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Laryngopedia

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

Laryngopedia By Bastian Medical Media

Multimedia Encyclopedia


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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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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.



Laryngitis

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).


Chronic Bacterial Laryngitis

Chronic bacterial laryngitis is a laryngologic problem looking for a more definitive solution. Seen in persons who have undergone radiotherapy or who have an immune defect. The laryngitis can often be improved with antibiotics, but often recurs when antibiotics are discontinued. Sometimes chronic antibiotic administration is needed. Or, laryngeal irrigations.

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Bacterial infection? (1 of 5)

This young man has an autoimmune disorder and is taking a immunomodulator drug. He has been chronically hoarse for months. Is this further auto-immunity or a chronic bacterial infection?

Yellow mucus (2 of 5)

Notice yellowish mucus in the subglottis and the intense erythema of the subglottis. Culture shows staph aureus.

Improvement (3 of 5)

After several weeks of dicloxacillin, voice is dramatically improved, as is the laryngeal appearance (compare with photo 1).

Improved voice (4 of 5)

During voicing, excellent vibratory blur, correlating with his much improved voice.

Infection returns (5 of 5)

Some months after discontinuing antibiotics, hoarseness has returned along with infected mucus.

Candida laryngitis, before and after treatment

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Candida laryngitis (1 of 4)

Severe laryngeal candidiasis, in a person using inhaled steroids at high dose. Standard light.

Candida laryngitis (2 of 4)

Closer view shows more clearly not only the white areas, but also surrounding inflammation. Standard light.

Candida laryngitis, 15 days after starting treatment (3 of 4)

After 15 days of oral fluconazole. Obvious improvement, but incomplete resolution of tissue changes.

Candida laryngitis, several months later (4 of 4)

After longer-term fluconazole, along with reduction of inhaled steroid dose, complete resolution. Strobe light, closed phase of vibration at high vocal pitch.
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lesions are vague, hazy, and best seen anteriorly on the right cord

Candida laryngitis (1 of 4)

Candidiasis in patient using inhaled steroids for asthma. Under standard light, the lesions are vague, hazy, and best seen anteriorly on the right cord (left of image).
vascularity

Candida laryngitis (2 of 4)

Same patient, narrow-band illumination. This not only emphasizes vascularity, but brings out the candida colonies.
Candida laryngitis after treatment

Candida laryngitis, after treatment (3 of 4)

After treatment with fluconazole, the colonies have virtually disappeared.
post-treatment examination

Candida laryngitis, after treatment (4 of 4)

Same post-treatment examination, under narrow-band illumination. Note that there are normal specks of mucus (such as at the arrows) in the view.
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whitish discoloration on the left vocal cord

Candida laryngitis (1 of 3)

Elderly woman with a history of laryngeal amyloidosis requiring laser sculpting several years earlier. Now using high-dose inhaled steroids, antibiotics, and oral steroids for unrelated pulmonary problem. Marked increase of hoarseness, and whitish discoloration, especially of the left vocal cord (right of image).
hazy white areas and irregular right cord margin

Candida laryngitis (2 of 3)

Closer view of hazy white areas and irregular right cord margin (left of image), presumed to be candida overgrowth. Empiric treatment with fluconazole is justified, given history and findings.
white areas are completely resolved

Candida laryngitis, after starting treatment (3 of 3)

Two weeks after starting fluconazole; the white areas are completely resolved. The patient’s voice had improved markedly within three or four days of starting the treatment.

Gradual Healing of Ulcerative Laryngitis

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Ulcerative laryngitis (1 of 4)

Ulcerated area, free margin of both vocal cords. When diagnosed at this early stage, the patient is notified that recovery will likely require as much as six weeks.

Ulcerative laryngitis (2 of 4)

Same view, but using narrow band illumination to accentuate the ulcers.

1 month later: ulcerative laryngitis healing (3 of 4)

One month later, under narrow band illumination. Ulceration dramatically diminished.

3 months later: ulcerative laryngitis virtually all healed (4 of 4)

At three months, standard illumination. Virtually complete healing, with excellent return of voice. The prominent vascularity at area of ulcer will eventually fade.

Vocal Cord Ulcer

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Vocal cord ulcer (1 of 2)

In a patient who had had hoarseness lasting several months, this inflammatory lesion of the right vocal cord (left of image) was identified. There is hazy leukoplakia surrounding a central intensely erythematous ulcer. It most resembles an aphthous ulcer, though these are not previously reported on the vocal cord, and this lesion's duration is longer than the typical aphthous ulcer.

Vocal cord ulcer (2 of 2)

Closer view, under narrow-band light. The vessel pattern looks inflammatory and not neoplastic. There is heaped-up leukoplakia surrounding the lesion. After this lesion persisted for more than four months, it was removed. Tissue examination showed inflammatory response and keratosis without atypia.

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

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Pachyderma

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

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Open phase of vibration

Acid reflux (1 of 2)

Open phase of vibration, strobe light, with white mucus sometimes but not always suggestive of acid reflux laryngitis.
Closed phase of vibration

Acid reflux (2 of 2)

Closed phase of vibration, strobe light, with same mucus findings.
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Phonation under strobe light

Acid reflux (1 of 2)

Phonation under strobe light. Mild capillary prominence.
Acid Reflux during phonation

Acid reflux (2 of 2)

As phonation proceeds, appearance of large amounts of viscous white mucus.

Acid Reflux Laryngitis

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interarytenoid pachyderma

Acid reflux laryngitis (1 of 2)

Panoramic view, shows interarytenoid pachyderma (“elephant skin”) at upper blue arrow; arytenoid redness at green arrows; and mucus retention cyst at lower blue arrow.
interarytenoid pachyderma

Acid reflux laryngitis (2 of 2)

During phonation, interarytenoid pachyderma and mucus retention cyst are typically obscured.

Croup, aka Laryngotracheitis

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Croup

Croup, aka laryngotracheitis (1 of 4)

Though croup is most often seen in children, this woman developed a barking cough and mild, non-anxiety provoking stridor in the context of an upper respiratory infection. In this panoramic view note in particular the prominence and redness of the conus part of the vocal cords (indicated by white lines).
laryngotracheitis

Croup, aka laryngotracheitis (2 of 4)

Closer view. Dotted lines signify normal airway diameter.
redness and narrowing of the posterior subglottic airway

Croup, aka laryngotracheitis (3 of 4)

Even closer view showing redness and narrowing of the posterior subglottic airway.
Croup

Croup, aka laryngotracheitis (4 of 4)

View within the posterior subglottic narrowing.


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.


Photos:

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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Pachyderma

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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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 (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 (3 of 4)

Closer view of the prominent capillaries.

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)

...in 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.


Laryngocele

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.


Photos:

Laryngocele

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Laryngocele (1 of 5)

Before phonation begins: the laryngocele is not visible.

Saccule (2 of 5)

Phonation begins: the saccule suddenly begins to inflate.

Saccule blocks airway (3 of 5)

The saccule is at peak inflation. Note how this obstructs the laryngeal airway.

Phonation ending (4 of 5)

The saccule is deflating. Note the motion blur; inflation and deflation each happens in a fraction of a second.

Phonation ended (5 of 5)

The laryngocele is again fully deflated and hidden from view.

Bilateral Laryngocele, Before and After Removal

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Bilateral laryngocele (1 of 8)

Vocal cords approaching point of best closure possible (due to left cord paresis). Faint dotted lines outline the approximate boundary of each laryngeal saccule, which not yet inflated.

Bilateral laryngocele (2 of 8)

As air just begins coming upward between the cords, one can see subtle inflation (dotted lines), particularly of the right saccule (left of image).

Bilateral laryngocele (3 of 8)

As phonation continues, inflation of the (now diagnosable) laryngocele becomes obvious, and the left laryngocele (right of image) is now more obviously inflated than before, again indicated by the dotted lines.

Bilateral laryngocele (4 of 8)

Near the end of a sustained period of voicing, maximum inflation of the laryngoceles is seen (dotted lines). On the right side (left of image), the stretching mucosa is so thinned as to appear translucent.

Bilateral laryngocele, after removal (5 of 8)

Same patient, breathing position, 12 weeks after complete removal of the bilateral laryngoceles via false cord incisions (lines of incision shown by dotted lines). This patient also has long-standing paralysis of the right vocal cord (left of image) and limited mobility of the left cord, so the cords don’t open fully for breathing.

Bilateral laryngocele, after removal (6 of 8)

Phonatory position. Note the lack of inflation of the now-absent laryngoceles, and compare that with photos 3 and 4 of this series.

Bilateral laryngocele, after removal (7 of 8)

Closer view of the posterior ends of the true vocal cords during maximal abduction for breathing. Space between the vocal cords is an estimated 50% of normal, because of the paralyzed right cord and the limited mobility of the left cord.

Bilateral laryngocele, after removal (8 of 8)

Same close-up view, but during phonation. The left vocal cord (right of image) has shifted slightly toward the midline, but the cords do not actually close and, thus, the patient cannot produce glottic (true vocal cord) voice. An implant could help to close this gap, but the patient will first try developing a “false cord voice.”

Laryngocele, Seen in a CT Image

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Laryngocele, seen in a CT image (1 of 1)

The patient’s left-sided saccule is dilated and filled by air, forming a laryngocele (the largest black spot in the image). The right-sided saccule is not seen because it is of normal size. The two smaller black spots show air in the pyriform sinuses (a normal finding).

Videos:

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.


Laryngologist

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.



Laryngomalacia

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).


Laryngopharynx

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.


Photos:

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Laryngopharynx (1 of 1)

Panoramic view of the laryngopharynx, showing the base of the tongue, the vallecula, epiglottis, vocal cords in abducted (breathing) position, and posterior pyriform/ postarytenoid “crescent,” which serves as the superiormost entrance to the foodway (cervical esophagus).


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.


Photos:

Acid Reflux

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Open phase of vibration

Acid reflux (1 of 2)

Open phase of vibration, strobe light, with white mucus sometimes but not always suggestive of acid reflux laryngitis.
Closed phase of vibration

Acid reflux (2 of 2)

Closed phase of vibration, strobe light, with same mucus findings.
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Phonation under strobe light

Acid reflux (1 of 2)

Phonation under strobe light. Mild capillary prominence.
Acid Reflux during phonation

Acid reflux (2 of 2)

As phonation proceeds, appearance of large amounts of viscous white mucus.

Acid Reflux Laryngitis

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interarytenoid pachyderma

Acid reflux laryngitis (1 of 2)

Panoramic view, shows interarytenoid pachyderma (“elephant skin”) at upper blue arrow; arytenoid redness at green arrows; and mucus retention cyst at lower blue arrow.
interarytenoid pachyderma

Acid reflux laryngitis (2 of 2)

During phonation, interarytenoid pachyderma and mucus retention cyst are typically obscured.

Acid Reflux and Sicca Syndrome

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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 (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 (3 of 4)

Closer view of the prominent capillaries.

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.


Laryngoscopy

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



Laryngospasm

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:


Videos:

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.


Larynx

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:

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Larynx: breathing position (1 of 2)

Normal larynx with vocal cords in abducted, breathing position. This is a view from from above, looking on line with the trachea beyond the vocal cords.

Larynx: phonatory position (2 of 2)

Normal larynx with cords in adducted, phonatory (voicing) position. Continuous light. Notice the straight match of the cords, and the narrow, physiologic gap between the cords at the prephonatory instant, just before vibratory blurring.

Pitch Effects on Vocal Cord Length and Vibratory Amplitude

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Abducted breathing position (1 of 10)

Abducted (separated) vocal cords, during breathing.

Phonatory blurring (2 of 10)

Making voice under standard light at G2 (~98 Hz), showing blurring of the margins ßà due to 98 vibrations per second! Pluck a rubber band at low tension for a visual analogy.

Phonation (3 of 10)

Voicing, but now at a pitch nearly 2 octaves higher, E4 (~330 Hz). Vocal cords are stretched lengthwise (longer) and vibratory amplitude much less, and this explains the narrower blur. See also photos 7 and 8. Stretch and then pluck the same rubber band for a visual analogy.

Open phase, A2 (4 of 10)

Under strobe light, the open phase of vibration, using a breathy, under-energized production to increase the amplitude (distance traveled laterally) of vibration.

Closed phase, A2 (5 of 10)

Closed phase of vibration at A2 (~110 Hz).

Open phase, firm voice (6 of 10)

Open phase of vibration using a firm voice production and this reduces the amplitude of vibration as compared with Photo 4, even though the pitch is the same as in that photo.

Closed phase, E4 (7 of 10)

Closed phase of vibration at E4 (~330 Hz).

Open phase, E4 (8 of 10)

Open phase also at E4, showing the smaller amplitude of vibration and explaining why the grey margin blur seen in photo 3 is “narrow” as compared with when vibratory amplitude is greater.

Closed phase, A4 (9 of 10)

Closed phase of vibration at A4 (~440 Hz). Vocal cords are lengthened to create high pitch (compare especially with photo 5).

Open phase, A4 (10 of 10)

Open phase vibration also at A4. Amplitude at this high pitch is less than for E4 (photo 8) and certainly than at A2 (photo 6). Note that amplitude of vibration is altered by loudness and not only pitch.

The Asthenic But Normal Larynx

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Asthenic larynx (1 of 6)

This quiet, soft-spoken teenager was being examined for a reason other than her voice. On an incidental basis, hers is a good example of the asthenic larynx. Detailed findings described in Photo 2.

Slender vocal cords (2 of 6)

Closer view under narrow band light. Note how slender her vocal cords are. Ventricles are capacious. There is no “conus” bulk below the vocal cord margins.

Prephonatory instant (3 of 6)

At the prephonatory instant for G5 (784 Hz), standard light. Note the significant space between the cords, but not due to MTD, in that the posterior cords are fully adducted.

Phonatory view (4 of 6)

Also at G5, vibration blurs the margins.

Strobe light (5 of 6)

Under strobe light at F5 (698 Hz). Posterior vocal cords remain together.

Closed phase (6 of 6)

Still at F5, but closed phase of vibration is not fully closed.

Videos:

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.


Laser

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:

Laser Surgery for Bilateral Vocal Cord Cancer

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squamous cell carcinoma

Squamous cell carcinoma (1 of 6)

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

Tumor on the vocal cords (2 of 6)

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

Granuloma delays voice recovery (3 of 6)

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

Closer view of granuloma (4 of 6)

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

Granuloma is smaller (5 of 6)

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

Granuloma doesn't impede voice (6 of 6)

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

Laser Removal of Vocal Cord Cancer with Bilateral Disease

For treatment of early vocal cord cancer, both laser excision and radiotherapy are in competition as good treatment modalities. See also Early Vocal Cord Cancer: Remove with a Laser, or Radiate? Often, radiation is used when disease is bilateral, in the interest of preserving voice. This is an example of the ability to do fairly extensive laser surgery bilaterally, yet preserving good voice. This man had a friend who had severe difficulty with radiation, and he was therefore opposed to that option.

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Vocal cord cancer (1 of 10)

This 70-something man is a longterm smoker. Here you see an obvious cancer of his left vocal cord (biopsy-proven), but disease on the right side as well that is more superficial.

Stippling (2 of 10)

At higher magnification and using narrow band light, some of the vascular abnormality (stippling) is better seen (arrows).

Granulation (3 of 10)

A week after definitive excision of his cancer. Typical early wound appearance, with a suggestion of granulation on the left side (right of photo).

Reparative Granuloma emerges (4 of 10)

Six weeks later, healing is nearly complete other than a typical reparative granuloma on the left (right of photo).

Granuloma interferes with voicing (5 of 10)

During voicing, the granuloma interferes with closure, explaining in part his ongoing severe hoarseness. Note also the typical medial-to-lateral capillary reorientation.

Granuloma fades away (6 of 10)

Now 3 months postop, the granuloma is smaller. Classic capillary reorientation is again seen.

Closer view (7 of 10)

Under strobe light, closed phase of vibration. Voice is highly functional, since the granuloma no longer interferes with closure.

Granuloma cleft (8 of 10)

Open phase of vibration under strobe light shows the bilobed, clefted nature of the granuloma, where the right vocal fold “fits into” the granuloma (arrows at cleft).

Blood tattoo (9 of 10)

At nearly 5 months postop, the granulation tissue has auto-detached, leaving only a small “blood tattoo.” Here, under strobe light and closed phase of vibration.

Open phase of vibration (10 of 10)

Voice is somewhat hoarse but highly serviceable, and “better than it has been in years,” according to the patient.

Hemorrhagic Polyp, Treated By Thulium Laser

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Hemorrhagic polyp, treated by thulium laser

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

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

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.
polyp is released from the fiber

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.
12 weeks after thulium laser treatment

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

12 weeks after thulium laser treatment (6 of 8)

During phonation, with vibratory blur. Standard light.
12 weeks after thulium laser treatment

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

12 weeks after thulium laser treatment (8 of 8)

Open phase of vibration, also at B-flat 4 (~466 Hz).

Capillary Ectasia, Before and After Laser Coagulation

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Capillary ectasia (1 of 3)

Bilateral capillary ectasia, made to stand out with the help of narrow-band illumination.

Capillary ectasia, right after laser coagulation (2 of 3)

At the conclusion of pulsed-KTP laser coagulation, performed in a videoendoscopy procedure room with patient awake and sitting in a chair.

Capillary ectasia, 6 weeks after laser coagulation (3 of 3)

Six weeks later; the capillaries have vanished, as expected.

Lidocaine Injection for Aggressive “Office” Laser Treatments

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Laser ablations performed in office (1 of 6)

After radiotherapy a few years earlier for vocal cord cancer, this patient continually develops exuberant leukoplakia with severe dysplasia and fragments of carcinoma in situ within weeks after each procedure to remove it, including two aggressive laser excisions in the O.R. In an attempt to avoid hemilaryngectomy or even total laryngectomy, a series of laser ablations is being performed just weeks apart in an "office" videoendoscopy procedure room. Needle for anesthesia is aiming for the spot indicated by the dot, left vocal cord (right of image)

Infiltrating anesthetic (2 of 6)

The needle shaft is seen at close range, infiltrating local anesethetic (lidocaine) into the vocal cord because the procedure is too uncomfortable to do with topical anesthesia alone.

Thulium laser procedure (3 of 6)

At the beginning of this "aggressive" laser procedure. The blue fiber is delivering thulium laser energy to coagulate the abnormal tissue. These vocal cords lost their ability to vibrate long before this procedure.

Post-surgery (4 of 6)

At the conclusion of this episode of treatment, aggressively coagulated tissue which will slough off in coming days and weeks.

Six weeks post-surgery (5 of 6)

Six weeks later, at beginning of next thulium laser treatment.

Second laser sugery (6 of 6)

Near the end of this subsequent thulium laser treatment.

Perfect Candidate for Thulium Laser

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Lesion (1 of 4)

Years ago, papillomas covered both true cords. After many surgical and adjuvant treatments, the disease has for several years been virtually in remission, and his voice stable and near-normal. This single, asymptomatic lesion is being addressed "In the chair" under topical anesthesia.

Lesion under narrow-band light (2 of 4)

Narrow-band light and a closer view make the lesion and its true cord extension more evident.

Coagulated with thulium laser (3 of 4)

In the lower left of the photo, the main lesion and true cord extension have been coagulated.

Finishing up (4 of 4)

To finish up, contact mode (while the fiber was touching and even spearing the lesion) has coagulated more deeply the false cord component that does not threaten voice. Pre- and post-procedure voice are unchanged and the coagulum will spontaneously detach within the next few days.

Leukoplakia Battled Over Time

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Leukoplakia (1 of 8)

Leukoplakia, recurrent, in a former smoker, several years after initial diagnosis. The patient has had this removed in the operating room several times elsewhere, and pathology has only shown hyperkeratosis. HPV testing is negative. Notice both the “cake icing” (green arrows) and “spilled milk” (white arrow) components of the leukoplakia. At this examination, the patient is severely hoarse.

Spilled Milk (2 of 8)

Closer view, under narrow-band illumination, which accentuates in particular the “spilled milk” component (arrows) of the leukoplakia on the left vocal cord (right of image).

Thulium laser (3 of 8)

In the midst of coagulation using the thulium laser, delivered via glass fiber (right of image).

Coagulated tissue (4 of 8)

The thulium laser session is done. On the left cord (right of image), mostly near-contact mode was used, and the coagulated tissue, which has gone from leukoplakia-white to coagulated-white, will slough off within days. On the right cord (left of image), contact mode was used, to coagulate more deeply and detach the bulkier lesion. An additional surface layer will also slough on this cord.

Leukoplakia (5 of 8)

A year and a half later, after a few interval laser treatments, there is a small persistent patch of leukoplakia.

Detachment (6 of 8)

At the conclusion of another thulium laser procedure, using brief contact mode for superficial detachment of the patch of leukoplakia.

Superficial vascular pattern (7 of 8)

Fourteen months after photos 5 and 6. After roughly a dozen treatments spanning more than a decade, the voice sounds effortless and has no syllable dropouts. It is mildly husky but entirely satisfactory to the patient. Note how well-preserved and “unscarred” the superficial vascular pattern of the mucosa is (arrows), after so many surgical procedures.

Coagulated tissue (8 of 8)

At the conclusion of thulium coagulation of this linear patch of leukoplakia. Arrows show the line of coagulated tissue.

Leukoplakia, Before, During, and After Laser Coagulation

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Leukoplakia, not yet seen (1 of 6)

A few years earlier, this patient underwent superficial laser cordectomy of the right vocal cord (left of photo) for cancer. The voice result is excellent, and the patient is being seen this day for a routine interval examination, and has no new complaints.

Leukoplakia (2 of 6)

At closer range, tiny points of leukoplakia (inside the green dotted oval) become evident. The bright white spot in the photo is just a light reflection.

Leukoplakia (3 of 6)

Still closer view, again confirming the tiny patches of leukoplakia. There is another light reflection in this view, right in the middle of the photo.

Leukoplakia, coagulated by laser (4 of 6)

Thulium laser coagulation of the leukoplakia lesions, through a glass fiber (blue-ish cylinder at top-right of photo), as seen under narrow-band illumination. The Thulium laser had been placed on stand-by prior to the routine examination, to save the patient a potential second visit. The coagulated tissue is also white, but will slough off within a few days, and along with it, the leukoplakia.

Leukoplakia, 3 months after laser treatment (5 of 6)

Three months after laser treatment, the patient has healed.

Leukoplakia, 3 months after laser treatment (6 of 6)

Three months after laser treatment, a close up view shows no signs of leukoplakia spots.

Mid-Tracheal Papilloma, Treated By Thulium Laser

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Mid-tracheal papilloma, being treated by thulium laser (1 of 5)

The papilloma is seen attached to the posterior tracheal wall, at the midpoint of the trachea. Note the areas of scarring from prior laser procedures. The dots seen indicate reference points for photo 5.

Months after treatment: no papilloma (5 of 5)

Durable resolution of papilloma, many months afterwards. Compare with photo 1.

Mid-tracheal papilloma, being treated by thulium laser (2 of 5)

Using the channel scope, a blue glass fiber is extended from the tip of the scope.

Mid-tracheal papilloma, being treated by thulium laser (3 of 5)

In a closer view, the papilloma has been mostly cauterized using near-contact (not touching) mode.

Mid-tracheal papilloma, being treated by thulium laser (4 of 5)

The papilloma is then penetrated multiple times to deliver laser energy to its base. Some of the papilloma is pulled off by attachment to the fiber, and the remainder will slough off and be swept upwards by the mucociliary blanket (thin layer of mucus being swept upward) within the trachea.

Capillary Ectasia and Hemorrhagic Polyp, Treated by Thulium Laser

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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.

Vocal cord margin (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).

Capillary ectasia and hemorrhagic polyp, after treatment (7 of 7)

Also at F4 (~349 Hz). The mucosa of both cords is completely supple. The patient considers his voice to be perfectly normal—"original equipment."

Thulium Laser Surgery, With Local Anesthetic Injection, to Treat Leukoplakia

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Leukoplakia, about to be treated with laser (1 of 4)

Leukoplakia of the vocal cords in a patient radiated years earlier for glottic cancer. This disease is mostly benign, but foci of carcinoma-in-situ have also been removed twice in the operating room, yet with rapid return of leukoplakia. The patient has had no glottic voice. In an effort to avoid total laryngectomy, we are managing these visual abnormalities with the thulium laser in an outpatient videoendoscopy room.

Injection of local anesthetic (2 of 4)

Since this patient cannot tolerate aggressive laser therapy with topical anesthesia alone, we are here adding injection of local anesthetic. Note the blanching of tissue surrounding the needle.

Injection of local anesthetic (3 of 4)

Further injection of the local anesthetic.

Right after thulium laser treatment (4 of 4)

At the completion of aggressive laser coagulation of abnormal tissue. Compare with photo 1. The patient will return in a month for additional laser treatment as indicated.

Tracheal Papillomas and the Thulium Laser

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HPV 11 (1 of 2)

High tracheal papillomas from HPV subtype 11. If allowed to grow, these eventually cause airway symptoms. This is one of many procedures to keep these papillomas in check.

Post laser coagulation (2 of 2)

After thulium laser coagulation, using not only near-contact mode, but also after inserting the fiber into the substance of the papillomas repeatedly. Most of this material will slough away in coming days.

Office-Based Surgery When General Anesthesia Is too Risky

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Involuntary inspiratory voice (1 of 6)

This elderly man is tracheotomy-dependent due to inability to open the vocal cords. Here while breathing in, there is a posterior “keyhole” from the divots caused by pressure necrosis of the breathing tube. Still, due to inspiratory airstream, he produces involuntary inspiratory voice. General anesthesia for laser widening of the airway (posterior commissuroplasty) would be very risky due to his diabetes and many other medical problems. Hence, the decision to attempt this with patient awake and sitting in a chair.

Laser posterior commissuroplasty (2 of 6)

The posterior right vocal cord is injected with lidocaine with epinephrine, in preparation for office laser posterior commissuroplasty. F = false vocal cord. T = true vocal cord, near its posterior end. The left vocal cord is injected similarly prior to the procedure that follows.

During the commissuroplasty (3 of 6)

The thulium laser fiber is being used to excavate the posterior commissure. Note the existing divot of the opposite (right) vocal cord (dotted lines) which will also be enlarged (next photos).

Deepening divot (4 of 6)

With view rotated clockwise approximately 45 degrees, work is commencing to deepen the right vocal cord divot.

Inspiratory indrawing decreased (5 of 6)

At the conclusion of the procedure. Not only is the ‘keyhole’ seen in photo 1 larger, but inspiratory indrawing of the rest of the vocal cords is greatly diminished.

Phonation (6 of 6)

Now phonating, voice is similar to the beginning of the procedure, because the vibrating part of the vocal cord was not disturbed. Of course, number of words per breath is slightly lower, due to increased use of air through the keyhole—air wasting.

Videos:

https://vimeo.com/144528275
Thulium laser
This video gives an example of office-based thulium laser ablation of residual laryngeal papilloma.


Latency

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.



Lateral

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.



Laughing

Ever wonder how we laugh?

https://vimeo.com/160649997
VESS of the laryngopharynx during laughter
VESS Recorded at Bastian Voice Institute
https://vimeo.com/166868972
Laughing that can be seen and heard!
In this video, Dr. Bastian looks into the esophagus via VESS.


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:

LCA Weakness

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Phonation in the low chest register

LCA weakness, in a patient with vocal cord paralysis (1 of 2)

Phonation in the low chest register (note the wide zone of vibratory blurring). Here, the vocal process is clearly seen to turn laterally (arrow), a tell- tale indicator of LCA weakness. As other views of this particular patient would indicate, she actually also has weakness of the TA and PCA muscles, not just LCA-only paresis, but this view alone would correspond to a patient who had LCA-only paresis.
LCA weakness, masked by high pitch

LCA weakness, masked by high pitch (2 of 2)

Phonation at very high pitch (as expected, the vibratory blur narrows). The antero-posterior lengthening of the left cord (right of image) at this high pitch turns the vocal process on that side back towards the midline (compare with photo 1), masking the LCA weakness. This low voice/high voice difference in the posterior commissure is routinely but not universally seen with LCA weakness.

Bilateral LCA Weakness?

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Weak, air-wasting voice (1 of 4)

Forty-something tradesman who developed weak voice abruptly after an upper respiratory infection, but that was more than a year prior to this examination. Panoramic view during breathing shows some inflammation but the voice quality is of air-wasting, not laryngitis.

Pre-phonatory instant (2 of 4)

A closer view at the pre-phonatory instant of D4 (~294 Hz). The posterior-most arytenoid surfaces are in contact, but the vocal processes turn a little bit laterally, and this seems to account for the gap between the cords. This is not typical bowing.

Phonatory blurring (3 of 4)

At G3 with phonatory blurring, the cords are shorter, but the lateral turning and posteriorly-shifted “pseudo-bowing” remains.

Bilateral LCA weakness (4 of 4)

At even lower pitch, E3 (~165 Hz), the remarkable gap is again seen to originate primarily from lateral turning of the tips of the vocal processes, suggesting bilateral LCA weakness.

Severe MTD or Bilateral LCA Weakness?

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Breathiness (1 of 6)

Older middle-aged woman with a great deal of breathiness creeping into her voice, despite good training and long singing experience. Here, in breathing position, the vocal cords look fairly normal.

Phonation (2 of 6)

At closer range during phonation at G3, note that the vocal processes are both turned slightly laterally. The membranous folds are blurred due to vibration.

Closed phase (3 of 6)

As seen under strobe light during closed phase of vibration at G3 (196 Hz), the lateral turn of the vocal processes is again seen.

Open phase (4 of 6)

Open phase at the same pitch.

Large gap (5 of 6)

At the higher pitch of G4 (392 Hz), note the lengthening of the vocal cords, which often turns vocal processes a little bit more to the midline, but they remain distinctly turned laterally, explaining the large gap.

Open phase (6 of 6)

Open phase at the same pitch. This appears to be bilateral LCA weakness given relative abruptness of onset in a highly trained and experienced singer. Why this happened is unknown.

Paresis Visual Taxonomy Can Be Trusted, But Is This Taking the LCA Cue Too Far?

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Post carotid endarterectomy (1 of 7)

Immediately after carotid endarterectomy a few weeks earlier this voice was drastically altered due to left vocal cord “paralysis” -- actually paresis as we shall see. Note that the left cord (right of photo) is bowed and atrophied (spaghetti-linguini sign). TA muscle is definitely wasted. Curiously, the left vocal process almost appears straight or faintly medial-turning (arrow), suggesting preserved LCA action.

PCA muscle (2 of 7)

The lack of abduction of left vocal fold (right of photo) signifies the left PCA muscle isn't working.

Maximum closure (3 of 7)

Maximum closure during strobe examination. Neither side has enough recoil to oscillate back to midline. This person is elderly.

Open phase (4 of 7)

At the same pitch but open phase of vibration. Neither side has significantly greater lateral amplitude. The LCA question (at ?) generated by photo 1 cannot yet be answered, because the expected lateral turning of the vocal process is unable to be evaluated. See the next photo.

LCA muscle (5 of 7)

With view directed to the posterior commissure, the vocal processes can be identified and left LCA does indeed appear to be working. That is, it is not turning laterally, as it would be if LCA were out. Can it be that PCA and TA are out, and LCA working? Watch for future examination photos…

Voice gel injection (6 of 7)

Voice gel injection in progress, with needle inserted into the left paraglottic space.

Phonation (7 of 7)

Producing voice after gel injection, there is no gap in the posterior commissure contrary to expectation if LCA were not functioning on the left. This might also explain why voice result after voice gel is better than expected when treating paralysis.

Evolution of the Wound After Laser Removal of a Vocal Cord Cancer: Not Pretty at First, but Voice Result Can Be Very Good

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Vocal cord cancer (1 of 8)

Bulky but superficial right vocal cord cancer (arrow, left of photo).

Voice-making with tumor (2 of 8)

Voice-making position. Notice the more lateral turning of the right vocal process (left of photo) as compared with the left (right of photo). As the remaining series shows, it is impossible to know if this is compensation for the bulk of tumor, or weakness of the LCA muscle.

One week post-removal (3 of 8)

A week after definitive removal, swelling, early granulation, and a division of the wound into upper and lower “lips” that must bind together with healing.

Voice-making, post-removal (4 of 8)

Note again the lateral turning of right vocal process (arrow, left of photo).

Six weeks post-op (5 of 8)

Six weeks after surgery, the wound is “bound together,” and there is a residual granuloma on the upper surface anteriorly (arrow).

Voice-making, post-op (6 of 8)

Making voice, there is still that peculiar lateral turning of the vocal process on the right (left of photo).

Four months post-op (7 of 8)

Now a full 4 months since laser excision, the cord is fully healed though still pink as expected. The anterior upper surface is coated with mucus.

Voice-making, four months post-op (8 of 8)

Making voice, again that lateral deviation of the right vocal process (arrow, left of photo). Voice is very functional but a little weak. Vibratory blur is greater for left than right cord.


Leukoplakia

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. It is the descriptive term for what, on biopsy, may prove to be keratosis, carcinoma in situ, or carcinoma.


Photos:

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Leukoplakia (1 of 2)

Leukoplakia, left vocal cord (right of image), standard light.

Leukoplakia (2 of 2)

Same lesion, under narrow band illumination.
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Cake-icing Leukoplakia (1 of 4)

The leukoplakia here is heaped up in three main areas, as what some might call "cake-icing" leukoplakia. With this view only, a person could easily overlook the second component of "hazy" or " spilled milk" leukoplakia shown in the next three photos. All of this leukoplakia would be considered "bland" and non-threatening because there is no component of vascular prominence or erythema (erythroplasia). Erythroplasia would much more strongly indicate the need for biopsy.

Hazy Leukoplakia (2 of 4)

Pre-phonatory phase, showing mild bowing of the vocal cords. There is also the hazy leukoplakia component indicated by the dotted line.

Leukoplakia (3 of 4)

Vocal cords are in the nearly closed phase of vibration. The bluish light from the strobe light makes the hazy leukoplakia even more evident (indicated by the dotted line).

Closer look (4 of 4)

Open phase of vibration, shown under strobe lighting.

Leukoplakia, Before and After Surgical Removal

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Diffuse Leukoplakia (1 of 4)

Diffuse leukoplakia (seen under standard light) in a man who had undergone removal elsewhere at least twice, with rapid return of diffuse disease on both vocal cords.

HPV effect (2 of 4)

Closer view, using narrow-band illumination. Leukoplakia is accentuated, but punctate vascular markings are also accentuated. We sometimes call this “HPV effect,” though in fact this man’s HPV subtyping was negative.

Leukoplakia, after surgical removal (3 of 4)

Two years after one superficial yet intensely precise peeling of the leukoplakia, plus one follow-up thulium laser ablation of scattered residual disease. The patient, a tenor, considers his voice to be normal. Closed phase of vibration, as seen under strobe light.

Leukoplakia, after surgical removal (4 of 4)

Open phase of vibration, demonstrating that the mucosa on both vocal cords remains flexible. The shifting hazy patches seen here and in photo 3 are collections of mucus.

Leukoplakia Battled Over Time

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Leukoplakia (1 of 8)

Leukoplakia, recurrent, in a former smoker, several years after initial diagnosis. The patient has had this removed in the operating room several times elsewhere, and pathology has only shown hyperkeratosis. HPV testing is negative. Notice both the “cake icing” (green arrows) and “spilled milk” (white arrow) components of the leukoplakia. At this examination, the patient is severely hoarse.

Spilled Milk (2 of 8)

Closer view, under narrow-band illumination, which accentuates in particular the “spilled milk” component (arrows) of the leukoplakia on the left vocal cord (right of image).

Thulium laser (3 of 8)

In the midst of coagulation using the thulium laser, delivered via glass fiber (right of image).

Coagulated tissue (4 of 8)

The thulium laser session is done. On the left cord (right of image), mostly near-contact mode was used, and the coagulated tissue, which has gone from leukoplakia-white to coagulated-white, will slough off within days. On the right cord (left of image), contact mode was used, to coagulate more deeply and detach the bulkier lesion. An additional surface layer will also slough on this cord.

Leukoplakia (5 of 8)

A year and a half later, after a few interval laser treatments, there is a small persistent patch of leukoplakia.

Detachment (6 of 8)

At the conclusion of another thulium laser procedure, using brief contact mode for superficial detachment of the patch of leukoplakia.

Superficial vascular pattern (7 of 8)

Fourteen months after photos 5 and 6. After roughly a dozen treatments spanning more than a decade, the voice sounds effortless and has no syllable dropouts. It is mildly husky but entirely satisfactory to the patient. Note how well-preserved and “unscarred” the superficial vascular pattern of the mucosa is (arrows), after so many surgical procedures.

Coagulated tissue (8 of 8)

At the conclusion of thulium coagulation of this linear patch of leukoplakia. Arrows show the line of coagulated tissue.

Leukoplakia, Before, During, and After Laser Coagulation

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Leukoplakia, not yet seen (1 of 6)

A few years earlier, this patient underwent superficial laser cordectomy of the right vocal cord (left of photo) for cancer. The voice result is excellent, and the patient is being seen this day for a routine interval examination, and has no new complaints.

Leukoplakia (2 of 6)

At closer range, tiny points of leukoplakia (inside the green dotted oval) become evident. The bright white spot in the photo is just a light reflection.

Leukoplakia (3 of 6)

Still closer view, again confirming the tiny patches of leukoplakia. There is another light reflection in this view, right in the middle of the photo.

Leukoplakia, coagulated by laser (4 of 6)

Thulium laser coagulation of the leukoplakia lesions, through a glass fiber (blue-ish cylinder at top-right of photo), as seen under narrow-band illumination. The Thulium laser had been placed on stand-by prior to the routine examination, to save the patient a potential second visit. The coagulated tissue is also white, but will slough off within a few days, and along with it, the leukoplakia.

Leukoplakia, 3 months after laser treatment (5 of 6)

Three months after laser treatment, the patient has healed.

Leukoplakia, 3 months after laser treatment (6 of 6)

Three months after laser treatment, a close up view shows no signs of leukoplakia spots.

Vocal Nodules, Leukoplakia, and Capillary Ectasia

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Vocal nodules, leukoplakia, and capillary ectasia (1 of 4)

Abducted breathing position, standard light. Notice not only the margin swellings (nodules) but also the ectatic capillaries and the roughened leukoplakia. This person illustrates well the idea that vibratory injury can be manifested differently. Many express the injury more in the form of sub-epithelial edema and other changes; this person also has considerable epithelial change.

Vocal nodules, leukoplakia, and capillary ectasia (2 of 4)

Prephonatory instant, standard light.

Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (3 of 4)

Partial resolution of mucosal injury as a result of behavioral changes directed by a speech pathologist. Strobe light, open phase of vibration.

Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (4 of 4)

Strobe light, moving towards closed phase of vibration.

Glottic Furrow / Leukoplakia / Acid Reflux

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Glottic furrow / Leukoplakia / Acid reflux

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

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

leukoplakia (2 of 4)

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

Glottic furrows (3 of 4)

Furrows seen bilaterally.
Gap between vocal cords during closed phase

Gap during closed phase (4 of 4)

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

Thulium Laser Surgery, With Local Anesthetic Injection, to Treat Leukoplakia

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Leukoplakia, about to be treated with laser (1 of 4)

Leukoplakia of the vocal cords in a patient radiated years earlier for glottic cancer. This disease is mostly benign, but foci of carcinoma-in-situ have also been removed twice in the operating room, yet with rapid return of leukoplakia. The patient has had no glottic voice. In an effort to avoid total laryngectomy, we are managing these visual abnormalities with the thulium laser in an outpatient videoendoscopy room.

Injection of local anesthetic (2 of 4)

Since this patient cannot tolerate aggressive laser therapy with topical anesthesia alone, we are here adding injection of local anesthetic. Note the blanching of tissue surrounding the needle.

Injection of local anesthetic (3 of 4)

Further injection of the local anesthetic.

Right after thulium laser treatment (4 of 4)

At the completion of aggressive laser coagulation of abnormal tissue. Compare with photo 1. The patient will return in a month for additional laser treatment as indicated.


Lidocaine

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.


Photos:

Thulium Laser Surgery, With Local Anesthetic Injection, to Treat Leukoplakia

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Leukoplakia, about to be treated with laser (1 of 4)

Leukoplakia of the vocal cords in a patient radiated years earlier for glottic cancer. This disease is mostly benign, but foci of carcinoma-in-situ have also been removed twice in the operating room, yet with rapid return of leukoplakia. The patient has had no glottic voice. In an effort to avoid total laryngectomy, we are managing these visual abnormalities with the thulium laser in an outpatient videoendoscopy room.

Injection of local anesthetic (2 of 4)

Since this patient cannot tolerate aggressive laser therapy with topical anesthesia alone, we are here adding injection of local anesthetic. Note the blanching of tissue surrounding the needle.

Injection of local anesthetic (3 of 4)

Further injection of the local anesthetic.

Right after thulium laser treatment (4 of 4)

At the completion of aggressive laser coagulation of abnormal tissue. Compare with photo 1. The patient will return in a month for additional laser treatment as indicated.


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.



Luffing

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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