A surgical procedure that removes part of the front of the larynx. Typically, a hemilaryngectomy is done in order to remove a cancerous growth. This procedure was once the primary treatment option for medium and large vocal cord cancers that could not be removed by endoscopic (through the mouth) laser. Today, when laser cannot be used because of patient preference or anatomical difficulty, chemotherapy and radiation therapy are usually attempted first. The biggest role for hemilaryngectomy now seems to be for carefully selected tumors (in the earlier stages, T1 through large T2) that have persisted or recurred after initial treatment of radiation therapy with or without chemotherapy.
In a hemilaryngectomy, the surgeon removes part of the thyroid cartilage, including the underlying vocal cord or cords. The extent of removal varies from procedure to procedure. In fact, the term “hemilaryngectomy” is somewhat misleading; “hemi” means “half,” but most hemilaryngectomies remove much less than half of the larynx. A very minimal procedure might only remove most of one side of the thyroid cartilage with the underlying soft tissue but not touch the arytenoid cartilage. On the other hand, a very extensive procedure might remove most of both sides of the thyroid cartilage, leaving the patient with only one arytenoid. Many other procedures would fall on a spectrum between these two extremes.
Panoramic view (1 of 4)
Hemilaryngectomy, with standard (unmodified) epiglottic reconstruction. Panoramic view. Right true cord (left of photo) with arytenoid and anterior left true cord have been removed. The right arytenoid mucosa (left of photo) flops anteriorly because the arytenoid cartilage that would lift and stiffen this mucosa is gone on that side. Epiglottis remains in its original position, with petiole (P) opposite asymmetrical arytenoid mounds.
Interior of larynx (2 of 4)
Close up view of interior of larynx during quiet breathing. The vocal process of left arytenoid (right of photo) by "V" and the petiole of the epiglottis by "P". The upper rim of the cricoid is labeled as well.
Phonation (3 of 4)
During phonation, the vocal process swings medially but there is nothing at the vocal cord level available to vibrate.
Panoramic view (1 of 6)
Panorama of the laryngopharynx in a patient with post-radiation persistence of glottic cancer at the anterior commissure, prior to salvage hemilaryngectomy. Note here the still-normal anatomy: in the foreground, the epiglottis and its characteristic shape (green dotted lines), and in the background, the partially abducted vocal cords (blue dotted lines) occupying part of the glottal space.
Post hemilaryngectomy (2 of 6)
Same patient, after hemilaryngectomy with modified epiglottic laryngoplasty. Compare with image 1. Dotted lines indicate where the margins of the vocal cords once were. Note that, to compensate for the removed vocal cords, the epiglottis has been pulled down and folded (arrows) so that the aryepiglottic cords can more easily vibrate together as a sound source during phonation.
Pre-hemilaryngectomy (3 of 6)
Back to the patient’s pre-hemilaryngectomy exam, but with a closer view than image 1. The tips of the vocal processes are indicated by green dots. In the foreground, note (as in image 1) the normal shape of the epiglottis, prior to being surgically pulled down and folded.
Post-hemilaryngectomy (4 of 6)
Back to the patient’s post-hemilaryngectomy exam, but with a closer view than image 2. The tips of the vocal processes (now exposed by the absent vocal cords) are again indicated by green dots. Compare with image 3 to see the anatomical changes created by the hemilaryngectomy and epiglottic laryngoplasty. The petiole of the epiglottis has been sutured to the cricoid cartilage, at the dotted line.
Phonation (5 of 6)
Still post-hemilaryngectomy, during phonation. The vocal cords have been removed and can no longer be the sound source, but the modified epiglottic laryngoplasty has enabled the aryepiglottic cords and apical arytenoid mucosa (blurred due to vibration here) to serve as a substitute sound source.
Hemilaryngectomy (1 of 4)
After removal of the anterior larynx (hemilaryngectomy) for cancer that recurred after radiation therapy. Though not well seen here, the vocal cords are surgically absent. The black dot seen is for orientation to the next photo. A = arytenoid; E = epiglottis.
Within the larynx (2 of 4)
A view within the larynx. Note again that vocal cords are surgically absent, with only the arytenoid cartilages remaining at the level of the cords. The black dot, on the left arytenoid cartilage, orients to the prior photo. The dot is on the right vocal process.
"Wolfman Jack" voice (3 of 4)
The patient is about to produce his rough, “Wolfman Jack” voice but the arytenoid mounds have not yet started to vibrate.
Food and liquid blocked from trachea (1 of 3)
This view is just inside the upper esophagus in a man who has undergone laryngectomy. The white-edged “disc” at the bottom of the photo is the inner flange of the TEP device. The arrow points towards the valve just inside the flange. This valve says “no” to any food or liquid that wants to pass in the direction of the arrow and into the trachea (not seen here).
Closer look at closed valve (2 of 3)
Here, we see the flapper valve more clearly. Again in its “closed” position, it will not let food or liquid enter.
Opened valve (3 of 3)
Now we see the flapper valve lifted out of its housing. The patient is placing his thumb over the tracheostome (not seen here) and diverting air through the TEP device and into the esophagus. The esophageal walls are brought into vibration to produce continuous, pulmonary air-powered esophageal voice.
A vocal polyp that looks like a “blood blister” on the vocal cord. A hemorrhagic polyp may occur because of acute vocal trauma—sudden and extreme overuse of the voice—and may result in abrupt and fairly severe hoarseness that is persistent. In time, the blood may resorb and leave a translucent polyp; this kind of polyp may be prone to re-bruising intermittently.
Small hemorrhagic polyps may heal on their own, but usually require many months to do so. Larger ones should be surgically removed. Fortunately, the prognosis for full recovery after surgery is excellent.
Hemorrhagic polyp (1 of 4)
Hemorrhagic polyp, right cord. Notice the “blood blister” appearance. Recent further bleeding evident from yellowish discoloration of upper surface of the cord, due to breakdown products of a bruise, estimated two weeks earlier. Hemorrhagic polyps sometimes re-bruise intermittently.
Hemorrhagic polyp (3 of 4)
Vocal cords are coming into vibratory contact, beginning of closed phase.
Hemorrhagic polyp: 1 week after surgery (4 of 8)
Same patient, one week after surgical removal of the polyp, standard light.
Hemorrhagic polyp: 1 week after surgery (5 of 8)
Strobe light, open phase of vibration. Compare with photo 2. Note here that the vibratory amplitude of both cords is the same, showing that the operated cord remains flexible.
Hemorrhagic polyp: 1 week after surgery (6 of 8)
Strobe light, closed phase of vibration. Compare with photo 3; the vocal cords now match much better during voicing, and the voice is completely normalized.
Hemorrhagic polyp: 7 months after surgery (7 of 8)
Seven months later. Strobe light, closed phase of vibration. The patient feels his voice is normal, and swelling checks don't indicate any impairment.
12 weeks after thulium laser treatment (5 of 8)
Twelve weeks after removing the hemorrhagic polyp via thulium laser. View under standard light, at the pre-phonatory instant. Both the patient and physician regard the patient's voice as completely normal in quality and capabilities.
12 weeks after thulium laser treatment (6 of 8)
During phonation, with vibratory blur. Standard light.
12 weeks after thulium laser treatment (7 of 8)
View under strobe light. During phonation, at the closed phase of vibration, for the pitch B-flat 4 (~466 Hz).
12 weeks after thulium laser treatment (8 of 8)
Open phase of vibration, also at B-flat 4 (~466 Hz).
Hemorrhagic polyp, treated by thulium laser (1 of 8)
Hemorrhagic polyp, right vocal cord (left of image). This professional singer has struggled with severe limitations for six months. Note the feeding vessel, both anterior and posterior to the polyp, at arrows. These will be the first target of treatment.
Hemorrhagic polyp, treated by thulium laser (2 of 8)
Using near-contact mode with a thulium laser, the feeding vessels have been coagulated, to reduce bleeding when the polyp itself is addressed. In contrast to what would be seen with a pulsed-KTP laser, one can see here hazy superficial coagulation affecting epithelium surrounding the vessels—so superficial that it will not affect vibratory flexibility.
Hemorrhagic polyp, treated by thulium laser (3 of 8)
The remaining laser energy is delivered to the polyp in contact mode, while stretching it away from the cord.
Hemorrhagic polyp, treated by thulium laser (4 of 8)
At the conclusion of the procedure, the polyp is released from the fiber. There is no damage to the vocal cord surrounding the polyp. A follow-up visit will be scheduled as "possible laser," in case there is any residual polyp that did not slough off.
Capillary ectasia and hemorrhagic polyp, after treatment (3 of 4)
Abducted breathing position after vocal cord microsurgery, standard light. Note that the right cord is normalized, the capillary ectasia on the left is smaller, but persists in spite of spot-coagulation. A simple pulsed-KTP laser procedure in the videoendoscopy procedure room abolished this residual lesion.
Capillary ectasia and hemorrhagic polyp (1 of 2)
Note the differing patterns of capillary ectasia—fine “stream;” meandering “river,” and “pond.” Brilliant white areas are reflection of light; more indistinct submucosal white area right cord raises question of possible cyst (arrow).
Capillary ectasia and hemorrhagic polyp (1 of 7)
Open position for breathing, standard light. There is capillary ectasia on both vocal cords, and there is also a hemorrhagic polyp of the left vocal cord margin (right of photo).
Capillary ectasia and hemorrhagic polyp (2 of 7)
During voicing, the polyp interferes with accurate approximation of the vocal cords, which explains this man's chronic hoarseness.
Capillary ectasia and hemorrhagic polyp, thulium laser treatment (3 of 7)
Using the thulium laser to spot-coagulate and interrupt the flow in dilated capillaries.
Capillary ectasia and hemorrhagic polyp, thulium laser treatment (4 of 7)
Coagulation of the polyp, with fiber tangential to the vocal cord and sometimes lifting medially during contact mode. A second, similar procedure was needed a few weeks later, only for residual polyp.
Capillary ectasia and hemorrhagic polyp, after treatment (5 of 7)
Several weeks later, capillary areas are blanched, but the vocal cord mucosa is fully mobile.
Capillary ectasia and hemorrhagic polyp, after treatment (6 of 7)
Vocal cord margin match and mucosal flexibility are best tested in high voice. This is strobe light, closed phase of vibration, at F4 (~349 Hz).
One week post-op, prephonatory instant (7 of 8)
One week after surgical removal, prephonatory instant, at C5 (523 Hz). Note the gap between the cords, much the same as preoperatively in prior photos.
One week post-op, phonation (8 of 8)
Phonation also at C5. Vibratory blur is equal bilaterally, and upper voice dramatically restored, even before “surgical laryngitis” has resolved.
Young woman with hoarse voice (1 of 8)
Young woman who fits the "vocal overdoer" profile and who has been hoarse for many years. The hoarseness has become intolerable in the past 2 months.
Inspiratory phonation (2 of 8)
At much closer range, with the right polyp (left of photo) displaced with inspiratory phonation to show the considerable left cord (right of photo) injury. Note large vessel coursing along the right polyp (left of photo) and the capillary prominence within the left vocal cord (right of photo) injury as well. Note as well the bruising distant from the origin and yellowish discoloration of partially resolved bruising.
Open phase, rumble (5 of 8)
At F3 (175 Hz), open phase of vibration. At this pitch the polyp flutters and adds a second low rumbling sound to the main pitch she is singing.
Bilateral chronic injuries (1 of 8)
Young music teacher and choral director with chronic hoarseness for more than a year. Note bilateral chronic injuries, and also recent bruise of the right cord (left of photo).
Closeup of injuries (2 of 8)
Closeup of injuries and their "refusal" to let the cords approximate, when attempting (unsuccessfully) to sing a high pitch.
Post microsurgery (3 of 8)
7 days after vocal cord microsurgery, the voice can already pass for normal quality and capability. Compare with photo 1.
Prephonatory instant (4 of 8)
Prephonatory instant at high pitch, showing that the match of the cords is already markedly restored. The tiny elevation will disappear with further healing.
Closed phase, A-flat 3 (5 of 8)
Closed phase of vibration at A-flat 3 (208 Hz), seen under strobe light.
Open phase (6 of 8)
This open phase shows what is equally important: that both cords display equal vibratory flexibility; that is, there is no stiffness or scarring.
Dramatically improved match (7 of 8)
This man also has clear, normal falsetto voice: closed phase of vibration at A-flat 4 (415 Hz), again showing dramatically improved match.
Hemorrhagic polyp (1 of 4)
Kindergarten teacher with severe double pitch and hoarseness. Right vocal cord hemorrhagic polyp and scattered ectatic (dilated) capillaries.
Attempted voice production (2 of 4)
Attempting to produce voice with interference and “rattling” of the polyp.
Post surgery (3 of 4)
A few weeks after surgical removal of the polyp, and spot-coagulation of the dilated capillaries.
Polyp (1 of 7)
This large polyp resulted from an episode of extremely aggressive voice use six months earlier. In this photo, one cannot tell if the point of attachment covers the same area of the circumference of the lesion, or if it is smaller.
Inspiration (2 of 7)
Here, the examiner has elicited rapid inspiration. The rush of air inward pulls the polyp inward and downward, revealing its stalk or peduncle. The attachment is indicated by the dotted line.
Closed position (3 of 7)
The vocal cords are closed while continuing to draw air in. The polyp is now hidden below the point of closure of the cords.
Phonatory view (4 of 7)
When voice is produced, the polyp flips upwards between the colds and now lies on the upper surface of the vocal colds. None of this movement could happen if the polyp were not pedunculated.
After removal (5 of 7)
A week after removal of the polyp. Compare with photo 1 to see that the “wound” (area of vascularity) is far smaller than the diameter of the original polyp (dotted line), showing in a second way the idea that the attachment had “pinched in” to a stalk.
Polyp (1 of 8)
Many months after formation in a low-voiced male, this hemorrhagic polyp has become mobile. Here, inspiration draws the polyp downward towards the undersurface of the left cord (right of photo). When the original bleeding event occurred this polyp would have for some months been more fixed at the free margin, pressing into the left vocal cord (right of photo) at the point of the arrow on the left side (right of photo).
Polyp rides upwards (2 of 8)
As the vocal cords close to produce voice, the polyp rides upwards. The dotted line circles a slight depression, and shows where the polyp originally pressed inward against the left cord (right of photo).
Post-surgery (3 of 8)
A week after vocal cord surgery, the operated side (left of photo) shows residual bruising at the base of the ~ 5mm “wound.” The dotted line on the left cord (right of photo) shows the slight concavity sustained by months of pressing against the polyp, especially during the time before it became pedunculated.
Prephonatory view (4 of 8)
At a prephonatory instant, mild post-surgical swelling of the right cord (left of photo) is seen as subtle convexity. But the slight concavity caused by the pressure of the polyp on the left (unoperated) vocal cord (right of photo) is seen even more clearly (dotted line).
Six weeks post-surgery (5 of 8)
Six weeks after surgery, voice is normal, including high falsetto. The operated right vocal cord (left of photo) looks better than the unoperated one…
Phonation (6 of 8)
During phonation under standard light, the mild concavity of the left (unoperated) vocal cord (right of photo) is seen more clearly.
Hertz is the term (symbol Hz) used by physicists and many voice clinicians as a unit of frequency. One hertz means “one cycle per second.” Thus, 440 Hz in a musical tone is called “concert A,” also known as A4 or “A above middle C.” This means that the vocal folds are vibrating at 440 cycles per second in order for the human ear to hear “A4.”
Histology is the study of the microscopic structure of tissue. In clinical medicine, this kind of study is typically done by a pathologist on a biopsy specimen.
Infection by a fungal organism, Histoplasma capsulatum. This organism is found in soil, especially in areas contaminated by bird or bat droppings. Sometimes it is called “spelunker’s disease,” and it seems to be commoner in the Mississippi River valley than in other areas of the United States. Persons who contract this organism may not even know it, as they may have a self-limited, mild, flu-like syndrome. As with many infections, histoplasmosis can of course be more severe and even disseminated in persons who are immunocompromised. Transmission is primarily respiratory, and the primary target is the lungs, where it can cause non-progressive granulomas. It is quite rare in the larynx.
Histoplasmosis of the larynx: Series of 4 photos
History of the Present Illness
History of the present illness refers to the “story line of the problem” for which a patient is seeing a physician or other healthcare provider. Information sought includes such things as time of onset, symptoms, prior treatments and results, and so forth. The history may be provided by the patient or family members. During a voice-focused history, the information most relevant to the diagnostic process is carefully sought and organized.
Human Papillomavirus (HPV)
A DNA virus that may cause cutaneous warts, genital warts, or the clinical condition recurrent respiratory papillomatosis (RRP) in susceptible individuals. Human papillomavirus (HPV) may occur in as many as 150 or more subtypes. The most common subtypes seen in patients with RRP are HPV 6 and 11. Other less common subtypes that can induce papillomas or other growths within the larynx include HPV 16, 18, 31, 44, 45, 55, 69, 84 & 11, 33 & 45 and some of these subtypes are associated with a higher risk of cancer formation. See the photo series below, displaying all of the subtypes mentioned above.
Common Questions About HPV
Q: What is the relationship between the terms RRP, HPV, and Papilloma?
A: The underlying disorder is HPV (human papilloma virus) infection of the airway, especially the larynx. The virus “sets up house” chronically inside airway and stimulates a kind of proliferation called papillomas, or papillomatosis. Because these lesions tend to recur after surgical removal, the clinical syndrome has become referred to as recurrent respiratory papillomatosis (RRP).
Q: HPV apparently has different subtypes. What can you tell me about them?
A: Human papilloma virus infection can consist of as many as 150 different subtypes. Some are related to skin infection (causing warts). Some are more common in genital or respiratory sites. Genital lesions are typically called condylomata, or genital warts. In the airway, the lesions are typically called papillomas. Commonest subtypes in the airway are types 6 and 11. These two subtypes comprise the vast majority of our patients at BVI. We have patients who have also tested positive for types 16, 18, 45, 55, and a few others.
Q: I have a low-risk subtype of HPV. Can you explain what this means?
A: The human papilloma virus (HPV) comes in 150 or more subtypes. Think of it like the many models of automobiles that all fall under the designation “Ford.” Subtypes found most often in the respiratory and genital tracts are 6 and 11. HPV infection is associated with some degree of risk of stimulating, or converting to, a carcinoma. Hence the higher risk of cervical cancer in women with HPV infection. Some subtypes are considered to have a low risk of viral carcinogenesis; others have a high risk. At BVI, the majority of our many adult patients have 6 or 11, both of which are low-risk subtypes. We also have one or two who have both 6 and 11. Then we have a handful of patients with intermediate or high risk for cancer. A few of these high-risk subtypes have in fact caused cancers in our population of ~150 adult patients with RRP. Thankfully, all have responded well to treatment and none to my memory have died from their cancer.
More common subtype seen in the airway. HPV 6 is associated with a lesser risk of cancer formation, as is HPV 11.
Papillomas: HPV Subtype 6 (1 of 4)
Papilloma, left vocal cord (right of image), standard light. Voice is grossly hoarse. This patient has HPV subtype 6.
Papillomas, removed: HPV Subtype 6 (3 of 4)
After removal and cidofovir injection, normalized larynx. Voice is normal.
Subtle papillomas, HPV subtype 6 (1 of 3)
After achieving a normal voice through several procedures, the patient came in for reexamination due to the return of mild huskiness. This distant panoramic view with standard illumination does not reveal any obvious papillomas.
Subtle papillomas, HPV subtype 6 (2 of 3)
At close range, using narrow band illumination, a subtle but definite HPV effect is seen. Notice the stippled vascular markings and the faintly increased pinkness at the margins of the cords, indicated by dotted lines.
Standard light, HPV-6 infection (1 of 4)
Breathing position, standard light in a young woman with longstanding HPV-6 infection. Voice remains quite good, many months after her last microsurgery with cidofovir injection. The only obvious “lesion” is posterior right cord (left of image) but the characteristic punctate vascular marks are not seen. The black lines are purely for use to orient photo 4.
Stobe light, vocal cord margin irregularity (2 of 4)
With such a clear voice, this prephonatory instant under strobe light reveals a surprising degree of vocal cord margin “serpentine” irregularity. Black lines again support orientation with photo 4.
Narrow band light, vascular marks seen (3 of 4)
At very close range and also using narrow band light, the tiny punctate vascular marks are seen in the lesion first seen in photo 1. Faint vascularity like that demonstrated here can be a correlate of relatively stable, inactive disease, which has clinically been the case here.
Narrow band light, papilloma formation (4 of 4)
This narrow band view includes only the anterior half of the vocal cords from the black lines of photos 1 and 2 to the anterior commissure (at x). Inside the faint circles, note the vascular markings that suggest papilloma formation to explain the serpentine margin.
Two papillomas (1 of 3)
Approximately one month after removal of papillomas and Avastin injection in a man who has battled aggressively-recurring disease caused by HPV, type 6. In this view using narrow band light, only two small papillomas are visible.
Stippled vascularity (2 of 3)
At closer range, careful inspection shows no papilloma (yet), but only the stippled vascularity typical of HPV infection.
Stippled vascularity not seen (1 of 4)
Diffuse involvement of true and false cords with papilloma caused by HPV 6. After hundreds of procedures from childhood through early adulthood, the stippled vascularity is not extremely evident in this standard-light view.
HPV vascular effect (2 of 4)
At closer range, still under standard light, the characteristic vascularity—what we term “HPV vascular effect”—is only beginning to be evident (arrows).
Vascularity clearly seen (3 of 4)
At still closer range, and now under narrow-band light, stippled vascularity is clearly seen (arrows).
“Curative mode” plan (1 of 7)
Known HPV 6-induced laryngeal papillomas, with resulting gross hoarseness. The plan is “curative mode” defined as 3 or more successive, surgical cleanouts with adjuvant injection to see if the disease can be put into remission or at the least “tamed” to less rapid recurrence.
Closer view (2 of 7)
At closer range. Still, the full extent of disease becomes more obvious at the anterior right vocal cord (left of photo at arrow) in the next photo, when viewed under narrow band illumination (NBI).
Narrow-band illumination (3 of 7)
Now under NBI, the right anterior vocal cord (left of photo) involvement is seen clearly.
Post surgery (4 of 7)
A few days after surgical removal using the usual “basement membrane peel” technique of removal and in this case cidofovir injection. Voice is already dramatically improved, the right cord (left of photo) retains vibratory ability, and the grey wound base is seen clearly.
Towards “management mode” (5 of 6)
Voice had been “normal” until recent weeks, and so the patient therefore waited longer than intended for followup surgery, to the point that we are drifting out of “curative mode” and over into “management mode.” Here, under standard light, the disease is not that obvious.
Same view under NBI (6 of 7)
Under NBI at closer range, the carpet of HPV upper surface and one actual papilloma are more evident, but it is still not quite clear why the patient says voice has been getting slightly hoarse.
One of the more common subtypes seen in the airway. HPV 11 is associated with a lesser risk of cancer formation, as well as HPV 6.
Papillomas: HPV Subtype 11 (1 of 4)
Papillomas at posterior vocal cords, with left side (right of image) much larger than right. This patient has HPV subtype 11.
Papillomas: HPV Subtype 11 (2 of 4)
Closer view, under narrow band illumination, which accentuates the vascular pattern.
Papillomas, removed: HPV Subtype 11 (3 of 4)
Two weeks after microsurgical removal, cidofovir injection, and return of normal voice.
Papillomas: HPV Subtype 11 (1 of 3)
Panoramic view, standard light, shows papillomas on the aryepiglottic cord, false cords, anterior face of arytenoid, and at anterior commissure. This patient has HPV subtype 11.
Papillomas: HPV Subtype 11 (2 of 3)
Closer view, standard light, shows more clearly the papillomas on the anterior face of the right arytenoid and at the anterior commissure.
Papillomas: HPV Subtype 11 (1 of 2)
Vocal cords, narrow band light, showing papillomas on the upper surface of the anterior vocal cords. This patient has HPV subtype 11.
Less common in the airway than the more common subtypes 6 and 11. HPV 16 is associated with a higher risk of cancer formation, along with HPV subtypes 18, 31, 45, 55, and others.
Lesions of HPV Subtype 16 (1 of 3)
Recurring inflammatory and leukoplakic lesions caused by HPV subtype 16. A left vocal cord cancer (right of image) was removed several years earlier, and the patient developed a right vocal cord cancer almost a year later.
Lesions of HPV Subtype 16 (2 of 3)
Slightly magnified view, focusing on the anterior (frontward) ends of the vocal cords. The cords' stippled vascularity, which often accompanies HPV infection, is more apparent here.
Cancer: HPV Subtype 16 (1 of 5)
Cancer, in a patient with HPV subtype 16. The divot and blood seen on the left vocal cord (right of image) are the result of a biopsy performed elsewhere (not by BVI physician) earlier the same day as this examination.
Cancer: HPV Subtype 16, after radiation therapy (3 of 5)
Six weeks after the end of radiation therapy, the tumor is no longer seen. However, part of the left cord (right of image) is missing, due to sloughing of the tumor that had eaten away part of the cord’s normal tissue.
Cancer: HPV Subtype 16, after radiation therapy (4 of 5)
Phonation. Strobe light, open phase of vibration, shows that the margin of the left cord (right of image) is at a lower level than the right’s, due to loss of some of the bulk of the cord where the tumor died and sloughed away.
This is less common in the airway than the more common subtypes 6 and 11. HPV 18 is associated with a higher risk of cancer formation, along with HPV subtypes 16, 31, 45, 55, and others.
Papillomas seen (1 of 4)
Middle-aged man with chronic hoarseness and the lesions seen here, diagnosed by the pathologist as papillomas.
Stippled vascularity (2 of 4)
Closer view. Stippled vascular markings consistent with HPV effect are seen more clearly here.
This is less common in the airway than the more common subtypes 6 and 11. HPV 31 is associated with a higher risk of cancer formation, along with HPV subtypes 16, 18, 45, 55, and others.
Papillomas: HPV Subtype 31 (1 of 4)
Standard light, showing lesions on the vocal cords, in particular the stippled vascular pattern we call "HPV effect." The patient's voice was nearly gone, with numerous syllable drop-outs and a very effortful quality. Compare with photo 3.
Papillomas: HPV Subtype 31 (2 of 4)
Closer view, using narrow-band light to accentuate the vascular pattern of "HPV effect." Biopsy and additional testing of these lesions showed squamous papilloma with moderate dysplasia, and HPV subtype 31 was confirmed, which is high risk for eventually causing cancer. After the patient underwent several injections of cidofovir, the lesions persisted but seemed to become more indolent. On compassionate grounds, this fairly young person was then prescribed celecoxib for six months.
Papillomas, in remission: HPV Subtype 31 (3 of 4)
Three years after photos 1 and 2, standard light view. Within two months of the start of celecoxib, voice improved very noticeably, and the "HPV effect" vascularity resolved. Still, it is unknown what roles in this recovery were played by the patient's immune system, the cidofovir, and the celecoxib, respectively.
Hazy leukoplakia, HPV suspected (1 of 4)
This 20-something nonsmoker without reflux symptoms is chronically hoarse. HPV infection is suspected for the following reason: While hazy leukoplakia can be occasionally seen as a result of excessive voice use, it would be most unusual to this degree, and this far lateral to the vocal cord margin. Biopsy shows only chronic inflammation, and HPV testing is positive for subtype 31.
Leukoplakia remains (2 of 4)
Several months later, the inflammatory reaction with leukoplakia remains.
Leukoplakia demarcated (3 of 4)
Narrow band illumination here makes the leukoplakia patches more demarcated.
Carcinoma in situ (1 of 4)
This man developed hoarseness spontaneously a year before this visit. He had accumulated 30 pack-years as a smoker, but had quit 7 years earlier. Removal of “polyps” elsewhere returned a diagnosis of carcinoma in situ (CIS), the earliest stage in the development of cancer.
HPV subtype 31 (2 of 4)
Under narrow band light, note some unusual “suspicious” capillaries, and the stippled “HPV effect” at the arrow. These findings triggered HPV subtyping and identification of high-risk subtype 31.
Excisions (3 of 4)
After 2 prior excisions elsewhere with positive margins, somewhat aggressive excision was performed in the operating room, attempting to avoid the need for radiotherapy in this fairly young man. The specimen showed severe dysplasia/ CIS, but with negative margins. After some months, voice became very functional.
Voiceless 50-year-old man (1 of 6)
This 50-year-old man is virtually aphonic. The vocal cord abnormality is already visible in this distant view.
Vascular stippling (2 of 6)
At closer range and under standard light, the vascular stippling is becoming more visible. The two small 'X's are for reference with Photo 3.
Narrow band light, vascularity (3 of 6)
At even closer range under narrow band light, the vascularity is even more evident. The two small 'X's are for reference with Photo 2.
4 months later, recurrent papillomas (4 of 6)
This man had marked improvement of voice after surgery 4 months earlier but within weeks, voice began to deteriorate due to regrowth of his papillomas.
Open position, narrow band light (5 of 6)
Still in open (breathing) position but now under narrow band light. The stippled vascular markings typical of HPV effect are seen more clearly.
This subtype is less common in the airway than the more common subtypes 6 and 11. HPV 45 is associated with a higher risk of cancer formation, along with HPV subtypes 16, 18, 31, 55, and others.
Papillomas: HPV Subtype 45 (1 of 2)
Papillomas in the supraglottis, left of image. The pink, velvety area of papillomas is outlined by small arrows.
HPV type 45 detected (1 of 7)
Panoramic view shows marked enlargement from tumor of false cords. Biopsy shows squamous cell and cancer HPV type 45 is also detected as the likely cause.
Closer view of HPV effect (2 of 7)
Closer view of the true vocal cords showing HPV effect of vascular stippling.
Post radiotherapy, glottic web seen (4 of 7)
After radiotherapy with complete response. A glottic web is now seen as a radiation side effect/complication.
Post-microlaryngoscopy, release of glottic web (6 of 7)
After microlaryngoscopy and release of glottic web. Tumor is gone.
Subtypes 33 & 45
Narrow band light (2 of 5)
At closer range, under narrow band light. Note the two distinct vascular patterns: a finer, stippled one of anterior 1/3 and a more coarse and aberrant one on the mid and posterior fold. The pathology report shows invasive carcinoma-in-situ, which was removed using the CO2 laser.
Healed (4 of 5)
After healing, the right fold normalizes remarkably and the patient’s voice sounds normal to her and to the clinician.
This subtype is less common in the airway than the more common subtypes 6 and 11. HPV 55 is associated with an intermediate degree of risk of cancer formation, as compared to other subtypes of HPV.
Papillomas: HPV Subtype 55 (1 of 4)
Papillomas of the vocal cords, in a patient with HPV subtype 55, which is intermediate-risk for progressing to cancer.
Papillomas: HPV Subtype 55 (2 of 4)
Same exam, with narrow-band lighting, which accentuates the vascular pattern of the papillomas.
Papillomas, in remission: HPV Subtype 55 (3 of 4)
Same patient, years later, in remission, and with normal voice. No sign of papillomas here or anytime during the prior three and a half years, after meticulous removal and Cidofovir treatment.
Standard lighting (1 of 2)
Here, right vocal cord (left of photo) is unaffected, while left cord is entirely covered with papillomas caused by HPV 69.
HPV 84 & 11
Chronic hoarseness, papilloma (1 of 5)
60-something man with chronic hoarseness due to these lesions, seen under standard light. Biopsy shows "papilloma" and HPV testing reveals subtypes 84 & 11.
Stippled vascularity, leukoplakia (2 of 5)
At closer range under narrow band light, the stippled "HPV effect" vascularity is seen more clearly. The lesion marked by 'X' in this photo and photo 1 shows a subtle degree of leukoplakia.
Post treatment, voice is very good (3 of 5)
After several micro laryngoscopes, first using cidofovir as an adjuvant, and then avastin, the larynx looks quite clear. Voice is also very good.
Narrowing of the entrance to the upper esophagus, at the junction of the throat and esophagus. Hypopharyngeal stenosis is a possible but uncommon complication for individuals with larynx or pharynx cancer who undergo radiation therapy as part of their treatment regimen.
Hypopharyngeal stenosis: not yet visible (1 of 2)
Panoramic view of the larynx, with the swallowing “crescent” in the middle of the view (indicated by the dotted lines). Several months prior, this patient had laser resection for hypopharyngeal cancer. Expected scarring from the surgery led to a stenosis (that is, a narrowing) at the entrance to the esophagus. The stenosis cannot be seen here, but is revealed in the next photo (for reference, an “X” marks the same point in the larynx in both photos).
Hypopharyngeal stenosis: revealed (2 of 2)
The patient performs the trumpet maneuver, which splays open the hypopharynx, revealing the stenosis; the dotted lines represent what would be a normal-sized opening. This stenosis affects swallowing of solid food, but the patient says this is no problem for him, if he eats a little more slowly and chews well.
Dilation for post-radiation hypopharyngeal stenosis (1 of 4)
Early after radiotherapy for left vocal cord cancer (indicated by arrow), tumor seems to have responded, but it has become difficult to swallow solid foods due to a radiation-induced stricture (indicated by solid oval) with expected lumen (indicated by the dotted lines).
Dilation for post-radiation hypopharyngeal stenosis (2 of 4)
Closer-range view of the stricture at opening to the esophagus.
Dilation for post-radiation hypopharyngeal stenosis (3 of 4)
A tapered device used for dilation (bougie) is now inserted into the stricture and down into the upper esophagus in order to enlarge the entrance to the esophagus.
Post radiation therapy (1 of 3)
This man finished chemotherapy + radiation therapy elsewhere for base of tongue cancer with neck disease, finishing a year prior to this examination. Despite swallowing therapy and VitalStim treatments, he was unable to swallow even his own saliva.The actual diagnosis is seen in the next photo. Panoramic view of hypopharynx.
Small stricture (2 of 3)
During “trumpet maneuver,” the larynx pulls anteriorly and reveals a stricture of very small size, at arrow. This would normally allow passage of saliva, but in this case it does not. View photo 3 for explanation.
Esophageal stenosis (3 of 3)
The stricture ends as a virtually blind pouch. Here, the scope has been inserted to a distance of nearly an inch into the stricture seen in prior photo, at which point a near-total stenosis is found. The arrow shows a pinhole opening less than a millimeter in diameter. The dotted line shows the expected size of opening at this level.