With a narrowing less than 50%, she is very symptomatic. Her breathing is noisy, and her forced inspiration time is about 3 seconds. Compare with photo 4.
Inflammation

Inflammation (2 of 5)

Closer visualization reveals the inflammatory nature of the stenosis.
distal chip flexible scope

Flexible scope (3 of 5)

Here the distal chip flexible scope has passed through the narrowing not only to see into distal trachea, but also as a breathing test. The patient becomes very aware of reduced space and this indicates a marginal airway.
Post-dilation

Post-dilation (4 of 5)

A week after dilation, triamcinolone injection and mitomycin C application, the patient says breathing is now normal, and forced inspiration time is only a second in duration--normal. Compare with photo 1.
Post-operative bruising

Post-operative bruising (5 of 5)

Closer visualization with early postoperative bruising. The trachea is now easily visible through the larger opening. Compare with photo 2.

A Different Approach to Inflammatory Tracheal Stenosis

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Planning on periodical injections (1 of 4)

Three months after successful dilation, the patient says breathing is still normal. We are planning an injection of triamcinolone every 3 or 4 months, attempting to lengthen the interval between dilation procedures. Please note that the *s (right of photo) are for comparison with photo 2.

Long-acting steroid (2 of 4)

A needle has been passed into the anterior neck to place submucosal long-acting steroid. Note the bulging and blanching at the *s and compare with photo 1.

Needle going into the posterior of stenosis (3 of 4)

Here the needle has been passed translumenally and into the posterior portion of the stenosis.

Posterior tracheal wall (4 of 4)

The posterior tracheal wall has flattened as compared with photo 3, due to the infiltrated medication.

Vascular Manifestations of Wegener’s-related Septum Changes, and Subglottic Stenosis Indistinguishable from Forme Fruste Wegener’s

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View inside left nostril

View inside left nostril (1 of 4)

This man has Wegener’s Granulomatosis, with sino-nasal, subglottic, and pulmonary effects, and is on immunosuppressive therapy with very good clinical results. This view is just inside his left nostril and our focus – seen better in the next photo – is the stippled vascular pattern sometimes seen in auto-immune disorders. (S = septum, and T = inferior turnbinate.)
Narrow band light

Narrow band light (2 of 4)

Under narrow band light, the unusual vascular pattern of both septum and turbinate becomes much more obvious.
Distant view

Distant view (3 of 4)

In this distant view, his subglottic stenosis looks just like the many other examples in Laryngopedia of forme fruste Wegnener's. The stenosis seen with both entities are visually indistinguishable.
Closer view

Closer view (4 of 4)

A closer view of the stenosis reveals more clearly the adherent mucus that is so difficult for such patients to cough out due to the “speed bump” interruption of the mucociliary blanket at the stenosis.

One Way to Deliver Topical Anesthesia Despite A Powerful Gag Reflex…

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Powerful gag reflex

Powerful gag reflex (1 of 4)

The usual method of dripping topical anesthesia into larynx, subglottis, and trachea from above through an Abraham cannula is difficult due to a powerful gag reflex. Here, the tip of a short 25 gauge needle has entered through the cricothyroid membrane, just below the anterior commissure.
needle with lidocaine

Patient inhaling (2 of 4)

2% lidocaine has just begun to squirt through the needle with the patient inhaling.
Patient coughs

Patient coughs (3 of 4)

Half a second later, the topical anesthetic is splattering (see streaks) and as the patient coughs. This will fully anesthetize the area topically.
Topical anesthesia applied

Topical anesthesia applied (4 of 4)

The topical anesthesia established by this method now allows injection of kenalog (see white submucosal bulge) into the posterior tracheal wall as a means of managing this patient’s subglottic stenosis likely due to forme fruste Wegener’s granulomatosis.

Videos:

Wegener’s Granulomatosis: Forme Fruste (incomplete expression)
Wegener’s granulomatosis is a rare autoimmune disorder in which blood vessels become inflamed. The inflammation causes swelling and scarring. Three typical organs attacked are sinus/nasal cavities, lungs, and kidneys. In the forme fruste variant, it is mostly an inflammatory stenosis (narrowing) of the area below the vocal cords, and also the trachea. A person becomes short of breath and begins to make harsh breathing sounds due to the narrowed passageway. This is an example of one means of management: dilation of the narrowed area during a very brief general anesthetic in an outpatient operating room.


Fracture of Larynx

A break, with or without displacement, of the thyroid or cricoid cartilage. Decades ago, a common source of larynx fractures was car accidents, with a person’s neck striking the steering wheel. In this age of protective airbags, the primary source is athletic injuries (e.g., an elbow to the neck while playing basketball). Many larynx fractures are treated conservatively, but occasionally they require repair.


Photos:

Larynx fracture: Series of 4 photos

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bruising and marked swelling of the right arytenoid eminence

Larynx fracture (1 of 4)

Panoramic view shows bruising and marked swelling of the right arytenoid eminence, as well as the right false vocal cord.
marked edema and bruising right vocal cord

Larynx fracture (2 of 4)

View of vocal cords shows marked edema and bruising right vocal cord.
Larynx fracture

Larynx fracture (3 of 4)

Similar view, during phonation.
brushing down into the trachea

Larynx fracture (4 of 4)

View from within subglottis, and down into the trachea shows bruising.

Antero-Superior Fracture of Cricoid Cartilage Containing the Cricoarytenoid Joint

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Breathing position

Breathing position (1 of 4)

Initial BVI examination, many months after an auto accident with laryngeal fracture. Voice is functional but remains abnormal. In breathing position of the vocal cords, note that tip of the vocal processes of the arytenoid cartilages (denoted by larger dots) are not opposite, but the left one (right of photo) is markedly farther anterior.
Vocal cords mismatch

Mis-match (2 of 4)

As the vocal cords approach adducted voice-making position, one can again see dramatic mis-match of the tips of the vocal processes.
Prephonatory view

Prephonatory view (3 of 4)

Closer view as the cords approach voice-making position. The dots again indicate the tip of the vocal process, with the right one (left of photo) just out of view.
Phonation

Phonation (4 of 4)

During phonation, the left vocal process (right of photo) also rides up over top of the right vocal cord (left of photo), and the tip of the right vocal process (left of photo) is again just out of view.

Probable Larynx Fracture Seen Via Endoscopic Cues

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Fracture suspected

Fracture suspected (1 of 5)

This man sustained a sports injury a few months earlier including a blow to the anterior neck. Voice was instantly drastically altered. A fracture is suspected via endoscopic "cues." Here a distant view during breathing shows anterior displacement of the arytenoid apex on the right (left of the photo). Compare the two * for reference.
Phonation

Phonation (2 of 5)

Still viewing from a distance but now while making voice. The arytenoid apices take a more symmetrical position, but the line of the medial wall of pyriform and post-arytenoid area is flattened on the right (left of photo).
Convex margin

Convex margin (3 of 5)

A shortened vocal cord tends to develop a convex margin, and can either mean the arytenoid is displaced anteriorly, or it could be that the thyroarytenoid muscle has pulled away from its attachment to the arytenoid cartilage. Note here as well that the posterior ventricle seems have been displaced anteriorly on the right (left of photo, at ---). The tip of the arrow suggests where the tip of the vocal process ends.
Closed phase

Closed phase (4 of 5)

Under strobe light, closed phase of vibration with some phase shifting. To the left of each arrow seems to be where flexible mucosa begins. The foreshortened convex, and more flaccid vibrating segment of the right (upper) vocal cord overlaps the left.
Open phase

Open phase (5 of 5)

Open phase of vibration, with arrows again indicated the junction between vibrating and adherent (cartilaginous glottis) mucosa.

Larynx Fracture—Endoscopic Nuances Are Fascinating!

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Hockey injury

Hockey injury (1 of 4)

Twenty years earlier, during a hockey game, this man’s anterior neck was hit by a puck. His voice has never been the same, and he was told there was a “voicebox injury.” Here, note that both vocal cords abduct fully, suggesting that the crico-arytenoid joint is not likely disrupted, and the PCA muscle is intact. The “smaller-looking “ right vocal cord (left of photo) cannot be due to a disturbed growth plate, as he was in his middle 20’s when the injury occurred. The anteriorly-displaced arytenoid (arrow, left of photo) provides a clue, however, that is explained in photo 4.
Phonation

Phonation (2 of 4)

During phonation, the right cord (left of photo) appears bowed and atrophied. And is that lateral turning of the vocal process that we see? Is this TA + LCA paresis? Read on...
Phonation under strobe light

Phonation under strobe light (3 of 4)

The answer is revealed when the vocal cords approach midline for phonation (under strobe light): Here’s the answer: The tip of the right vocal process (left of photo) is displaced anteriorly as compared with the left. This can be seen by comparing the *’s. The apparent lateral turning of the right vocal process is not in fact of the vocal process, but of the soft tissue of the membranous part of the vocal cord.
Foreshortening of soft tissue

Foreshortening of soft tissue (4 of 4)

Open phase of vibration under strobe light shows that the amplitude of vibration is greater on the right (left of photo). To see this more clearly, compare faint dotted lines along the margin of each cord. This “flaccidity finding” is not due to paresis, but instead to foreshortening of the soft tissue (TA muscle and ligament) of the vocal cord. CT of the larynx suggests that the upper lamina of the cricoid is fractured forward on the right, carrying with it an intact and functioning cricoarytenoid joint. Hence, full mobility, yet anterior displacement of the right arytenoid.


Fundamental Frequency

Fundamental frequency (Fo), in an acoustic spectrum, refers to the lowest tone in a harmonic series. Using auditory perception, fundamental frequency correlates with pitch.



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