Schedule a video conversation   |   Read our patient reviews   |   Now accepting Laryngology Fellowships!
Schedule a video conversation
Now accepting Laryngology Fellowships!

Laryngopedia

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

Laryngopedia By Bastian Medical Media

Multimedia Encyclopedia


  1. A
  2. B
  3. C
  4. D
  5. E
  6. F
  7. G
  8. H
  9. I
  10. J
  11. K
  12. L
  13. M
  14. N
  15. O
  16. P
  17. Q
  18. R
  19. S
  20. T
  21. U
  22. V
  23. W
  24. X
  25. Y
  26. Z
You're viewing encyclopedia entries under G. You can click a different letter above to browse other entries.

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.




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 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

Visual Portfolio, Posts & Image Gallery for WordPress
a partial ring of capillaries around the glottic sulcus

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 in narrow-band illumination

Glottic sulcus, before surgery (2 of 3)

Same patient. Narrow-band illumination shows the vascular markings more clearly.
Glottic sulcus after surgery

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

Visual Portfolio, Posts & Image Gallery for WordPress
Glottic sulcus

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 in strobe lighting

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.
Closed phase of vibration

Glottic sulcus (3 of 10)

Closed phase of vibration, but not quite closing completely.
Glottic sulcus on both cords

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

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.
Glottic sulcus with 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

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

Voice gel injection (8 of 10)

The other vocal cord is now being injected.
After the injection

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

Visual Portfolio, Posts & Image Gallery for WordPress
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).
Visual Portfolio, Posts & Image Gallery for WordPress
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.
Visual Portfolio, Posts & Image Gallery for WordPress
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.
Visual Portfolio, Posts & Image Gallery for WordPress
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.
Visual Portfolio, Posts & Image Gallery for WordPress
Shallow sulcus

Glottic sulcus (1 of 1)

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

Glottic Sulcus and Glottic Furrow

Visual Portfolio, Posts & Image Gallery for WordPress
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

Visual Portfolio, Posts & Image Gallery for WordPress
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

Visual Portfolio, Posts & Image Gallery for WordPress
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?

Visual Portfolio, Posts & Image Gallery for WordPress
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

Visual Portfolio, Posts & Image Gallery for WordPress
lateral lip of her glottic sulci

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.
full-length oscillation

Open phase (2 of 4)

Open phase of vibration at the same pitch, showing full-length oscillation.
closure of the short oscillating segment

Closed phase (3 of 4)

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

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

Visual Portfolio, Posts & Image Gallery for WordPress
Breathing position of the vocal cords of a very hoarse actor

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.
right sulcus

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.
pen phase of vibration

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

Closed phase, same pitch (4 of 6)

At the same pitch, the closed phase again includes the full length of the cords.
only the anterior segment is opening for vibration

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 of vibration involves only the tiny anterior segment of the vocal cords

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

Visual Portfolio, Posts & Image Gallery for WordPress
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 of vibration

"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 shows linear groove just below the margin of each cord.

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.
open mouth of a right-sided glottis sulcus

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.

Mottled Vocal Cord Mucosa May Hide Glottic Sulci

Visual Portfolio, Posts & Image Gallery for WordPress
Vocal cord swelling

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.
projecting polypoid swelling

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.
mismatch of the vocal cord margins

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.
open mouth of a right-sided glottis sulcus

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

Visual Portfolio, Posts & Image Gallery for WordPress
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.

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 [intlink id=”454″ type=”post”]mucosa[/intlink] 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:











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

Visual Portfolio, Posts & Image Gallery for WordPress
Proud flesh within cricoid ring

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 of granulation tissue

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.
subglottic scar band

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).
anterior border of the scar band

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

Visual Portfolio, Posts & Image Gallery for WordPress
scarring of the posterior commissure

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.
granulation and scarred area

Closer view (2 of 8)

Tip of the iceberg view of granulation and scarred area.
granulation has finally matured

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.
area of posterior scarring

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.
widened space posteriorly

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.
vocal cords Six months after posterior commissuroplasty

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 of the airway

Closer view (7 of 8)

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

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.


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.



  1. A
  2. B
  3. C
  4. D
  5. E
  6. F
  7. G
  8. H
  9. I
  10. J
  11. K
  12. L
  13. M
  14. N
  15. O
  16. P
  17. Q
  18. R
  19. S
  20. T
  21. U
  22. V
  23. W
  24. X
  25. Y
  26. Z