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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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Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD) is a syndrome caused by structural or functional incompetence of the lower esophageal sphincter, such that it permits retrograde flow of acidic gastric juice into the esophagus, and up to the level of the larynx and pharynx (throat). GERD is made more likely by obesity, large, late meals before bed, alcohol, and acidic, salty, or spicy foods. Treatment can include dietary modification, placing the frame of the bed on a head-to-toe slant, and a variety of medications that decrease stomach acidity.

Sometimes acid reflux is diagnosed when it isn’t the real problem. The do-it-yourself trials in this downloadable article can help a person and his or her personal physician verify if acid reflux is the appropriate diagnosis: When Acid Reflux Treatment Takes You Down a Rabbit Trail

1. Originally published in Classical Singer, April 2009. Posted with permission.

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.”


Gastrostomy (G) Tube

Gastrostomy (G) tube is a tube that passes directly through the abdominal wall and into the stomach in order to deliver fluids and nutrition. Liquid food is nutritionally complete and can support life and health in individuals who are unable to swallow, like those with absent swallow reflex.



General anesthesia

General anesthesia is a state of drug-induced, reversible loss of consciousness used, for example, to facilitate surgery. Drugs that induce general anesthesia may be administered intravenously or by inhalation of a gas or vapor.



Glottic Furrow

A disorder in which a furrow or groove is seen on the vocal cord, running parallel to, and at or just below, the cord’s free margin. This glottic furrow normally represents a defect in the underlying vocal ligament. Often, the deepest part of the furrow is lined with epithelium that is attached directly to thinned vocal ligament. Pseudobowing (due to mucosal and ligament abnormality more than atrophic muscle) is also a common feature.

Glottic furrow vs. glottic sulcus

A furrow is to be distinguished from a sulcus, which is more a defect within the mucosal layer only, and is thought to represent the empty sac of what was formerly a cyst. A furrow is typically shallow, and its lips are apart; a sulcus is usually deeper, and its lips are in contact and therefore harder to see. A furrow normally adheres to the vocal ligament, and the apex or deep surface of a sulcus often does as well. However, in the case of a sulcus, the vocal ligament itself is normal. Also, in the case of a furrow, the mucosal layer—often only an epithelial layer, in fact—will tend to adhere more broadly to the ligament, due to loss of the Reinke’s space layer of the mucosa.


Photos:

Glottic Furrow

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Glottic furrow

Glottic furrow (1 of 4)

Congenital furrows, on both vocal cords, in a 14-year-old with lifelong husky, air-wasting voice. Seen here at a distance, under standard light, with cords in breathing position. The margin of each cord, especially that of the left cord (right of photo), has a "flattened" appearance.
Glottic furrow

Glottic furrow (2 of 4)

As the cords come nearly to phonatory position, notice the pseudo-bowing, and persistence of flattening or even "farmer's field" furrow.
Glottic furrow

Glottic furrow (3 of 4)

Phonation, open phase of vibration, under strobe light, shows large amplitude (lateral or outward excursions) and, at each line of arrows, an "edge" of mucosa. This edge is seen because the mucosa of the broad expanse of the free margin is closely adherent and cannot oscillate.
leading edge of non-adherent vocal cord mucosa has slid medially

Glottic furrow (4 of 4)

At this patient’s most closed phase of vibration, under strobe light. Note that the leading edge of non-adherent vocal cord mucosa (again indicated by arrows) has slid medially (compare with photo 3).

Glottic Furrow / Leukoplakia / Acid Reflux

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Glottic furrow / Leukoplakia / Acid reflux

Glottic furrow / Leukoplakia / Acid reflux (1 of 4)

Panoramic view, standard light. Note general inflammatory appearance, left vocal cord leukoplakia, interarytenoid pachyderma. Some would call this a sulcus.
leukoplakia

leukoplakia (2 of 4)

Furrow-like groove best seen on the left vocal cord (arrow). Beneath the arrow is the leukoplakia. Notice loss of fine surface vessels in this area.
Glottic furrows

Glottic furrows (3 of 4)

Furrows seen bilaterally.
Gap between vocal cords during closed phase

Gap during closed phase (4 of 4)

Strobe light, closed phase. Note the slight gap; this is often seen as a kind of pseudo-bowing with furrow.

Glottic Sulcus and Glottic Furrow

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Glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (1 of 4)

This patient has a glottic sulcus on the left vocal cord (right of image) and a glottic furrow on the right vocal cord.
inspiratory phonation with glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (2 of 4)

Same patient, inspiratory (breathing in) phonation. Note how this accentuates the opening of the sulcus on the left vocal cord (right of image).
Glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (3 of 4)

Same patient. Compare with photo 4 to observe the vibratory appearance of the sulcus and furrow.
Glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (4 of 4)

Same patient. Compare with photo 3 to observe the vibratory appearance of the sulcus and furrow.

Glottic Furrow, Showing Adherent Furrow Muscoa

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Glottic furrow, showing adherent furrow muscoa

Glottic furrow, showing adherent furrow muscoa (1 of 4)

Standard light showing partially abducted cords. Here, the furrow on the right cord (left of photo) is seen best.
bilateral glottic furrows

bilateral glottic furrows (2 of 4)

Closer view, now showing the bilateral glottic furrows more clearly (indicated by the dotted lines).
medial oscillatory position

medial oscillatory position (3 of 4)

Under strobe light, closed phase of vibration. Focus on the right cord (left of photo), and note that the dotted line shows medial oscillatory position of mobile mucosa. The small elevation indicated by the large dot is a reference for comparison with next photo.
mucosal wave is very far lateral on the upper surface of the vocal cord

Mucosal Wave (4 of 4)

Open phase of vibration. The mucosal wave is very far lateral on the upper surface of the vocal cord, indicated now by the curved dotted line. The small elevation has barely lateralized, consistent with the adherent stiff mucosa of the furrow itself.

Glottic Furrow—A Thinning of Reinke’s Space

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bilateral glottic furrows

Glottic furrow (1 of 4)

This man has performed intense popular music for many years, and has developed loss of strength and clarity of voice. Here, the tiny dots outline bilateral glottic furrows, where the epithelium is more closely adherent to the vocal ligament than it is elsewhere.
right-sided furrow

Strobe light (2 of 4)

This view under strobe light shows the right-sided furrow enclosed by tiny dots.
vocal cord margins match well at high pitch

High pitch (3 of 4)

At very high pitch under strobe light, vocal cord margins match well; the cause of this man's hoarseness is not a typical vibratory injury such as nodules or a polyp.
Thinning of Reinke's space

Thinning of Reinke's space (4 of 4)

Open phase of vibration, with only the lateral edge of the furrows marked with a dotted line. Part of the stretchy "cushion" of Reinke's space is lost and with it the mechanical de-coupling of mucosa from vocal ligament beneath.

Double Whammy: Intubation Injury + Glottic Furrows

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Intubation injury + glottic furrows (1 of 4)

Extremely poor voice in elderly man after severe, life-threatening illness with complications; including an 18-day endotracheal intubation for purposes of ventilation. Now he is being evaluated for his very poor voice. Here, open (breathing) position at a distance does not show the findings as clearly as in subsequent photos. Small X's are for reference with remaining photos. The arrows denote tip of vocal processes.

Bilateral glottic furrows (2 of 4)

At closer range, divots begin to be appreciated (above the X's) and bilateral glottic furrows are more clearly noted.

Intubation injury (3 of 4)

As the vocal cords begin to close, this view (deep into the posterior commissure) shows clearly the divots caused by pressure necrosis outline where the breathing tube sat. Dotted lines show what would be the normal line of posterior vocal cords.

Phonatory position (4 of 4)

Now in closed voice-making position, posterior defect is out of view, but the vocal processes remain visible and come into contact at arrows. This shows that the endotracheal tube injuries are divots only without scarring of the joint capsules (that if present would prohibit contact of the vocal processes at arrows). There is air wasting through the posterior keyhole not visible here, and the bilateral glottic furrows and pseudo-bowing are extremely evident. They cause additional air-wasting, and adherence of mucosa at the depth of the furrows interferes with the mucosa’s vibratory ability.

Furrow Causing Chronically Husky Voice After Years of Extensive and Often Intense Voice Use

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Huskiness

Huskiness (1 of 4)

Huskiness in the context of the series title. Subtle "depressions" in the area outlined become more obvious in the following photos.
Pre-phonatory view

Pre-phonatory view (2 of 4)

As the vocal cords come slightly towards each other in preparation to make voice, the depressions are a little more evident.
Depressed area

Depressed area (3 of 4)

Here the depressed area is best seen at low pitch.
High pitch

High pitch (4 of 4)

At high pitch, the depression elongates and becomes shallower.

Glottic Furrow—Not Just Bowing and not Glottic Sulcus

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Bowing vocal cords with furrows

Bowing vocal cords with furrows (1 of 4)

This middle-aged man's voice has become increasingly husky and weak across many years. In retrospect, it was never a "strong" voice. The cords are bowed, and the furrows seen here (arrows) become more visible in subsequent photos.
Closed phase

Closed phase (2 of 4)

Under strobe light at B-flat 2 (117 Hz), this is the "closed" phase of vibration, perhaps better defined in this instance as the "most closed" phase.
Open phase

Open phase (3 of 4)

The open phase at the same pitch, shows a linear groove just below the margin of each cord. Some might call these glottic sulci, but "furrow" would be the better definition, as seen in the next photo.
Lower pitch reveals furrow

Lower pitch reveals furrow (4 of 4)

At lower pitch, the amplitude of vibration is larger and the right cord (left of photo) reveals more clearly that the the linear depression is a wide furrow, not a slit-like sulcus.

Glottic Furrow—Not Sulcus

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A rough and fuzzy voice

A rough and fuzzy voice (1 of 6)

This middle-aged woman describes a fuzzy and rough voice quality with fading of strength and endurance across a typical day's use. A part of the explanation is seen here: an obvious furrow of the left vocal cord (arrow, right of photo). Glottic furrows are usually congenital defects involving thinning of the vocal ligament and application of epithelium (mucosa) directly to the ligament with little if any "Reinke's space" (superficial layer of lamina propria).
Furrow

Furrow (2 of 6)

Narrow band light makes the furrow more evident.
asymmetrical vibration

asymmetrical vibration (3 of 6)

Partially open phase of vibration, seen at F4 (349.23Hz) under strobe light reveals the issue of asymmetrical vibration and phase shifting that often correlates with rough quality.
Closed phase

Closed phase ( 4 of 6)

Closed phase of vibration, with the furrow still very visible.
vibration points amplify

vibration points amplify (5 of 6)

At lower pitch (approximately G3 (196.0Hz), very large amplitude of vibration points out the flaccidity of the vocal cords, and the furrow at the arrow.
furrow

Furrow (6 of 6)

At closed phase of vibration still under strobe light, the furrow is seen again more clearly.


Glottic Sulcus

A degenerative lesion consisting of the empty “pocket” of what was formerly a cyst under the mucosa of the vocal cord. The lips of a glottic sulcus may be seen faintly during laryngeal stroboscopy. Or, vibratory characteristics may suggest this lesion.

A glottic sulcus may be overlooked unless one is familiar with this entity. To paraphrase eminent French laryngeal microsurgeon Dr. Marc Bouchayer, these lesions are diagnosed much more frequently once you know about them than before. At present, aside from having the patient coexist peacefully with this problem via voice therapy and other measures, surgery is the primary treatment modality.


Photos:

Glottic Sulcus, before and after surgery

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Glottic sulcus, before surgery (1 of 3)

Glottic sulcus, normal light, showing retained material/ granulation emerging from within the sulcus. There is a partial ring of capillaries around the sulcus on the right (left of photo), but no significant vessels within the sulcus (also see next photo).

Glottic sulcus, before surgery (2 of 3)

Same patient. Narrow-band illumination shows the vascular markings more clearly.

Glottic sulcus, after surgery (3 of 3)

Same patient, after surgery. Note microvasculature where it was not present prior to operation; especially noticeable on the right side (left of photo). There is a now a continuous layer of mucosa.

Congenital glottic sulcus and bowing, before and after injection

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Glottic sulcus (1 of 10)

This young patient has a husky, air-wasting voice quality. View of the vocal cords, in breathing position. An abnormality can be seen, especially on the right cord (left of photo, at arrows).

Glottic sulcus (2 of 10)

Under strobe lighting, during phonation, open phase of vibration, at a normal speech frequency (pitch), showing an unusually large amplitude of vibration.

Glottic sulcus (3 of 10)

Closed phase of vibration, but not quite closing completely.

Glottic sulcus (4 of 10)

Closer view, during inspiratory phonation, reveals very clearly that this patient has sulci on both cords, with the open pocket especially visible on the right cord (left of photo).

Sulcus with bowing, just prior to injection (5 of 10)

At the prephonatory instant, under standard light. In addition to a sulcus, this patient has congenital bowing.

Sulcus with bowing, just prior to injection (6 of 10)

Phonation, under standard light, at the pitch E-flat 4 (~311 Hz). Notice in particular the generous width of the zone of vibratory blurring, which correlates with the flaccid, large-amplitude vibration seen in photo 2's strobe view.

Voice gel injection (7 of 10)

The left vocal cord (right of photo) is now being injected with voice gel. The injection is centered so that the undersurface, free margin, and ventricle all show evidence of bulging.

Voice gel injection (8 of 10)

The other vocal cord is now being injected.

After the injection (9 of 10)

After voice gel injection is completed. At the prephonatory instant. Notice the reduced gap between the vocal cords (compare with photo 5).

After the injection (10 of 10)

During phonation, under standard light, again at E-flat 4 (~311 Hz). The width of vibratory blurring is reduced (compare with photo 6), consistent with reduced amplitude of vibration and reduced air-wasting.

Glottic Sulcus

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Faint line of glottic sulcus

Glottic sulcus, closed (2 of 2)

Faint line of glottic sulcus at arrow. Essentially the result of a cyst that has completely emptied of its contents (OR).
instrument holds one lip of the sulcus

Glottic sulcus, open (1 of 2)

Same patient, while instrument holds one lip of the sulcus, splaying it open to reveal the empty “pocket” (OR).
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Bilateral glottic sulcus

Glottic sulcus (1 of 2)

Bilateral sulci, more subtle; opening closer to the free margin.
tiny opening of the sulcus right at the margin of the left vocal cord

Glottic sulcus (2 of 2)

Same patient. Note the tiny opening of the sulcus right at the margin of the left vocal cord.
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Mucosal bridge / glottic sulcus

Glottic sulcus (1 of 2)

Mucosal bridge / glottic sulcus.
Glottic sulcus

Glottic sulcus (2 of 2)

Same patient, showing sulci (arrows) under strobe light.
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Glottic sulcus

Glottic sulcus (1 of 2)

Note that the "lips" of the glottic sulcus are open; compare to image #2. Also see the video for this.
Glottic sulcus

Glottic sulcus (2 of 2)

Note that the "lips" of the glottic sulcus are closed; compare to image #1. Also see the video for this.
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Shallow sulcus

Glottic sulcus (1 of 1)

Shallow sulcus, left vocal cord (right of image), at the free margin.

Glottic Sulcus and Glottic Furrow

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Glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (1 of 4)

This patient has a glottic sulcus on the left vocal cord (right of image) and a glottic furrow on the right vocal cord.
inspiratory phonation with glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (2 of 4)

Same patient, inspiratory (breathing in) phonation. Note how this accentuates the opening of the sulcus on the left vocal cord (right of image).
Glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (3 of 4)

Same patient. Compare with photo 4 to observe the vibratory appearance of the sulcus and furrow.
Glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (4 of 4)

Same patient. Compare with photo 3 to observe the vibratory appearance of the sulcus and furrow.

Glottic Sulcus Operation

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Glottic sulcus

Glottic sulcus operation (1 of 7)

Preoperative exam image, the glottic sulcus is indicated by arrows. (In the remaining photos the view of the larynx is reversed, so the affected area will be on the opposite side of the photo).
inflammation, capillary prominence, and margin swelling

Glottic sulcus operation (2 of 7)

Initial operative view showing inflammation, capillary prominence, and margin swelling of the right vocal cord. The sulcus is indicated by arrows, but can be seen much more easily in the next photo.
instrument causes the sulcus to gape open

Glottic sulcus operation (3 of 7)

Rolling the cord laterally with an instrument causes the sulcus to gape open.
needle is inserted lateral to the still-gaping sulcus

Glottic sulcus operation (4 of 7)

A needle is inserted lateral to the still-gaping sulcus to infiltrate for both vasoconstriction and hydrodissection.
epithelial-lined pocket is nearly dissected

Glottic sulcus operation (5 of 7)

The epithelial-lined “pocket” is nearly dissected free from the interior of the cord.
medial and lateral mucosal flaps are retracted

Glottic sulcus operation (6 of 7)

The medial and lateral mucosal flaps are retracted to show the deep layer from which the epithelial-lined pocket was dissected.
Incision line after successful surgery

Glottic sulcus operation (7 of 7)

At completion of surgery, there is no loss of surface mucosa, and only an incision line.

Surgical Removal of Glottic Sulcus

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cord is infiltrated with lidocaine/epinephrine to provide hydrodissection and to expand the mucosa

Surgical removal of glottic sulcus (1 of 4)

At beginning of surgery, the cord is infiltrated with lidocaine/epinephrine to provide hydrodissection and to expand the mucosa. Line of the sulcus is seen proceding anteriorly from the point of the needle entry.
elliptic incision around the lips of the sulcus

Surgical removal of glottic sulcus (2 of 4)

An elliptic incision has been made around the lips of the sulcus.
Right-curved alligator clip tents the medial mucosal flap

Surgical removal of glottic sulcus (3 of 4)

Right-curved alligator clip tents the medial mucosal flap. Arrows indicate the fine line that represents the opening into the sulcus. Curved scissors dissect the anterior aspect of the sulcus pocket from the underlying vocal ligament.
gossamer mucosa is tented medially to show remaining flexibility

Surgical removal of glottic sulcus (4 of 4)

After the sulcus pocket is removed, gossamer mucosa is tented medially to show remaining flexibility. The voice is expected to be improved, but normal upper voice capabilities are only sometimes achieved.

Open Cyst or Sulcus?

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nuances besides the vascularity and hyperemia

Hoarse voice (1 of 4)

This music teacher has been hoarse for several years. Look for the nuances besides the vascularity and hyperemia, right cord (left of photo) greater than left (right of photo). The next photo makes the findings more obvious.
pearl of keratin emerging from the faintly grey sulcus

Open Cyst Definition (2 of 4)

Under narrow band light, note the “pearl” of keratin emerging from the faintly grey sulcus outlined by the tiny dotted lines. When a lot of keratin is retained, we call this an open cyst; when little or none, just a sulcus. Dotted line on the left vocal cord (right of photo) indicates the middle of the sulcus on that side.
lateral lip of the sulcus

Closed phase (3 of 4)

Closed phase of vibration under strobe light at A4 (440 Hz). The right sided sulcus is concealed, but the left side is more visible. The white line (superimposed dots) represents the lateral lip of the sulcus.
medial and lateral lips with a linear depression between them

Open phase (4 of 4)

Open phase of vibration at the same pitch shows medial and lateral lips with a linear depression between them.

Sulcus and Segmental Vibration

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Glottic sulci (1 of 4)

Closed phase of vibration, strobe light, at G3 (196 Hz) in a young high school teacher/ coach who is also extremely extroverted. Faint dotted lines guide the eye to see the lateral lip of her glottic sulci.

Open phase (2 of 4)

Open phase of vibration at the same pitch, showing full-length oscillation.

Closed phase (3 of 4)

Closed phase of vibration at E-flat 5 (622 Hz). Arrows indicate closure of the short oscillating segment.

Segmental vibration (4 of 4)

Open phase of vibration also at E-flat 5, Only the tiny segment opens significantly. As expected the patient’s voice has the typical segmental “tin whistle” quality.

Open Cyst and Sulcus; Normal and Segmental Vibration

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Margin swelling (1 of 6)

Breathing position of the vocal cords of a very hoarse actor. Note the margin swelling of both sides. The white material on the left vocal cord (right of photo) is keratin debris emerging from an open cyst. Find the sulcus of the right vocal cord (left of photo) which is more easily seen in the next photo.

Narrow band light (2 of 6)

Further magnified and under narrow band light. The right sulcus is within the dotted outline. Compare now with photo 1.

Open phase, strobe light (3 of 6)

Under strobe light, open phase of vibration at A3 (220 Hz). The full length of the cords participate in vibration.

Closed phase, same pitch (4 of 6)

At the same pitch, the closed phase again includes the full length of the cords.

Segmental vibration (5 of 6)

At the much higher pitch of C5 (523 Hz) a “tin whistle” quality is heard and only the anterior segment (at arrows) is opening for vibration. The posterior opening is static and not oscillating, as seen in the next photo.

Closed phase (6 of 6)

The closed phase of vibration involves only the tiny anterior segment of the vocal cords, at the arrows. The posterior segment is not vibrating and is unchanged.

Glottic Furrow—Not Just Bowing and Not Glottic Sulcus

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Bowing vocal cords with furrows

Bowing vocal cords with furrows (1 of 4)

This middle-aged man's voice has become increasingly husky and weak across many years. In retrospect, it was never a "strong" voice. The cords are bowed, and the furrows seen here (arrows) become more visible in subsequent photos.
Closed phase

Closed phase (2 of 4)

Under strobe light at B-flat 2 (117 Hz), this is the "closed" phase of vibration, perhaps better defined in this instance as the "most closed" phase.
Open phase

Open phase (3 of 4)

The open phase at the same pitch, shows a linear groove just below the margin of each cord. Some might call these glottic sulci, but "furrow" would be the better definition, as seen in the next photo.
Lower pitch reveals furrow

Lower pitch reveals furrow (4 of 4)

At lower pitch, the amplitude of vibration is larger and the right cord (left of photo) reveals more clearly that the the linear depression is a wide furrow, not a slit-like sulcus.

Mottled Vocal Cord Mucosa May Hide Glottic Sulci

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Vocal cord swelling and mucosa (1 of 4)

This young “dramatic” soprano is also a bona fide vocal overdoer. Her vocal capabilities have been diminishing for over two years. In this medium-range view, note the rounded swelling of the right cord (left of photo), but more significantly as we shall see, the increased vascularity and mottled appearance of the mucosa.

Same view under strobe light (2 of 4)

Under strobe light, at open phase of vibration at C#5 (523 Hz), we see a projecting, polypoid swelling of the right vocal cord, but not yet the more difficult problem.

Closed phase (3 of 4)

Closed phase of vibration, at the same pitch of C#5 shows the mismatch of the vocal cord margins. Is this the entire explanation for this patient's hoarseness? Read on.

Glottic sulcus is visible (4 of 4)

At close range and high magnification, the open mouth of a right-sided glottis sulcus is seen. This side can be operated safely due to the excess, thick mucosa and would be expected to improve the margin match. On the left (right of photo), a sulcus is also seen, but the thinner mucosa makes successful surgery on the left more challenging.

A Case That Clearly Shows the Relationship Between Cyst & Sulcus

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white lesion on right vocal cord

White Lesion on Right Vocal Cord (1 of 6)

This young man is known as vocally exuberant. For some years, he has used his voice socially to the point of hoarseness countless times, including at heavy metal rock concerts. In the past year or so, his hoarseness never went away. In this distant view, a white lesion is seen on his right vocal cord (left of photo).
White Lesion Under Strobe Light

White Lesion Under Strobe Light (2 of 6)

Under strobe light and with higher magnification, the open phase of vibration shows this lesion as a white nubbin protruding from a fossa.
lesion in closed phase of vibration

White Lesion Under Strobe Light (3 of 6)

The closed phase of vibration shows more clearly the depression from which the lesion is protruding.
White Lesion Removed

White Lesion Removed (4 of 6)

After surgical removal and healing, voice is improved though not fully restored. The lesion was granulation and keratosis. It was plucked from the depression without deepening the pre-existing “divot.”
trough from which the lesion was removed

Vocal Cords (5 of 6)

At the open phase of vibration, showing the trough from which the lesion was removed. There is a smaller depression on the left also consistent with vibratory trauma.
closed phase of vibration post removal

Vocal Cords without Lesion (6 of 6)

The closed phase of vibration. Compare with photo 3.

Nuances of Endotracheal Tube Injury

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 following 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.


Glottic Sulcus: Laryngeal Videostroboscopy
Glottic sulcus is a degenerative lesion consisting of the empty “pocket” of what was formerly a cyst under the mucosa of the vocal fold. The lips of the sulcus may be seen faintly during laryngeal stroboscopy. Or, vibratory characteristics may suggest this lesion.
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.


Glottic Web

An abnormal, continuous sheet of mucosa that joins the vocal cords together. This glottic web is analogous to the web one sees between adjacent fingers. Normally, in the absence of a glottic web, the mucosa covers each vocal cord individually to form a crisp “V”.

A glottic web may be congenital, or it may result from injury. Classic teaching is that surgeons ought not to operate on the anterior portion of both vocal cords simultaneously, because the raw, de-epithelialized surfaces may grow together and create an anterior glottic web. Some webs do not need to be addressed because the effect on voice is minimal; in other cases, surgical approaches are indicated because of the poor voice often associated with this abnormality.


Photos:

Glottic web, divided and treated with steroid injections

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Glottic web

Glottic web (1 of 12)

Glottic web, inflammatory, progressive, without antecedent trauma.
blade attached to biopsy forceps

Glottic web (2 of 12)

Lab procedure: 11-blade attached to biopsy forceps, wrapped with tape to “guard” all but the tip.
Web partially divided

Glottic web (3 of 12)

Web partially divided.
Web fully divided

Glottic web (4 of 12)

Web fully divided.
Vocal cords are re-adhering where the web was divided two weeks earlier

Glottic web (5 of 12)

Vocal cords are re-adhering where the web was divided two weeks earlier.
Biopsy forceps used to separate the adhesion.

Glottic web (6 of 12)

Biopsy forceps used to separate the adhesion.
Slight bleeding at point of re-separation of the cords

Glottic web (7 of 12)

Slight bleeding at point of re-separation of the cords.
Result

Glottic web (8 of 12)

Result (compare with photo 5).
depot form of steroid injection

Glottic web (9 of 12)

A depot form of steroid injection in the videoendoscopy laboratory (patient in chair). The intent is to abolish or diminish the inexorable re-adhesion of the vocal cords, sometimes many months after apparent complete healing and re-mucosalization. Note white submucosal material.
Injection at apex of the web

Glottic web (10 of 12)

Injection at apex of the web. Note condensed white submucosal steroid, from prior injection.
16 months after last of a series of web divisions

Glottic web (11 of 12)

16 months after last of a series of web divisions as depicted above. The web does not show any sign of re-forming. Compare with photos 1 and 2.
glottic aperture

Glottic web (12 of 12)

Closer view, again showing maintenance of the deep "V" shape of the glottic aperture, rather than the short, fat "U" seen before web division. The patient has no shortness of breath.

Inflammatory Glottic Web Without Known Cause

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Inflammatory web

Inflammatory web (1 of 4)

Chronic hoarseness and peculiar inflammatory web in a woman who has never smoked. Acid reflux has been put aside as a cause, too. Biopsies show severe inflammation and dysplasia. HPV subtyping was negative.
combination of inflammation, granulation, and leukoplakia

Closer view (2 of 4)

Closer view under narrow band illumination shows the combination of inflammation, granulation, and leukoplakia.
inflammation remains significant

After treatment (3 of 4)

Soon after superficial peeling of the abnormal tissue, kenalog injection, and mitomycin C application. The web is less; voice is much better, but inflammation remains significant.
chronically inflamed cords

Closer view (4 of 4)

A closer view of the chronically inflamed cords. In cases of idiopathic (unknown cause) inflammatory webs of this sort, the rule is gradual recurrence of the web not in the early postoperative period as is seen with conventional webs, but instead across many months. Occasionally, transformation to CIS or early cancer then opens the door to radiation therapy.

Web After Radiotherapy

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Post radiation

Post radiation (1 of 2)

More than a year after radiation and chemotherapy for HPV-induced larynx cancer, voice is serviceable but still hoarse. The vocal cord mucosa would have been raw from the radiation, and fused together anteriorly.
Anterior band

Anterior band (2 of 2)

At closer range, the band between the anterior vocal cords is clearly seen. The vocal cords should be unattached to approximately the tip of the arrow.

Glottic Web from Birth

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glottic web attaches most of both vocal cords together

Glottic web (1 of 4)

This younger woman has been hoarse from birth and has had four prior procedures elsewhere for her congenital glottic web. Here, note that the web attaches most of both vocal cords together. She is very hoarse. The large and small dots are for orienting purposes with following photos. The recommendation: start with simple outpatient web division.
Surgical division of web

Surgical division of web (2 of 4)

A few weeks after surgical division of the web, topical mitomycin C, early postop voice use to prevent reattachment. Voice is already noticeably improved. As expected, there is a small web re-forming, but well below the margins of the cords (at 'X').
Polyp-like mounds

Polyp-like mounds (3 of 4)

Under strobe light, the stretched web tissue has retracted after division into polyp-like mounds, especially on the right side (left of photo).
Complete healing

Complete healing (4 of 4)

Four months later, with complete healing and a residual subglottic web that does not interfere with vibration. The patient says voice improvement is “moderate” for both quality and effort required. She also noted that “people no longer ask me if I’m sick.” She does not feel the need to attempt any further improvement via trimming for better match.

Glottic Web After Surgery

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Cyst and web

Cyst and web (1 of 4)

After surgery elsewhere, a glottic web and mucus cyst. The original laryngeal condition that led to surgery is not known.
Surgical division of web

Surgical division of web (2 of 4)

A few weeks after surgical division of the web, topical mitomycin C, early postop voice use to prevent reattachment. Voice is already noticeably improved. As expected, there is a small web re-forming, but well below the margins of the cords (at 'X').
Coagulating cyst

Coagulating cyst (3 of 4)

Given her prior bad experience with surgery, the patient was unwilling to go to the operating room to address the web, but was willing to address the cyst in the voice lab, using the Thulium laser. The cyst originates from well below the vocal cord, and can therefore be coagulated without risk to voice.
Complete healing

Complete healing (4 of 4)

Four months later, with complete healing and a residual subglottic web that does not interfere with vibration. The patient says voice improvement is “moderate” for both quality and effort required. She also noted that “people no longer ask me if I’m sick.” She does not feel the need to attempt any further improvement via trimming for better match.

Glottic web—Take A Simple Approach First, Not A Keel

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Glottic web

Glottic web (1 of 4)

Chronic hoarseness and glottic web after surgery elsewhere for recurring papillomas.
Proposed incision

Proposed incision (2 of 4)

Closer view under narrow band light. The dashed line shows proposed incision during upcoming vocal cord microsurgery.
oice is still hoarse, but definitely less effortful

Less effortful voice (3 of 4)

Several weeks after the web was divided, and topical Mitomycin C applied. Voice is still hoarse, but definitely less effortful, and with a (desirable) lower pitch. The patient is pleased.
re-mucosalization is nearly complete

Re-mucosalization (4 of 4)

Narrow band light shows that, as indicated by fine capillary pattern, re-mucosalization is nearly complete, other than within dotted line.

Nuances “Gleaned” From Daily Examinations

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Vocal "overdoer" (1 of 4)

A vocal “overdoer” with hoarseness. Note broad-based swelling of both vocal cord margins. A micro-web, thought to be congenital, is also seen at the arrow. Tiny dots indicate a subtle wrinkle or shallow sulcus.

Inspiratory phonation (2 of 4)

The patient has been asked to produce inspiratory phonation to reveal the translucent polyp and “sulcus,” again at tiny dots.

Translucent polyp (3 of 4)

Under strobe light, the translucence of the polypoid elevation is seen more clearly.

Open phase (4 of 4)

At open phase of vibration again under strobe light, the broad based left vocal cord elevation is also seen.

Glottic Web Management Without A Keel

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web joining the anterior half of the vocal cords

Glottic Web (1 of 7)

More than a year after laser excision elsewhere of a small vocal cord cancer, this man has a web joining the anterior half of the vocal cords. Voice is a whisper. A simple division with a microscissor is worthwhile before contemplating something more invasive, such as insertion of a keel.
Glottic Web

Glottic Web (2 of 7)

A closer view. The dotted line indicates the proposed division. The tag of extra tissue at * in all photos is not to be disturbed, preferring to preserve all tissue until the mucosa’s vibratory ability could be assessed.
anterior vocal cords have not yet re-mucosalized

Glottic Web (3 of 7)

A week after that simple endoscopic division of the web, steroid injection, and topical mitomycin C application. The anterior vocal cords have not yet re-mucosalized. Voice is remarkably functional.
3 weeks after division

Glottic Web (4 of 7)

Approximately 3 weeks after division, voice remains very good. Compare with photo 1.
small part of the cut surface is not yet covered with new mucosa

Glottic Web (5 of 7)

Only a small part of the cut surface is not yet covered with new mucosa. This photo is illuminated with narrow band (blue-green) light to accentuate capillaries on re-grown mucosa.
closed phase of vibration

Glottic Web (6 of 7)

Under strobe light, the closed phase of vibration.
restoration of oscillatory ability on both cords

Glottic Web (7 of 7)

Open phase of vibration, showing restoration of oscillatory ability on both cords. Voice remains rough but highly functional without syllable dropouts or “effort” in the quality.


Glottis

The glottis is the middle part of the larynx, between the supraglottis and the subglottis, where the vocal cords and the space between them are located.



Granulation Tissue

Granulation tissue is tissue that develops as an exuberant “over-healing” response to irritation or injury. This irritation or injury could be due to an endotracheal tube, or a superficial cordectomy wound from surgery, or a number of other causes. Granulation tissue that forms on the posterior vocal cord is called a contact granuloma.


Photos:

Subglottic granulation and curving airstream: Series of 4 photos

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Intubation injury (1 of 4)

After a 9-day intubation for serious illness, the patient has difficulty breathing due to this “proud flesh” response to injury within the cricoid ring, posteriorly. Breathing has improved in the past week, leading to a decision to await further maturation, rather than proceeding to microlaryngoscopic removal.

Lobules (2 of 4)

Close-up view of the lobules of granulation tissue. Air can easily pass around the obstruction as indicated by the arrows.

2 months later (3 of 4)

As predicted, breathing continued to improve to the point of seeming normal to the patient, and 2 months later, the granulation tissue has matured and detached, leaving behind a subglottic scar band (parallel lines).

Scar band (4 of 4)

Here is a close-up of the scar band. A solid line denotes the anterior border of the scar band for reference in all 4 photos, but compare especially to photo 2.

Sometimes you DO remove granulation to avoid tracheotomy: Series of 8 photos

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Granulation (1 of 8)

Prior to this first visit, this person suffered extensive burns, was intubated for 10 days, and then underwent tracheotomy, and then was decannulated (tracheotomy removed). She has scarring of the posterior commissure outlined by the dotted line. The granulation extends well down into the subglottis. She is uncomfortable with a marginal airway and noisy breathing. Laser and microdebrider are planned to try to avoid having to reinsert the tracheotomy.

Closer view (2 of 8)

Tip of the iceberg view of granulation and scarred area.

Post microlaryngoscopies (3 of 8)

After a series of microlaryngoscopies purely to improve airway and avoid tracheotomy, the granulation has finally matured. Airway is no longer marginal, but is still very limited for significant activity.

Scarring (4 of 8)

At close range, the area of posterior scarring is again indicated by dotted line; the dark area of the actual airway is narrow and slit-like.

Post posterior commissuroplasty (5 of 8)

A month after posterior commissuroplasty, breathing is improved due to the widened space posteriorly. Compare the dark area for breathing with photo 3.

Breathing improved (6 of 8)

Six months after posterior commissuroplasty, breathing remains much improved. Compare dark airway contour again with photo 3 above.

Closer view (7 of 8)

A closer view of the airway, which is much wider posteriorly than preoperatively (photo 4).

Phonatory view (8 of 8)

When patient makes voice, there is a persistent space posteriorly, where the airway was surgically widened, but again, this has not significantly affected the voice.

Laser surgery for Bilateral Vocal Cord Cancer

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squamous cell carcinoma

Squamous cell carcinoma (1 of 6)

This man developed hoarseness across a few months. Biopsy elsewhere revealed squamous cell carcinoma, seen here on both vocal cords. Based upon a friend’s experience, he rejected radiotherapy, opting for laser resection, knowing it could be very hard on voice.
Tumor on the vocal cords

Tumor on the vocal cords (2 of 6)

At closer range and under narrow band (blue-green) light to accentuate the vascular abnormalities associated with this tumor.
superficial laser cordectomy

Granuloma delays voice recovery (3 of 6)

Six weeks after superficial laser cordectomy, the larynx is almost healed with the exception of a small granuloma, left vocal cord (right of photo). When healing includes granulation, voice recovery is delayed as the granuloma resolves.
granuloma prevents vibratory closure

Closer view of granuloma (4 of 6)

He has hoarse but functional voice, but under strobe light, the granuloma prevents vibratory closure. Note the medial-to-lateral capillary reorientation so typical after laser cordectomy.
Granuloma on vocal cord

Granuloma is smaller (5 of 6)

Now 3 ½ months from surgery, voice has improved further and he considers it “75%” of original...One can see that the granuloma is smaller.
ranuloma no longer prevents vibratory closure

Granuloma doesn't impede voice (6 of 6)

Note that the granuloma no longer prevents vibratory closure and this explains further improvement of voice. Compare with photo 4.

Arytenoid Perichondritis—an Issue of “Festering”

This middle-aged man has had a chronically sore throat on the left for at least 6 months.  When asked to indicate where, he doesn’t gesture towards the throat as a whole, but points with one finger to the upper part of the thyroid cartilage fairly far laterally.  He doesn’t remember being ill, or any other explanation. After seeing the lesion below, read the introductory article of this post for treatment of this condition.

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Arytenoid perichondritis (1 of 4)

A distant, panoramic view shows some cobblestoning but nothing (yet) focal to the left.

Lesion (2 of 4)

At a mid-range view, a small lesion is seen on the anterior face of his left arytenoid (arrow). There is mild surrounding redness.

Closer look at lesion (3 of 4)

At closer range, the lesion is more easily seen to be significant and quite different from the right. It is not a typical contact granuloma, which would be found lower, on the vocal process.

Vascular atypia (4 of 4)

At very close range, under narrow band light. One can see that there is a “pitted” center, and some vascular atypia of chronic inflammation/healing.


Granulomatosis with Polyangiitis (GPA)

A newer term for the auto-immune disorder previously called Wegener’s Granulomatosis.



Gross Aspiration

Aspiration to a significant degree, in which a large amount of liquid or food material enters the airway. If a person commonly experiences gross aspiration, then he or she is at significant risk of aspiration pneumonia, especially if the person does not respond to it with aggressive coughing.



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