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
1. Originally published in Classical Singer, April 2009. Posted with permission.
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 int he 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 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.
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.
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 (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 (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.
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.
Glottic furrow / Leukoplakia / Acid reflux (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 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.
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 (3 of 4)
Same patient. Compare with photo 4 to observe the vibratory appearance of the sulcus and furrow.
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.
Glottic furrow, showing adherent furrow muscoa (2 of 4)
Closer view, now showing the bilateral glottic furrows more clearly (indicated by the dotted lines).
Glottic furrow, showing adherent furrow muscoa (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.
Glottic furrow, showing adherent furrow muscoa (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 (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.
Strobe light (2 of 4)
This view under strobe light shows the right-sided furrow enclosed by tiny dots.
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.
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.
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.
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 (2 of 4)
As the vocal cords come slightly towards each other in preparation to make voice, the depressions are a little more evident.
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 (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 (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.
(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).
(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.
(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.
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.
Glottic Sulcus, before and after surgery
Congenital glottic sulcus and bowing, before and after injection
Glottic Sulcus and Glottic Furrow
Glottic Sulcus Operation
Surgical Removal of Glottic Sulcus
Open Cyst or Sulcus?
Sulcus and Segmental Vibration
Open Cyst and Sulcus; Normal and Segmental Vibration
Glottic Furrow—Not Just Bowing and Not Glottic Sulcus
Mottled Vocal Cord Mucosa May Hide Glottic Sulci
A Case That Clearly Shows the Relationship Between Cyst & Sulcus
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.
Glottic web (2 of 12)
Lab procedure: 11-blade attached to biopsy forceps, wrapped with tape to “guard” all but the tip.
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.
Glottic web (10 of 12)
Injection at apex of the web. Note condensed white submucosal steroid, from prior injection.
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.
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.
Closer view (2 of 4)
Closer view under narrow band illumination shows the combination of inflammation, granulation, and leukoplakia.
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.
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.
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.
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 (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 (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 (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.
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.
Web (2 of 4)
At much closer range, both abnormalities are seen more clearly. The dotted line indicates the extent of the web.
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.
Glottic web (1 of 4)
Chronic hoarseness and glottic web after surgery elsewhere for recurring papillomas.
Proposed incision (2 of 4)
Closer view under narrow band light. The dashed line shows proposed incision during upcoming vocal cord microsurgery.
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.
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.
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 (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.
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.
Glottic Web (4 of 7)
Approximately 3 weeks after division, voice remains very good. Compare with photo 1.
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.
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 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.
Subglottic granulation and curving airstream: Series of 4 photos
Sometimes you DO remove granulation to avoid tracheotomy: Series of 8 photos
Granulomatosis with Polyangiitis (GPA)
A newer term for the auto-immune disorder previously called Wegener’s Granulomatosis.
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.