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

Laryngopedia By Bastian Medical Media

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La belle indifference

La belle indifference is a French term that indicates a peculiar lack of concern on the part of a patient about the problem for which they have come to be evaluated, even when one would think the average person would be distressed by it. Sometimes such individuals do not seem that interested in options for recovery as well. Observation of la belle indifference should cause the clinician to think about possible nonorganicity. This phenomenon in a patient may be magnified by certain elicitation techniques on the part of the clinician.

Laryngeal closure or diversion for aspiration

One of several potential treatments for a person who suffers from gross aspiration to the extent that, even without taking any nourishment by mouth, this person has repeatedly incurred aspiration pneumonia (i.e., due to saliva alone). In this scenario, subsequent pneumonias start to become more severe and even life-threatening as the lungs progressively deteriorate. At this point, there is a list of options:

  1. Tracheotomy. This procedure makes it possible to suction out the trachea and any aspirated secretions on a frequent basis, and to inflate a balloon on the outside of the tube in order to reduce the volume of aspirated secretions.
  2. Tracheal transection, with or without diversion. This option deprives the person of voice and makes him or her an obligate neck breather. In this procedure, a physician transects the trachea and sews the stump below the larynx completely shut. The lower stump is sewn to the skin, making the person a neck breather. If the person’s ability to swallow returns, then theoretically the trachea can be reattached. A variant of this procedure is to sew the upper stump into the esophagus so that secretions that enter the larynx can drain into the esophagus.
  3. Total laryngectomy. This option is the most definitive way to stop life-threatening aspiration. Its best application is in an individual whose ability to swallow is certain not to recover. Total laryngectomy consigns the person to neck breathing (like option 2), but a tracheoesophageal voice can be established and swallowing becomes perfectly safe, because the airway and foodway are completely separated.

Laryngeal Dystonia

Laryngeal dystonia is a benign neurological condition affecting the larynx associated either with voice disturbance or, much less commonly, with breathing disturbance or, yet more infrequently, with both. The voice disturbance is referred to as spasmodic dysphonia. The breathing manifestation is called respiratory dystonia.

Laryngeal electromyogram (LEMG)

See electromyogram.

Laryngeal Examination

Laryngeal examination is the process of visualizing the interior of the larynx, or voicebox. This is part three of the integrative diagnostic model. Screening examination can be completed with the time-honored laryngeal mirror examination. The flexible fiberoptic scope or laryngeal telescope can also be used. Examination is further enhanced through use of strobe illumination to provide apparent slow-motion views of vocal fold vibration, and also by videodocumentation of the examination to allow review and collaboration with other clinicians.

See also laryngeal videostroboscopy.

Laryngeal Image Biofeedback (LIB)

A technique first described to our knowledge by Dr. Bastian, in which videoendoscopy is performed and shown to the patient in real time, rather than being recorded and reviewed with the patient. The purpose of LIB is to allow the individual to modify his or her laryngeal behavior (and the vocal sound that results) using not only auditory and kinesthetic feedback, but also visual feedback.

Laryngeal mirror examination

Laryngeal mirror examination is a time-honored method for visualizing the interior of the larynx and pharynx, and especially the vocal folds. This method was originally described in the 19th century by famed singing teacher Manuel Garcia. An angled “dental” mirror is held against the soft palate and over the base of the tongue, and illuminated, typically by head mirror or headlight. The larynx is then visualized in this mirror while the patient phonates on the /i/(eee) vowel.

Laryngeal Penetration

When food or liquid enters the laryngeal vestibule but, unlike with aspiration, does not descend below the level of the vocal cords themselves. Laryngeal penetration alone would be an indication of mild swallowing dysfunction, but it would not by itself create a risk of pneumonia, as aspiration might.

Photos of laryngeal penetration:

Laryngeal penetration: Series of 1 photo

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Blue applesauce on the laryngeal surface of the epiglottis

Laryngeal penetration (1 of 1)

After the patient swallowed several boluses of blue-stained applesauce, there were traces visible on the laryngeal surface of the epiglottis, indicative of penetration into the earliest part of the airway. By itself, soiling of the laryngeal vestibule to this minor degree does not threaten the person’s ability to eat by mouth.

All It Takes Is A Drip to Make You Cough: Series of 4 photos

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Laryngeal vestibule

Coughing (1 of 4)

This patient is annoyed by occasional coughing when she sips liquids. She has had no pneumonias, weight loss, or increased time required to eat/drink. Here, the patient has just taken a sip of blue water and holds it in her mouth.
blue water flowing into laryngeal vestibule

Coughing (2 of 4)

Just before swallowing, a tiny drip of blue water “gets away” and begins to trickle down into her throat. Vocal cords remain unsuspectingly open.
blue water in left aryepiglottic fold

Coughing (3 of 4)

The drip (arrow) has now reached the left aryepiglottic fold, which is the “side of the boat” that keeps liquid out of the airway. The drip looks smaller than in photo 2 because it is farther away. She does not cough.
blurry blue water in throat

Coughing (4 of 4)

During a different swallow, if a much larger amount of water were to drip prematurely down into her throat, a part of it would enter the laryngeal entrance and provoke coughing. If coughed back up, there would be little risk of pneumonia.

Laryngeal Ventricle

A fossa (Latin for “trench”) between the true and false vocal folds, running in an anteriorposterior direction. The laryngeal ventricle is bounded laterally by a mucus membrane, beyond which is the inner surface of the thyroid cartilage. At the anterior end of the ventricle is the opening of the laryngeal saccule (or laryngeal “appendix”).

Laryngeal Vestibule

The “airspace” above the level of the vocal folds that is bounded by the posterior surface of the epiglottis, the medial surfaces of the aryepiglottic folds, and the anterior faces of the arytenoid cartilages.

Laryngeal Videostroboscopy

Laryngeal videostroboscopy is a technique of examining the larynx that includes special endoscopes coupled to both continuous and strobe light, a video system, a TV monitor, and a computer. This technique produces highly magnified views of the larynx that are video documented for later study or review with patient, speech pathologist, family, and so forth. In normal light the vibration of the folds would appear as a blur; the strobe light reveals apparent individual cycles of vibration for assessment.


An infection or inflammation of the larynx. The cause of laryngitis can be viral, bacterial, or fungal (candida). Or it can result from acid reflux, cancer radiation therapy, surgery (as temporary post-operative inflammation), or an auto-immune disorder.

See also: candida laryngitis, ulcerative laryngitis, laryngitis sicca, nonorganic voice disorder, and laryngopharynx acid reflux disease (LPRD).

Photos of laryngitis:

Laryngitis Sicca

A condition of severe dryness in the larynx, almost always with crusting of mucus. Laryngitis sicca often makes the voice hoarse.

Causes of Laryngitis Sicca:

One cause of laryngitis sicca is the use of radiation therapy for cancer in the larynx. As the radiation therapy kills the tumor it is targeting, it may also damage or destroy the larynx’s mucus-producing glands. These damaged glands may then produce less mucus, and mucus that is more proteinaceous and consequently more viscous or thick and sticky. This viscous mucus can also be easily colonized by bacteria, and become crusted, especially in winter, when humidity indoors is lower.

A second kind of laryngitis sicca seems to accompany bacterial infection alone, apart from any use of radiation therapy. The mucus crusts become yellow or green, and the mucosa reddens with inflammation.

Treatment for laryngitis sicca:

Antibiotic therapy may improve or resolve the problem, though some cases seem stubbornly resistant to such treatment, even with several courses of broad-spectrum antibiotics. Improved hydration of the larynx may help somewhat, as may having the patient learn to irrigate his or her larynx and “gargle” in the larynx.


Laryngitis Sicca

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Laryngitis sicca: crusting of dry, green mucus on vocal cords

Laryngitis sicca (1 of 2)

Laryngitis sicca, with crusting of dry, green mucus especially undersurface of the folds. Though a rare long-term complication, may be seen after laryngeal irradiation for cancer (Lab).

Laryngitis sicca (2 of 2)

Same patient, from slightly higher view (Lab).

Pachyderma, caused by laryngitis sicca: Series of 3 photos

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Heaped up Mucosa (1 of 3)

Pachyderma, here referring to the heaped up mucosa in the interarytenoid area, in a patient with laryngitis sicca.
Adducted (voicing) position with Pachyderma

Pachyderma (2 of 3)

Adducted (voicing) position. Note that the pachyderma does not interfere with closure of the cords. In this case, it does not directly affect the patient’s voice, which is typical, but the more generalized inflammatory condition (see the redness of the cords) does.
stippled vascular markings from Pachyderma

Stippled Vascular Markings (3 of 3)

Narrow-band lighting. This shows some stippled vascular markings, often seen with chronic inflammation or HPV infection.

Acid reflux and sicca syndrome: Series of 4 photos

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classic interarytenoid pachyderma

Acid reflux (1 of 4)

This man has obvious clinical symptoms of acid reflux such as heartburn, excessive morning mucus, husky morning voice. Note classic interarytenoid pachyderma, diffuse pinkness.
Prominent capillaries and mucus

Prominent capillaries and mucus (2 of 4)

Here we see loss of color differential between true and false cords. Capillaries are prominent (like bloodshot eyes) on the true cords. There is also adherent mucus.
Closer view of the prominent capillaries.

Closer view (3 of 4)

Closer view of the prominent capillaries.
upper trachea shows evidence of redness

Redness and inflammation (4 of 4)

Even the upper trachea shows evidence of redness and inflammation. This is not seen that often except with truly severe nocturnal acid reflux/ LPR.

Sicca laryngitis with micro-crusts: Series of 3 photos

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some small crusts on vocal cords

Laryngitis (1 of 3)

This 50-something man complains of chronic laryngitis of unknown cause. This distant view shows some small crusts, but closer viewing reveals more detail...
Sicca laryngitis

Closer view (2 of 3) this closer view, small crusts are seen more clearly, but an even closer visualization....
Tiny dots added to show micro-crusts

"Micro-crusts" (3 of 3)

...shows not just small, but also "micro-crusts" rather than the thin and wet mucus layer that should be slowly streaming upwards from the undersurface of the vocal cords. Tiny dots added to show these micro-crusts.


A disorder in which the laryngeal saccule is inflated and becomes abnormally enlarged. A common symptom of a laryngocele is hoarseness.

How it develops:

The laryngeal saccule, or laryngeal appendix, is a very small blind sac—a dead-end corridor, so to speak—which is located just above the vocal cords, one on each side, and is lined with glands that supply lubrication to the cords. When a person makes voice, it is possible for a little bit of the air being pushed up out of the trachea to slip into this saccule. If over time enough air enters the saccule with enough force, the saccule may begin to be inflated and stretched out, leading to a laryngocele.

In some cases, the air that slips into and inflates the laryngocele will slip back out again as soon as the person stops making voice, so that the laryngocele abruptly inflates and deflates with each start and stop of speech or voice-making. (The photos and video below are an example of this.) In other cases, the air cannot exit as easily, but it may be reabsorbed slowly during quiet times or during sleep—only to be inflated again at the next instance of more active speaking.

Laryngocele vs. saccular cyst:

A much more common disorder of the laryngeal saccule (compared with a laryngocele) is a saccular cyst, which can occur if the entrance to the laryngeal saccule becomes blocked. In this scenario, air is absorbed, but secretions build up and gradually expand the saccule.

Symptoms and treatment for laryngocele:

A common symptom is hoarseness, because while the saccule is inflated, it may press press down on the vocal cords, not allowing them to vibrate freely, or it may block the laryngeal vestibule just above the cords and partially muffle the sound produced by the cords. Standard treatment is surgical removal, through one of two approaches: a small incision on the neck that leads into the larynx from the outside, or a laryngoscope that is inserted through the mouth and down into the larynx so that the laryngocele can be removed using a laser.



Laryngocele: A Cause of Hoarseness
A laryngocele is a disorder of the saccule, or laryngeal appendix, in which air abnormally expands it. Watch this video to see how a laryngocele behaves in real-time, and why that can affect the voice.


A Laryngologist, is a sub-specialized otolaryngologist (ear, nose and throat physician), who focuses on disorders of the throat, including those involving the functions of voice, swallowing, and airway. As one might expect, laryngologists come in varying types. Some do not do cancer work that involves open operations on the larynx, nor do they do neck dissections. Some do not have much involvement with swallowing. Our laryngologists practice what we informally term full-service laryngology. This means that our practice encompasses, as a large part on one end of the spectrum, microsurgery on the vocal folds, up to and including, on the other end of the spectrum, the big operations of larynx cancer and larynx and tracheal reconstruction.


An abnormal laxity or softening of laryngeal tissues, most often seen during inspiration as floppiness and indrawing of the arytenoid mucosa or aryepiglottic cords. Sometimes the epiglottis acts like a sail and, caught by the inspiratory air, flips downward to partially cover the laryngeal vestibule. Laryngomalacia may be the result of structural weakness, especially in premature infants; it can also be “induced” or “allowed” in older children and adults of all ages, as one type of nonorganic breathing disorder.

Laryngomalacia Due to Breathing Tube Injury

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(1 of 4)

After a life-threatening illness including weeks in an ICU on a ventilator (breathing tube involved), this person underwent tracheotomy. Here, the old breathing tube injury of the vocal cords is clearly seen and explains a very hoarse voice. Arrows point out divots of tissue loss from pressure necrosis. Dotted lines indicate where the margins of the vocal cords would be if uninjured.

(2 of 4)

Viewing from barely below the vocal cords, the white tracheotomy tube enters the airway in the distance, and a synechia (s) and lateral scarring (sc) are seen in the foreground.

(3 of 4)

Viewing from deeper into the subglottis while the patient exhales with trach tube plugged, there is “blow-by” dark room around the #6 tracheotomy tube. The diagonal line, upper right, indicates junction between membranous (M) and cartilaginous (C) trachea.

(4 of 4)

When she inhales with tracheotomy tube plugged, the walls of the trachea collapse inward, and the patient cannot fill her lungs. Most noteworthy is the indrawing of the cartilaginous wall (arrow at C). Tracheal narrowing for exhalation can be managed with expiratory straw breathing. Collapse of this magnitude during inspiration implies the need for repair (resection of the bad segment and re-anastomosis).


The anatomical region that begins roughly at the base (back) of the tongue and goes down to the level of the upper part of the trachea/esophagus low in the neck. The laryngopharynx comprises an area in which both breathing and swallowing functions are shared. When one reaches the larynx/esophagus, at that point begin separate and dedicated passages for air and food.


Laryngopharynx acid reflux disease (LPRD)

A constellation of symptoms and findings caused by reflux (backwards flow) of stomach acid into the throat or larynx, typically during sleep. Laryngopharynx acid reflux disease (LPRD) may be seen with or without the heartburn, acid belching, etc., commonly associated with gastroesophageal reflux disease (GERD). The classic symptoms of LPRD may be exaggerated in the morning and include one or more of the following: dry throat, rawness or scratchy sensation, increased mucus production and attendant throat clearing, husky voice quality or low-pitched morning voice, irritative cough, and, if one is a singer, the need for prolonged warm-up. For appropriate treatment measures, see GERD.

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.



Laryngoscopy is the process of looking into the larynx. See laryngeal videostroboscopy, laryngeal mirror examination and microlaryngoscopy.


A sudden reflexive closure of the larynx occurring when an individual is trying to breathe. Laryngopasm occurs more frequently in persons who have vocal cord paralysis or in those experiencing sensory neuropathic cough; it is also seen as an aftermath of an upper respiratory infection.

A typical laryngospasm episode begins abruptly and lasts approximately one minute. The individual often makes loud inspiratory noises, the loudness of which abates gradually over the first minute or two. The voice may be choked off during the same time, making it difficult to speak. Laryngospasm is terrifying not only to the person experiencing it but also to family, friends, or strangers observing the episode. An attack may awaken its victim from sound sleep. Rarely, an individual will experience a series of laryngospasms, making it appear that they are having one much longer spasm.

Audio description:


Laryngospasm, Part I: Introduction
Dr. Bastian explains laryngospasm with video of the larynx and a simulated attack. You will hear the types of noises often made by the person experiencing laryngospasm and see what the vocal folds are doing at the same time.
Laryngospasm, Part II: Straw Breathing
Laryngospasm is a sudden, often severe attack of difficulty breathing, typically lasting between 30 and 90 seconds. In this video, Dr. Bastian explains a simple procedure — straw breathing — that can be used by individuals suffering an attack.


The larynx, also known as the voice box, is an organ of the anterior neck involved with breathing, phonation, and protection of the trachea. The vocal cords are housed within the larynx. The larynx connects the inferior part of the pharynx with the trachea.

Photos of the larynx:


Introduction to Larynx, Pharynx, and Airway Anatomy
In this presentation Dr. Bastian provides an introduction to larynx, pharynx, and airway anatomy. This video can help individuals understand other material on this website.

Larynx Lipoma

Lipoma is a benign fatty tumor that can occur in any part of the body. On the neck or some other unseen part of the body, it does not require removal. But in the larynx, slow enlargement may disturb voice or even breathing, and therefore these tumors need to be removed. Removal needs to be complete to prevent re-enlargement.

Larynx Lipoma: Series of 5 photos

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mass bulging the left vocal cord

Larynx Lipoma (1 of 5)

This extremely hoarse man underwent unsuccessful attempt elsewhere to remove this submucosal mass bulging the left vocal cord (right of photo). It is a lipoma (benign fatty tumor).
coronal CT image

Larynx Lipoma (2 of 5)

This coronal CT image shows the large tumor (radiolucent (black) lesion at the arrow). This tumor was removed definitively via a small neck incision. The intent was to make a small thyroid cartilage window to be sure of complete removal, but instead, the entire mass was able to be teased out through the cricothyroid space.
Larynx Lipoma

Larynx Lipoma (3 of 5)

A few weeks after removal of the mass. The patient’s voice is virtually normal. Note that the bulge of the left vocal cord (right of photo) is mostly gone, with residual swelling due to recent surgery.
Larynx Lipoma

Larynx Lipoma (4 of 5)

When the patient produces voice, the cords match (straight dark line), explaining why his voice is now “normal.”
CT image 6 months after surgery

Larynx Lipoma (5 of 5)

CT image, taken 6 months after removal of the lipoma. Compare with photo 2.


An acronym for “light amplification by stimulated emission of radiation.” Rather than producing light of varying wavelengths that scatters in every direction, as a light bulb does, the laser apparatus creates light that is coherent – meaning that only one wavelength is created and every photon (“packet”) of light travels in precisely the same direction. Somewhat confusingly, “laser” may be used to designate both the machine that produces the laser beam, and the beam itself.

See also: laser surgery.

Laser surgery

Laser surgery is surgery that uses a beam of laser light, rather than other instruments, to cut, dissect, remove, and so forth. The beam of light has advantages over other cutting instruments, such as scalpel or scissors. First, at the same time that it cuts, it tends to seal off tiny blood vessels and reduce bleeding. Second, it may be especially useful in endoscopic surgery, where there is not a lot of room for instruments. Third, it is very precise. Both the microspot carbon dioxide laser and the RevoLix laser used at our practice have minimum spot sizes of about 1/5 of a millimeter.

Photos of laser surgery:


Thulium laser
This video gives an example of office-based thulium laser ablation of residual laryngeal papilloma.


Latency (of voice production) occurs during the vocal capability battery’s elicitation, when a patient seems to pause an inappropriate amount of time before complying with a requested vocal task. Latency may be a sign of introversion or vocal inhibition or embarrassment, but much more often may be an indicator of nonorganicity, especially if it accompanies la belle indifference.


Away from the midline of a person’s body, along the left-right axis. For example: the lateral end of each eyebrow is the end that points away from the bridge of the nose. The opposite of medial.


Ever wonder how we laugh?

Laughing that can be seen and heard!
Laughing that can be seen and heard!

LCA-only paresis

LCA-only paresis refers to weakness or paralysis of the vocal cord’s lateral cricoarytenoid (LCA) muscle, but with normal function of the vocal cord’s other muscles. The LCA muscle helps to bring the vocal cord to the midline for voice production and, more specifically, to bring the “toe” of the arytenoid cartilage to the midline. The following are indicators of LCA-only paresis:

  • Movement: The vocal cord opens normally for breathing. From a distance, it can appear to close normally for voicing, but more acute and up-close inspection often shows a faint lag or reduction of crispness of approach to the midline, and inspection of the posterior commissure at close range shows that in fact it does not fully adduct.
  • Position and appearance: Position is normal during breathing, but again, the vocal cord does not come fully to the midline for voicing. A tell-tale indicator of LCA-only paresis is lateral turning of the vocal process. This lateral turning is seen best in low voice, and is a little less apparent with very high voice (as illustrated by a pair of photos below).
  • Appearance during voicing (under strobe lighting): Persistent slight gap between the vocal cords posteriorly, with the laterally turned vocal process, but no flaccidity of the cord with vibration. Normal tone and bulk of the vocal cord itself.
  • Voice quality: Weak and air-wasting, but without the luffing and diplophonia often apparent when the thyroartyenoid (TA) muscle is also paralyzed.

Other variants of vocal cord paresis include TA-only, TA + LCA, PCA-only (posterior cricoarytenoid muscle), and IA-only (interarytenoid muscle).

Photos of LCA-only paresis:


A white patch found on the mucosa anywhere in the body. In the larynx, leukoplakia is most often seen on the vocal cords, either in long-time smokers or in individuals with some other cause of chronic inflammation. Leukoplakia is the descriptive term for what, on biopsy, may prove to be keratosis, carcinoma in situ, or carcinoma.



The chemical name for a common topical and local anesthetic. When applied topically, lidocaine numbs the mucosa for between 15 and 30 minutes; when infiltrated via injection, the duration is about the same, unless a small amount of epinephrine is added, in which case the numbing effect may last 1 ½ hours or so.

Local Anesthesia

Local anesthesia as compared with general anesthesia, in which the entire body is rendered unconscious and asensate, local anesthesia “numbs” a local area, most commonly with lidocaine injected into the tissues to be operated upon.


Long Haul Covid-19 Breathing Tube Injuries Affecting Voice and Breathing

The term “long-haulers” has been used to refer to persons with lingering systemic symptoms after successful initial recovery from Covid-19. Symptoms such as coughing, fatigue, loss of taste and smell, brain fog, etc. occur weeks or months after first falling ill. Even some whose bout with Covid-19 seemed mild can experience this “long-haul” phenomenon. For more, here’s a link to a CDC publication describing this scenario before the words “long-haul” were attached to this syndrome.

Laryngologists are now seeing patients weeks or months after their recovery from severe Covid-19 infection that required hospitalization and intubation/ventilation. These patients seem to be presenting primarily for chronic breathing and voice complaints. We are finding what could be called “long-haul” injuries from the breathing tube used while they were on ventilators. These injuries can be unavoidable when it is necessary to leave these breathing tubes in place for days to weeks due to grave illness. Such injuries in non-Covid patients are documented on Laryngopedia (see, for example: Intubation injury – Laryngopedia). Below are photos showing tracheal stenosis (narrowing), and post-intubation phonatory (voice) insufficiency, in “long-haul” breathing tube injury Covid-19 patients.

Wheezing after Covid-19 can also be Large Airway Wheezing: Series of 4 photos

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Vocal Cords

Vocal Cords (1 of 4)

This person was experiencing some shortness of breath on exertion. She was not wheezing at rest and had no personal or family history of asthma. Still, auscultation of the lungs by a prior physician while requesting that she exhale forcefully revealed wheezing sounds. She was sent for evaluation of vocal cord dysfunction. At the beginning of airway examination, during forced exhalation and audible wheezing these widely separated vocal cords tell us the source of the sound is not the vocal cords.
anterior carina

Trachea & Anterior Carina (2 of 4)

Suspecting large airway wheezing, topical anesthesia was used to obtain this view of the trachea in an office setting. The anterior carina is designated in this and following photos with a *.
Trachea Bulges Inward

Trachea Bulges Inward (3 of 4)

Here, the patient has just begun exhaling forcefully. The membranous tracheal wall begins to bulge inward, not as an anatomical abnormality, but as a functional phenomenon that might occur in virtually any person.
bulging trachea

Trachea Bulges Inward (4 of 4)

At forceful end-expiration, however, the patient demonstrates unusually good ability to bulge her membranous trachea inward and nearly obstruct both mainstem bronchi. The result? Very audible wheezing. To distinguish this from actual asthma, the examiner need only listen over the manubrium and then peripheral lung fields. If this comparison reveals that wheezing is much louder centrally than peripherally, the explanation in my experience has always been large airway wheezing and not asthma. Of course, asthma AND large airway wheezing can occur together.

Tracheal stenosis as a complication of Covid-19 treatment: Series of 2 photos

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Narrowing in the Trachea

Narrowing in the Trachea > 50% (1 of 2)

This patient was in hospital for Covid-19 infection and was intubated for approximately 7 days. Now, 4 months later, she is well in general, and lung damage is mostly repaired. Yet, she is still short of breath. A key clue to the explanation is that she has “noisy breathing.” In this photo, seen in the distance below her open vocal cords, is a > 50% narrowing in her trachea (arrow). Air “squeezing” through this narrowing makes her harsh breathing noise.
Tracheal Opening

Expected Size of Tracheal Opening (2 of 2)

At much closer range, the dots outline the expected size of tracheal opening. This tracheal stenosis, has been caused by the combination of inflammation and infection coupled with the pressure of the sealing balloon of her breathing tube. It is possible that balloon had to be inflated more than preferred to handle high pressure ventilation (though we do not have this information).

Injury to the vocal cords causing voice change, as a complication of Covid-19 treatment: Series of 5 photos

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Erosions in the vocal cords

Erosions in the Posterior Vocal Cords (1 of 5)

This second patient was also intubated for Covid-19 and now, months later, continues to experience a drastic voice change. Initial examiners were unable to explain this voice change. Here, the vocal cords are fully apart, and the experienced eye can see erosions in the posterior vocal cords (arrows). Erosions like these do not cause the magnitude of hoarseness this patient is experiencing. A more likely is tissue loss + cricoarytenoid joint injury (as we shall see is the case…)
Pre-phonatory Instant

Pre-phonatory Instant (2 of 5)

This is the “pre-phonatory instant.” The vocal cords have been put into position for making voice, but vibration has not yet commenced. The cords seem to come together fairly well, and so again, the reason for her very severe hoarseness is not yet evident.
Phonatory Instant

Phonatory Instant (3 of 5)

Vibration has now commenced, producing an extremely hoarse voice, the cause for which is not yet seen in these “distant” views.
Vocal Cords

Close Up of Vocal Cords (4 of 5)

Now at much closer range, we again view the pre-phonatory instant, exactly as seen more distantly in photo 4. We see here that the gap between the cords is greater than appreciated from “afar.” And the erosions seen in photo 1 are actually significant divots, caused by pressure necrosis of the endotracheal tube.
vibrating vocal cords

Insufficient Compression of the Cords (5 of 5)

Vibration commences, exactly as in photo 3. But there is tremendous air-wasting through the keyhole created by the divots, and there is insufficient compression between the vibrating parts of the cords. Hence, the patient’s inability to say a normal number of words on one breath, and her severely degraded “breathy-pressed” voice quality.

Lower Esophageal Sphincter (LES)

A circular band of muscle surrounding the esophagus at its lower end. The lower esophageal sphincter (LES) should be in a state of continual contraction, relaxing only momentarily to allow food to pass into the stomach. Given that the muscle should immediately contract again once food or liquid has passed through, it serves as a “one-way valve,” letting food and liquid pass down into the stomach, but not from the stomach back up into the esophagus.

If the LES fails to remain adequately contracted, it can allow for acid reflux, leading to gastroesophageal reflux disease (GERD) or laryngopharynx reflux disease (LPRD). Alternately, if the muscle fails to relax appropriately when food or liquid reaches it en route to the stomach, the person has a condition called achalasia.

Lowered Vocal Ceiling

This is a type of vocal phenomenology most often seen in the perimenopausal voice. It may also be seen in cases of superior laryngeal nerve paralysis, or cricothyroid joint ankylosis. The individual with this problem may note that he or she cannot access some part of the upper part of the voice, anything from a few notes to an octave or more. As the individual approaches the ceiling of the voice, whether normal or lowered, one begins to hear muscular effort, and often a tendency for the voice to go flat against the person’s will.


Refers to the flaccid, flapping sound that occurs when more than the normal amount of air is passed between vocal cords, at least one of which is flaccid by virtue of a vocal cord paralysis or functional (non-organic) flaccidity. A breathy, diplophonic, unstable kind of vibration occurs that is characteristic of this laryngeal state. Luffing may not be heard if the individual is speaking very softly. It may often be elicited by asking the patient to phonate loudly. Once heard and identified, luffing is a quality easy for the uninitiated clinician to identify again.

Dr. Bastian’s example:

Patient’s example:

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