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Laryngopedia

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

Laryngopedia By Bastian Medical Media

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Macrophenomenology of voice

Macrophenomenology of voice:

As the sun’s trajectory, the North Star, and the magnetic compass are to navigation, so macrophenomenologies are to the diagnostic process that we use at our practice (see: integrative diagnostic model). Particular vocal macrophenomenologies might include things like: audible air-wasting, a three-second maximum phonation time, positive swelling checks, and latency of response. Elicited macrophenomenologies of the voice such as these, taken together, orient the examiner to a specific diagnosis. By contrast, see microphenomenology. Also, see elicitation.



Marfan Syndrome

A genetic connective tissue disorder caused by a defect in gene FBN1, which codes for abnormal structure of fibrillin-1, a protein crucial for formation of normal connective tissue. Most critical is Marfan syndrome’s effect on heart and blood vessels, which tend to dilate and be at risk of rupture. Connective tissue in bones, ligaments, and other parts of the body is also affected.

Laryngologists may encounter Marfan syndrome because parts or all of the aorta may need to be replaced over time, due to abnormal dilation of the weakened arterial wall, with risk of rupture. When such surgery is done, the left recurrent nerve is at risk of injury, and this would lead to left vocal cord paralysis. With Marfan syndrome, it is rare to live to age 70.


Photos:

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Marfan syndrome (1 of 5)

70-year-old patient whose left vocal cord (right of photo) was implanted 15 years ago with a silastic wedge to rehabilitate paralysis. Voice was reported as "normal" for many years, but in recent months has deteriorated.

Marfan syndrome (2 of 5)

As the right vocal cord (left of photo) moves toward the midline, the arytenoid cartilage (white dotted line) appears to emerge from the right vocal cord without bringing the membranous segment (green dotted line) with it.

Arytenoid cartilage (3 of 5)

At close range, one can see more clearly that the connective tissue attachment between the arytenoid cartilage and soft tissue of the vocal cord itself has been completely lost. As in photo 2 the white dotted line marks the arytenoid cartilage and the green dotted line marks the vocal cord's membranous segment.

Marfan syndrome (4 of 5)

A different view, showing again the vocal process of the arytenoid cartilage detaching from the vocal ligament/muscle of the membranous portion of the vocal cord.

Aneurysmal dilation (5 of 5)

Panoramic view of the hypopharynx, showing aneurysmal dilation of the internal carotid artery (bulge on right side of photo). Epiglottis is at the center and left.


Maximum phonation time (MPT)

The maximum time an individual can sustain a sung tone, after having filled the lungs maximally. In the literature, maximum phonation time (MPT) is often reported as having been measured on the vowel / i / (eee) at spontaneous, comfortable pitch and loudness.

However, MPT may vary markedly with pitch, vowel, effort, register, and so forth. Furthermore, MPT may differ dramatically among individuals all of whose larynges are otherwise considered normal. Hence, MPT is a useful measure primarily when it is very abnormal (less than seven seconds), and also when production constraints are more specific than “comfortable pitch and loudness.” At our practice, we routinely measure MPT at average/anchor frequency, during spontaneous speech.



Medial

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



Medialization Laryngoplasty

A surgical procedure performed to push a paralyzed, atrophied, or scarred vocal cord toward the other vocal cord and reduce flaccidity. A medialization laryngoplasty is typically performed under sedation and local (not general) anesthesia, on an outpatient basis.


Audio:

Patient with vocal cord paralysis, BEFORE medialization laryngoplasty:

Same patient, one week AFTER medialization laryngoplasty:


Photos:

Medialization, Before and After

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Medialization: before (1 of 7)

TA + LCA paresis of the left vocal cord (right of photo). Vocal cords in breathing position. The evidence of TA muscle weakness includes: convex margin; capacious ventricle; prominence of vocal process; and “sphaghetti-linguini” difference between the cords. It appears that the PCA muscle is working, as the left cord is quite lateralized. The LCA muscle is not fully evaluated until the patient phonates (next photo).

Medialization: before (2 of 7)

Phonation. Notice the lateral buckling of the membranous cord, indicative of TA weakness. In addition, notice the lateral turning of the vocal process (arrow), indicative of LCA weakness. For more on observing LCA weakness, see also our LCA-only paresis entry.

Medialization: 2 weeks after (3 of 7)

Two weeks after medialization of the left vocal cord (right of photo). There is expected inflammation and resolving bruising. The vocal cord is appropriately filled out. Voice is already dramatically improved.

Medialization: 2 weeks after (4 of 7)

Phonation. This view shows marked reduction of the gap, explaining why the voice is now strong, and no longer breathy.

Medialization: 3 months after (5 of 7)

A few months later. The implanted left vocal cord (right of image) remains plumped up, and is at the midline. The right cord abducts normally.

Medialization: 3 months after (6 of 7)

Phonation, under strobe light. There is good vocal cord approximation, which explains the patient's much improved voice. Note that the view here and in photo 7 is rotated at least 30 degrees counter-clockwise relative to photo 5 (see the false cord line, for reference), possibly giving the illusion that the implanted, paretic cord (right of image) is moving to close the gap, when in the fact the opposite cord is.

Medialization: 3 months after (7 of 7)

Phonation, open phase of vibration, under strobe light. This view shows that the implanted cord has better bulk and firmness than the un-implanted cord. Mucosal wave is greater in the un-implanted cord. Occasionally, a mobile but somewhat flaccid cord, such as seen here, if associated with weak voice leads to placement of a second implant into the mobile cord. In this case, the patient is content with his voice.

Vocal Cord Paralysis, Before and After Medialization

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Vocal cord paralysis: before medialization (1 of 12)

A classic example of “spaghetti-linguine” vocal cords, here in breathing position. The “linguine” cord (left of image) is normal; the “spaghetti” cord (right of image) is paralyzed, likely since birth. On the paralyzed side, notice the deep and broad ventricle, mild bowing of the margin of the cord, and reduced width of the upper surface of the cord (“spaghetti”-like), as compared with the non-paralyzed side.

Vocal cord paralysis: before medialization (2 of 12)

Phonation, more distant view, under standard light. Notice the considerable gap between the vocal cords. This gap correlates with the patient’s weak and air-wasting voice quality.

Vocal cord paralysis: before medialization (3 of 12)

Open phase of vibration, under strobe light. The paralyzed cord (right of image) has a much increased amplitude (lateral or outward excursion) and exaggerated bowing, due to its flaccidity.

Vocal cord paralysis: before medialization (4 of 12)

“Closed” phase of vibration, which is of course not closed at all, because the paralyzed cord (right of image) cannot come fully to the midline.

Vocal cord paralysis: 1 week after medialization (5 of 12)

One week after surgical medialization of the paralyzed cord (right of image), using a silastic implant buried deeply within the cord. Notice that the ventricle is no longer capacious, and the free margin is no longer bowed. Furthermore, in contrast with photo 1 of this series, the “spaghetti-linguine” description of these vocal cords is no longer apt.

Vocal cord paralysis: 1 week after medialization (6 of 12)

Phonation, under standard light. The gap between the cords is no longer seen (compare with photo 2), and the patient's spontaneous speaking voice sounds normal. She can recruit loudness effectively without any luffing or observable weakness.

Vocal cord paralysis: 1 week after medialization (7 of 12)

Open phase of vibration, under strobe light. The lateral or outward excursion of the paralyzed cord (right of image) is now similar to that of the non-paralyzed cord. Compare with photo 3.

Vocal cord paralysis: 1 week after medialization (8 of 12)

The closed phase of vibration is much more closed than preoperatively. Compare with photo 4.

Vocal cord paralysis: 5 months after medialization (9 of 12)

Five months after medialization. Compare this partially abducted position with photos 1 and 5 of this series.

Vocal cord paralysis: 5 months after medialization (10 of 12)

Phonation, under standard light, showing vibratory blur. Compare with photos 2 and 6 of this series.

Vocal cord paralysis: 5 months after medialization (11 of 12)

Open phase of vibration, under strobe light. As in photo 7 of this series, and in contrast to photo 3, the implant does not permit the paralyzed cord (right of image) to “buckle” laterally, or outward. If anything, the vibratory excursion of the non-paralyzed (and un-implanted) cord is greater than that of the paralyzed, implanted cord.

Vocal cord paralysis: 5 months after medialization (12 of 12

The closed phase of vibration is now virtually normal, similar to photo 8 and in contrast with photo 4.

Extrusion of Vocal Cord Implant

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Extrusion of vocal cord implant (1 of 3)

Patient with a paralyzed left vocal cord (right of image), who several years ago had successful medialization of that cord with a silastic wedge. More recently, several months ago, she noticed pain and swelling during some intense aerobic activity and then a persistently roughened voice quality. This view shows that the left cord is inflamed.

Extrusion of vocal cord implant (2 of 3)

Strobe lighting. Note the convex shape of the left cord’s anterior end (the lower end, in this photo). This convexity is not caused by over-medialization, but instead by the inflammatory reaction.

Extrusion of vocal cord implant (3 of 3)

Closer view shows that the problem is exposure of the silastic implant. The actual silastic is bare at the arrow. Whitish exudate covers the remaining exposed implant. This is a rare event after medialization with a silastic implant.

Paresis, TA + LCA, Before and After Medialization

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Paresis, TA + LCA (1 of 7)

This patient has idiopathic right TA + LCA paresis. From a distant view, the unopposed pull of the right PCA (left of photo) can already be detected, but is better seen in the next photo.

Paresis, TA + LCA (2 of 7)

At closer range and in a breathing position, both PCA muscles work to fully lateralize the cords. The right (left of photo, in red) TA paralysis/atrophy is seen via a spaghetti-linguini difference in the cords and a larger, deeper right ventricle. Most notably, the right vocal process pulls laterally because the paralyzed LCA does not resist unopposed pull of the active PCA.

Paresis, TA + LCA (3 of 7)

Beginning to approach phonation position, the cords begin to move to the midline via function of the IA muscles, and the left cord (right of photo) reaches the midline via function of the left LCA muscle. Absent function of the right LCA and TA (left of photo) continues to be seen clearly in this view.

Paresis, TA + LCA (4 of 7)

During phonation, vibratory blur is seen under standard light, and lateral buckling of the flaccid right cord (left of photo).

Paresis, TA + LCA: after medialization (5 of 7)

Soon after a simple medialization of right cord (left of photo) with a silastic wedge, resulting in the plumpness of the right cord. Compare with photos 1 and 2.

Paresis, TA + LCA: after medialization (6 of 7)

Again beginning to approach phonation position. See again the plumpness of the right cord (left of photo). Compare with photo 3.

Paresis, TA + LCA: after medialization (7 of 7)

During phonation, there is much better contact between the cords, and the right cord (left of photo) is no longer flaccid. Compare with photo 4.

Medialization, Before and After

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Before medialization (1 of 4)

Right vocal cord (left of photo) paralysis. During breathing as shown here, the right cord (left of photo) is paramedian, while the left cord (right of photo) is widely abducted. Note also the bowing (curvature) of the right cord (left of photo), and the prominent ventricle, both of which are indications of atrophy/ reduced bulk of the muscle within that cord.

Before medialization (2 of 4)

Phonation, with vibratory blurring under standard light. Right cord (left of photo) remains paramedian, and the left cord (right of photo) has swung to the midline. Even so, large gap between the cords shows that closure is incomplete, and this explains the weak, air-wasting voice; the patient can only say a few words before running out of air and having to take another breath.

After medialization (3 of 4)

After medialization and placement of a silastic implant, the right cord (left of photo) is less atrophied and the bowing much diminished. The cord has also been shifted slightly to the midline.

After medialization (4 of 4)

Phonation, again with vibratory blurring, but notice the much better approximation of the cords. The voice is stronger, and less air-wasting.

Videos:

Injection Medialization for Vocal Cord Paresis
See an example of one variant of vocal cord paresis and how it limits the voice. Then watch a medialization procedure in which voice gel is injected into the vocal cord affected by paresis, and hear how the voice thereafter improves.


Membranous Glottis

The anterior two-thirds of the vocal cord’s visible length and also, during breathing, the space between this segment of both cords. Also called the musculomembranous glottis. The layers of the membranous glottis, in order from deepest to most superficial, are: the thyroarytenoid muscle; the vocal ligament, made of elastin and collagen fibers; the mucosa, which comprises both a loose attachment zone called the lamina propria or Reinke’s space and, on the very surface of the cord, a layer of squamous epithelium. The other one-third of each vocal cord’s visible length is called the cartilaginous glottis.



Microlaryngoscopy

Microlaryngoscopy is an endoscopic procedure focused upon the larynx, performed under general anesthesia. A hollow lighted tube rests on the upper teeth and the base of the tongue and allows the physician to see the vocal cords. An operating microscope is used to brightly illuminate and highly magnify the vocal cords. Then, tiny instruments and/or a laser are used to remove the abnormality from the vocal cord or cords.

Amyloidosis of the Larynx as Seen Over Time, with Treatment

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yellowish proteinaceous material

primary laryngeal amyloidosis (1 of 7)

An example of primary laryngeal amyloidosis of the larynx. In this case, the yellowish, “candle-wax” proteinaceous material is being deposited just below the margin of the vocal cords (arrows)
bulky swelling

bulky swelling (2 of 7)

When this person produces voice, the bulky swelling just below the margin of the vocal cords creates turbulence, incomplete match, and a rough voice quality. After laser debulking, the patient had a much improved voice for many years.
re-deposition of amyloid material

Amyloidosis (3 of 7)

Eight years later, the patient reappeared. She said voice had been good for many years but had been getting increasingly hoarse for the prior couple of years. Here you see major re-deposition of amyloid material.
amyloid deposits

amyloid deposits (4 of 7)

At very close range, the yellowish color typical of amyloid deposits is better seen.
Vocal cords cannot close completely

Vocal cords cannot close completely (5 of 7)

During voice production under strobe light, the amyloid deposit under the left vocal cord prevents closure.
smally amyloid deposits remain

Amyloids Remain (6 of 7)

A year after laser debulking, the patient continued to have a very good voice, and only reappeared due to an unrelated question. As expected, smally amyloid deposits remain.
Amyloid doesn't affect voice

Voice remains clear (7 of 7)

When she produces voice, match and vibratory ability are very good, explaining her normal voice. It remans to be seen if amyloid will gradually reaccumulate over the next many years and need another debulking.


Mitomycin C topical application

Mitomycin C topical application is the use of the medication Mitomycin C to prevent post-procedural scarring in the larynx or trachea. Outside the field of laryngology, Mitomycin C is used more commonly as a cancer chemotherapy agent, but within laryngology, Mitomycin C is often applied by a clinician to prevent scarring after procedures like laryngeal or tracheal dilation or division of a glottic web.

A common way to apply Mitomycin C would be to take the drug in dilute form (e.g., 0.3mg per ml), saturate a cottonoid sponge with it, and then “paint” it on the area where one wants to inhibit a scarring response, holding the sponge in position for about three minutes. Mitomycin C’s mechanism of action is reported to be absorption of the drug by fibroblasts, which are then “decommissioned” from producing collagen, the major component of scar tissue.



Mixed AB-AD Spasmodic Dysphonia

The combination of both abductor (AB) and adductor (AD) vocal cord spasms in a person who has spasmodic dysphonia (SD). Most individuals with SD have a predominance of one spasm type or the other—AB or AD—such that we classify the person as having either “AB-SD” or “AD-SD.” Some individuals, however, have a significant amount of both types of spasms. That is, a person experiences phonatory arrests or squeezedowns caused by AD spasms, followed suddenly by dropouts to a whisper caused by AB spasms. This kind of person is described as having “mixed AB-AD spasmodic dysphonia.”

Treatment for SD usually involves two-muscle Botox injections: for AD-SD, injecting into both of the thyroarytenoid muscles; for AB-SD, into both of the posterior cricoarytenoid muscles. Treatment for mixed AB-AD SD usually begins with the two muscles causing spasms of which the patient is most aware; if the results are not satisfactory (often because the untreated kind of spasms come to the fore without competition from the other kind of spasms), some of these patients are then eventually treated with four-muscle injections.



Modeling (during vocal capability battery)

This term is used to indicate the process of clinician production of a sound that the patient is then asked to imitate or attempt to imitate. Not unlike “call and response” in some kinds of vocal music. The response is then judged to answer the examiner’s inner questions: “What does this voice do that it shouldn’t and what can’t it do that it should be able to do?” Modeling is performed by the clinician to elicit the voice’s phenomenology.



Motivated Laryngeal Examination

A “Motivated” laryngeal examination is an examination in which the clinician “pushes” the larynx to reveal its secrets. If topical anesthesia is used, this can be done without undue discomfort to the patient, and laryngeal images can be close and clear rather than far and fuzzy.


Photos:

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Motivated examination (1 of 4)

Typical view for laryngeal videoendoscopy or videostroboscopy. 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.

Motivated examination (2 of 4)

At closer range, two findings become evident. First, permanent capillary reorientation is seen (inside the white dotted oval), which is typical after superficial cordectomy; note the more jagged and left-right capillary patterns. Second, tiny points of leukoplakia (inside the green dotted oval) become evident on the opposite vocal cord. The bright white spot in the photo is just a light reflection.

Capillary and leukoplakia (3 of 4)

After vigorous throat clearing, and using a view that is closer still, capillary and leukoplakia findings are confirmed. Note that the brilliant white light reflection is now in a different location.

Leukoplakia (4 of 4)

Still closer view, again confirming the tiny patches of leukoplakia.

Subtle Papillomas and the Importance of A Motivated Examination

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Standard light, HPV-6 infection (1 of 4)

Breathing position, standard light in a young woman with longstanding HPV-6 infection. Voice remains quite good, many months after her last microsurgery with cidofovir injection. The only obvious “lesion” is posterior right cord (left of image) but the characteristic punctate vascular marks are not seen. The black lines are purely for use to orient photo 4.

Stobe light, vocal cord margin irregularity (2 of 4)

With such a clear voice, this prephonatory instant under strobe light reveals a surprising degree of vocal cord margin “serpentine” irregularity. Black lines again support orientation with photo 4.

Narrow band light, vascular marks seen (3 of 4)

At very close range and also using narrow band light, the tiny punctate vascular marks are seen in the lesion first seen in photo 1. Faint vascularity like that demonstrated here can be a correlate of relatively stable, inactive disease, which has clinically been the case here.

Narrow band light, papilloma formation (4 of 4)

This narrow band view includes only the anterior half of the vocal cords from the black lines of photos 1 and 2 to the anterior commissure (at x). Inside the faint circles, note the vascular markings that suggest papilloma formation to explain the serpentine margin.

Motivated Examination for Diagnostic Precision

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Chronic hoarseness, nodules suspected (1 of 2)

A person with chronic hoarseness. Working from a “typical” laryngeal examination photo alone, one might suspect vocal nodules.

Arrows point to papillomas (2 of 2)

By going to the trouble of getting an extremely close-range view such as this one, requiring use of topical anesthesia, one can see what appear to be papillomas, with stippled vascular effect associated with HPV-related disease. RRP is in fact the biopsy-proven diagnosis and papillomas are indicated by arrows.

Motivated Airway Examination Avoids Further Surgery

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Marginal airway (1 of 4)

This woman underwent radiotherapy for larynx cancer several decades earlier. Some years ago, progressive post-radiation fibrosis had nearly fixed the vocal cords in the midline and airway was marginal. A laser posterior commissuroplasty was done as an alternative to tracheotomy. During a recent hospitalization for pneumonia elsewhere, she was told that her airway was inadequate; she returned for examination for this reason. During this kind of distant view, her airway does indeed look marginal.

Airway at close range (2 of 4)

At close range using topical anesthesia, with the patient exhaling, her airway appears adequate. The dotted line is where the margin of the cords would be if the divots had not been removed.

Forced inspiration (3 of 4)

Forced inspiration draws the vocal cord mucosa medially to narrow the airway, and inspiratory noise is heard, but the posterior divots maintain a small but adequate airway and time to fill is only mildly prolonged.

Alternative to tracheotomy (4 of 4)

During phonation, the divots removed from the posterior vocal cords are more clearly seen. Voice is air-wasting, airway is of course suboptimal, but no tracheotomy or additional laser commissuroplasty is needed.


Mucosa

The mucous membranes (or mucosa) are to our interior as skin is to our exterior. Mucosa covers or lines various body cavities and internal organs. In laryngology, the mucosa of the vocal cords is the point of main susceptibility to vibration-induced traumatic abnormalities such as nodules, polyps, capillary ectasia, and so forth. Mucosa also lines the nose, mouth, pharynx, esophagus, and tracheobronchial tree.



Mucosal Bridge

A mucosal bridge lies in the family of disorders such as epidermoid cyst and glottic sulcus. Imagine a cyst that opens in two places, spilling its contents completely. The result is a narrow bridge of mucosa, attached anteriorly and posteriorly.


Photos:

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Mucosal Bridges from Severe Vocal Overuse

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Vibratory injury (1 of 4)

Severe vibratory injury in fitness instructor who is dynamic and extremely intense and "vocal" by nature. Click to enlarge this photo to better see tiny dotted lines that outline the mucosal bridge on each side. The bridges is extraordinarily slender on the right (left of photo).

Non-mucosalized granulation tissue (2 of 4)

Now viewed under narrow band light, the bridges are a little more easily seen, and they overlie non-mucosalized granulation tissue on the vocal ligament. A single asterisk is on the midpoint of each bridge.

Open phase of vibration (3 of 4)

Under strobe light, open phase of vibration at D4 (293.66Hz).

Closed phase (4 of 4)

Closed phase, at approximately the same pitch.


Mucosal Chatter

Mucosal chatter is an audible phenomenon of injured vocal cord vibration. It is commonly heard in the softly-sung upper voice of persons with nodules, polyps, etc.

Hoarseness or roughness are broad and nonspecific descriptors useful only for severe injuries. Small injuries that are nevertheless impairing the singing range may leave the speaking voice sounding normal. I suppose “hoarseness of singing range” could be used, but again, that would be an unsophisticated and basic description of vocal phenomenology. To hear more useful phenomena of injury, we elicit and thereby investigate the upper range of singing (even in nonsingers) because high, soft singing makes the phenomenology apparent.  This is why we have described “vocal cord swelling checks” and created a video to teach how to elicit them, and also how to evaluate and communicate the phenomenology that results. In particular, delays of phonatory onset (“onset delays”) above approximately C5 (523 Hz) may indicate mucosal injury even when speaking voice sounds normal. Also heard is air-wasting, where there is a “scratchiness” to the excess airflow. Segmental vibration is also a common audible phenomenon of a mucosal disorder can also be easily taught and recognized.

Vocal cord mucosal chatter adds an extremely rapid “shudder” on top of the pitch of the voice. I have used “chatter” rather than “shudder” because the latter suggests a lower frequency than the former. It could be called a very fine-grained diplophonia…but typical diplophonia, caused by independent vibrating segments, is a much grosser vocal phenomenon. While chatter is more subtle, once it is pointed out and taught briefly, most people can easily distinguish between onset delays, diplophonia, segmental vibration, the transient “squeaking” of a micro-segmental vibration,  the crackling sound of mucus dancing on the vocal cords, and “chatter.”  Those who master recognition of these phenomena can easily communicate them to colleagues. For our purposes, let me stress again that the above phenomena—and chatter in particular—do not happen in the normal larynx, where vocal cord margins match perfectly and the mucosa oscillates normally.  When heard—even in the person with a normal speaking voice—the examiner can strongly suspect a mucosal abnormality even before examining the vocal cords.  In fact, where these phenomena are heard and initial examination looks normal, it would be a good idea to “look harder.”

Patient examples:

Videos:



Mucosal Edema or Swelling

Mucosal edema or swelling is the build-up of edema (tissue fluid) within the mucosa, the layer of tissue that lines the body’s interior. In the larynx, this build-up of edema usually occurs at the mid-point of the vocal cords, as the body’s response to vocal overuse, and it resembles a small, low-profile blister.

Vocal overuse triggers this build-up of edema because, with vocal overuse, the vocal cords undergo more vibratory stress and trauma than they are designed to handle. The body responds by gathering edema to form a protective cushion. However, this swelling distorts the vocal cord’s shape and can limit its flexibility, which can thereby impair the voice, making it sound acutely husky or hoarse.

From mucosal edema to nodules:

If the voice is rested even moderately, this edema fluid will disperse rapidly—within 12 to 24 hours if not severe—so that the swelling vanishes and the voice returns to normal. However, if the voice continues to be overused, then the body may build up more chronic swelling materials (no longer just edema), so that the vocal cords develop nodules.


Photos:

Swelling

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Swelling (1 of 4)

Semi-abducted position, standard light.

Swelling (2 of 4)

Pre-phonatory instant. Standard light shows only the suggestion of margin swelling, as the dark space between the cords is not exactly the same along its length

Swelling (3 of 4)

Open phase of vibration. Strobe light shows both wide excursions (indicating mild flaccidity) and margin swellings.

Swelling (4 of 4)

Closed phase of vibration, strobe light. Shows margin swellings more clearly.

Indicator Swellings

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Pre-phonatory (1 of 4)

Pre-phonatory instant at E-flat 5 (622 Hz), conventional view with standard illumination shows no evident mucosal disorder.

Phonation (2 of 4)

Phonation, at E-flat 5 standard illumination, with vibratory blur and still no visible problem.

Subtle swellings (3 of 4)

Only at very high pitch and with high magnification can one see subtle swellings. Here, closed phase of vibration at C# 6 (1106 Hz).

Indicator swellings (4 of 4)

Open phase of vibration, also at C# 6 . Given the patient’s unimpaired “swelling checks,” these findings serve only as an indicator of past and potential over-use of voice, and should not be explained to the patient as being evidence of past problem and potential future problem if over-use again occurs, but, if voice is functioning well, not necessarily as a current problem.

Indicator Lesions and MTD

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Breathy voice (1 of 6)

Distant view at the prephonatory instant in young female singer. There is a wide gap between the cords. The explanation for this gap is not immediately evident, but the voice is breathy.

Phonation (2 of 6)

Phonation has started with margin blurring, and the sense of extra space between the cords remains.

Open phase (3 of 6)

Strobe light, open phase of vibration at B4 (494 Hz)

Closed phase (4 of 6)

Closed phase of vibration, still at B4. Note the incomplete closure posteriorly caused by MTD. Arrows indicate the vocal processes.

Open phase, indicator lesions (5 of 6)

Open phase of vibration, strobe light, at F#5 (740 Hz). Here, the subtle indicator lesions are seen more clearly; vocal cord margins are not perfectly straight.

"Closed" phase, MTD (6 of 6)

“Closed” phase of vibration is not really closed and the vocal processes do not come into full closure, again consistent with MTD.

Use High Voice & Close, Clear View to Reveal What Is Concealed

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Breathing position (1 of 4)

Young woman with singing voice complaints. Speaking voice is normal but swelling checks are strongly impaired. Here, breathing position, standard light, nothing is very noticeable except subtle elevation left vocal cord (right of photo).

Phonation (2 of 4)

Here, high pitch but under standard light and with only moderate magnification, the abnormality is still fairly unimpressive.

Obvious swellings, open phase (3 of 4)

At closer range, using strobe light, and at the same time using fairly high voice (F#5 740 Hz), the obvious margin swellings are seen.

Obvious swellings, closed phase (4 of 4)

Same pitch, closed phase of vibration. Now both vocal and visual findings are indeed obvious. After a trial of speech therapy, vocal cord microsurgery provided return of "original equipment" vocal capabilities.


Mucus Retention Cyst

A cyst that forms when one of the mucus glands just below the vocal cord’s free margin becomes plugged. Mucus glands in this location secrete mucus in order to bathe and lubricate the vocal cords, but if a gland becomes obstructed, then the mucus it produces gets trapped and accumulates, leading to a mucus retention cyst. A mucus retention cyst typically occurs without any correlation to vocal overuse, in contrast to epidermoid cysts as well as nodules and polyps.

Signs:

A mucus retention cyst can cause hoarseness, because it interferes with the normal vibrations of the vocal cords and the accuracy of their match with each other (see the videos below). The cyst is most often unilateral—that is, occurring on one cord but not the other. It appears as a bulge or deformation of the vocal cord’s free margin, and sometimes undersurface, and it may be yellowish in color.

Treatment:

The cyst may be surgically removed, by creating a small incision on the vocal cord and then dissecting the cyst from the cord. Photos of the surgical process can be found below. Also, the two videos below show how removing this kind of cyst can improve the voice.


Photos:

Removal of mucus retention cyst

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Mucus retention cyst (1 of 3)

Mucus retention cyst of right vocal cord. Yellowish spherical mass shines through overlying mucosa. This was causing the patient severe hoarseness. Incision to enter the cord at dotted line.

Removal of Mucus retention cyst (2 of 3)

Near completion of dissection of cyst from its final attachments, using curved scissors.

Mucus retention cyst (3 of 3)

After cyst’s removal. The patient’s voice sounded virtually normal in the recovery room, though upper voice still abnormal.

Removal of Mucus Retention Cyst

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Injecting Xylocaine (1 of 5)

The physician injects xylocaine with epinephrine into the tissue before surgery, so as to inhibit bleeding and to cause some of the layers of tissue to expand and spread apart (hydrodissection).

Hydrodissection effect (2 of 5)

The hydrodissection effect of the injection is now visible

Removal of cyst (3 of 5)

The incision has been made. Now, curved scissors (pointing downward) release the cyst’s anterior attachment.

Removal of cyst (4 of 5)

The cyst is now almost fully released from the vocal cord.

Cyst is gone! (5 of 5)

Removal completed. The line of incision is visible.

Mucus Retention Cyst

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Mucus retention cyst

Mucus retention cyst (1 of 1)

After laser excision of early vocal cord cancer, left vocal cord (right of image), a small mucus gland became plugged. This could instead be mistaken as a polyp, but a polyp does not fit this man's quiet nature and minimal vocal commitments. Note that the lesion is below the point of maximum vibratory contact that would produce a polyp. This man's voice is excellent.

Mucus-Retention Cyst—not Polyp—Before and After Removal

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Mucus-retention cyst (1 of 5)

This person has chronic hoarseness, without prior illness or voice overuse. The explanation is this left-sided mucus-retention cyst (right of photo). The next photo shows more clearly how we know this is a cyst and not a polyp.

Below the margin (2 of 5)

This photo is under a strobe light during the open phase of vibration and dotted line shows the free margin of the cord. It shows that the swelling originates from below this free margin, common for mucus-retention cysts. The two solid lines show the incision line options for planned dissection and removal of this cyst. Here the medial one (on the cyst) was chosen, as seen in the next photo.

One week post-op (3 of 5)

A week after incision and dissection and removal of the cyst. You can see the incision line at the dotted line.

Better medializtion (4 of 5)

Closed phase of vibration at E5 shows perfect match of the margins.

Better flexibility (5 of 5)

Open phase of vibration at same pitch shows that both cords make lateral excursions, confirming lack of stiffness and scarring due to the incision and dissection being below most of the vibrating part of the mucosa.

Videos:

Mucus Retention Cyst: Before and After
Watch this video to see images and hear audio of a mucus retention cyst’s effect on the vocal cords, followed by the surgical removal and the post-surgical results.
Mucus Retention Cyst II: Before and After
Another example of a mucus retention cyst, with images and audio before, during, and after the cyst’s surgical removal. This video highlights a bit more of the vocal capability battery.


Multi-modality Treatment

Multi-modality treatment is therapy that combines more than one method of treatment. See also: single modality treatment, combined modality treatment.



Muscular Tension Dysphonia (MTD)

The term muscular tension dysphonia (MTD) was coined by Morrison and Rammage at the University of British Columbia. This is a syndrome consisting of some or all of the following:

1) Excess tension, sometimes to the point of discomfort/ pain in the paralaryngeal and suprahyoid muscles;

2) An open posterior glottic chink during phonation;

3) High larynx position in the neck;

4) Inappropriate contraction of pharyngeal constrictors with phonation;

5) Often but not always, vibratory mucosal injury.

The vocal cord mucosal changes associated with MTD are usually fleshy vocal nodules. This syndrome is seen most often in young women.


Photos of muscular tension dysphonia:

Inappropriate Pharynx Contraction Is A Component of (MTD)

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Rest Position of Pharynx (1 of 6)

This talented teenaged classical singer is bothered by a sense of effort, fatigue, and discomfort when attempting her high soprano notes. Quiet breathing (seen here) establishes the rest position of pharynx (dotted lines), with wide open pyriform sinuses (P). A thin sheet of muscle is just beneath the mucosa.

Inactive Pharynx Musculature (2 of 6)

Pharynx muscle should be inactive (not contracted) until a singer reaches the top few notes of his or her range. This singer is producing voice at B3 (247 Hz), a low note for this singer. The pharynx musculature remains inactive, like in photo 1.

Contracted Pharynx (3 of 6)

At B4 (495 Hz), which is only middle voice, the pharynx begins to contract, inappropriately. Note the smaller diameter of pyriform sinuses (see lines), and the more curved pharyngeal wall contour (dotted lines).

Contracted Pharynx (4 of 6)

At E-flat 5, still far from upper range, the pharynx is contracting a lot, and again inappropriately. This degree of contraction should not be seen until much higher in her range. If she sings continually at this pitch and higher, she will experience paralaryngeal discomfort and effort, and sometimes a “reaching up” vocal quality.

Greater Contraction of Pharynx (5 of 6)

Now at “only” f#5 (_____ Hz), the contraction of the pharynx is maximal and pyriform sinuses closed. For a soprano, this degree of contraction is ideally not seen before reaching C6 (_____ Hz) or higher! As the pharynx is not designed for sustained contraction, upper voice singing will be impossibly uncomfortable for her.

Phonating Larynx (6 of 6)

Close-range visualization of the phonating larynx (note the vibratory blur) shows a characteristic posterior commissure gap (arrows). This finding is also characteristic of MTD.

Use Different Views for MTD Than for Frequently-Associated Nodules

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Convex vs. straight (1 of 4)

Only one of the two reasons this person has for vocal symptoms can be seen in this abducted (breathing position) photo: the margins of the vocal colds are convex rather than straight due to vibratory injury.

Swellings + MTD (2 of 4)

The adducted (voicing) position continues to show the margin swellings in the lower 1/3 of the photo, but adds the diagnosis of MTD, with separated “grey” vocal processes (dotted lines) within the posterior third of the vocal cords. 1 marks the center of view; 2 the midpoint of the nodules.

Strobe lighting (3 of 4)

A slightly magnified view under strobe light. Note the MTD again (persistently separated vocal processes), and the swellings.

Use different views (4 of 4)

Now the view is a little more magnified, and centered on the nodules, at 2. The nodules are much better seen, but the crucial information for diagnosing MTD (vocal process posture) is lost in this view. This series illustrates that often both views are needed, as views like photo 2 and 3 are not ideal for the nodules.

MTD Posturing Abnormality Transiently Corrected With Creaky Voice

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Breathing position (1 of 6)

Young soprano with short phrase length, paralaryngeal discomfort, and effortfulness in singing high range—all symptoms seen with MTD. In this distant view, no abnormalities are seen during breathing.

MTD posturing (2 of 6)

Under standard light, the MTD vocal cord posturing is seen at B-flat 4 (466Hz). Note the slight lateral turning of the vocal processes (arrows) and wide dark space/ blur between the cords.

"Closed" phase (3 of 6)

G4 (392 Hz) under strobe light. Even at this middle voice pitch, closed phase is not truly closed, especially at the vocal processes.

Open phase (4 of 6)

At the same pitch, this open phase view also helps to explain breathiness and short phrase length.

Creaky voice, closed phase (5 of 6)

The patient is asked to produce the voice with creaky quality just to prove that the vocal processes are physically able to adduct. Compare this closed phase view with photo 3.

Creaky voice, open phase (6 of 6)

Open phase, still in creaky voice at G4. Compare with photo 4. Creaky voice is one temporary diagnostic antidote to MTD, not a complete “treatment.”

Muscular Tension Dysphonia

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Muscular tension dysphonia (1 of 4)

Muscular tension dysphonia, in which posterior commissure inexplicably does not fully adduct. Prephonatory instant, standard light.

Muscular tension dysphonia (2 of 4)

Postphonatory instant with blurring, standard light.

Muscular tension dysphonia (3 of 4)

Maximum open phase of vibration, strobe light.

Muscular tension dysphonia (4 of 4)

Maximum closed phase of vibration, strobe light. Incidentally, the projection from the edge of the cord is mucus, not swelling.

To See MTD, You Must See Posterior Commissure and Vocal Process Mucosa Especially at High Pitch

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Breathy voice (1 of 4)

Young female singer developed breathy voice quality, a feeling of strain in the anterior neck and some cracking of the voice when using upper singing range. In this view, the explanation is not obvious for 2 reasons: First, the view is distant, and second, the posterior commissure is not seen due to overhang of the arytenoid apices.

Posterior gap (2 of 4)

Closer range, but at low pitch of B3 (247 Hz). Here, a posterior gap strongly suggests the diagnosis of MTD, but the view is still inadequate because the posterior commissure and specifically vocal process mucosa is still not seen.

MTD (3 of 4)

At slightly closer range under strobe light, and at much higher pitch of G5 (784 Hz) the explanation for her vocal symptoms is clearly seen. The vocal processes (covered by more "grey" mucosa indicated by tiny arrows) are not together. This is a classic finding of MTD. Even in this closed phase of vibration view, the gap between the cords is large, explaining the breathiness and short phrase lengths.

Open phase (4 of 4)

At the same pitch of G5, but now open phase of vibration. The arrows here are overlying the vocal process mucosa and diverge (point slightly laterally). If the vocal cord posture were correct, the arrows would point directly forward in parallel with each other.

Muscular Tension Dysphonia

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Muscular tension dysphonia (1 of 3)

This extensive voice user experiences upper voice limitations, extreme breathiness (air-wasting during phonation), and neck discomfort. When making voice, the cords are significantly separated posteriorly such that the major part of air is wasted. The white dotted lines should be fully together, with only a thin dark line between the cords.

Muscular tension dysphonia (2 of 3)

Strobe light, closed phase of vibration at B-flat 3 (approximately 233 Hz). The translucent, polypoid nodules come into early contact, but equally if not more importantly, the posterior vocal cords remain significantly separated as a vocal cord positioning inefficiency.

Muscular tension dysphonia (3 of 3)

Open phase of vibration at the same pitch.

Severe MTD With “Red Herring” Mucus Retention Cyst and “Reflux” Findings

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Possible reflux, barely visible lesion (1 of 4)

Singer in late teens, already with 11 years of vocal training but breathy quality. In this quiet breathing view, the dotted oval outlines interarytenoid pachyderma ( suggesting reflux). This, and a barely-visible lesion of the right cord (left of photo, indicated by black arrow) draw attention, but are red herrings. Dotted lines are for comparison with following photo.

Closed phase at D4, posterior gap (2 of 4)

Closer view under strobe light at D4 (approx. 294 Hz). This is the maximum closed phase, yet there is still a large gap posteriorly. Notice that the vocal processes (embedded beneath the grey area indicated by dotted lines) are inappropriately separated—the hallmark of MTD.

Closed phase at F#5, posterior gap (3 of 4)

Also under strobe light but at F#5 (approx. 740 Hz). This dramatic and undesirable, dysfunctional gap is seen at the maximum closed phase and is one visual correlate of this singer’s remarkably breathy voice.

Red herring mucus retention cyst (4 of 4)

Again at F#5 under strobe light, but at the maximum open phase of vibration. Now seen is a small mucus retention cyst of the right vocal cord (left of photo) at arrow, entirely a red herring finding. The important finding is the remarkable separation of the vocal processes, as in photos 2 and 3, indicated by dotted lines.

MTD at Prephonatory Instant, and During Phonatory Blurring

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Prephonatory instant (1 of 2)

Nineteen year-old singer with “small, quiet, breathy voice,” whose throat feels strained, tight, and choked when she tries to sing. This view shows the position of the cords one frame (1/30 th of a second) before vibration begins. Note the remarkably wide “stance” of the cords.

Phonatory blur (2 of 2)

Eleven video frames (1/3 of a second) later, during phonation, the vibratory blur makes the cords appear slightly closer, but the “stance” of the cords is actually the same as in photo 1 above. See short vertical lines for reference between photos.

Looks Like MTD, but Isn’t

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Weak, effortful voice (1 of 4)

A middle aged woman describes a weak, effortful voice. Many months earlier, she recovered fully from a grave illness that put her in a coma for several days. She dates the voice change from that event.

Prephonatory instant (2 of 4)

At the prephonatory instant, a split-second before vibration begins, showing that the cords do not adduct fully.

Phonatory blur (3 of 4)

Phonatory blur under standard light. Notice that the vocal cords are separated posteriorly to the same degree as in the prior photo. This can be mistaken for MTD, but is not.

Endotracheal tube injury (4 of 4)

At closer breathing view, one can see an endotracheal tube injury. There is an erosion of the posterior left vocal cord (right of photo), with loss of the expected straight line ( dotted lines). The 'X' shows additional area of scarring from the endotracheal tube. The issue here is that the cricoarytenoid joints are damaged; they allow full abduction (separation) of the cords for breathing, as in this photo and photo 1, but do not allow full adduction (approximation) for voicing (seen in photos 2 and 3). Hence, her normal breathing, but weak and air-wasting voice. The therapy approach here would be similar to for MTD, however, and there are some modestly-helpful surgical interventions that can also be considered.

Persistent MTD and Pharynx Recruitment in Young Singer After Sulcus Removal

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Squamous mucosa lining the sulcus (1 of 5)

Closed phase at A5 (880 Hz) under strobe light. Arrow points to line of sulcus. The entire white area (within dotted line) is buried squamous mucosa lining the sulcus.

Open phase, distance posteriorly of cords (2 of 5)

Also at A5, but open phase of vibration. Sulcus opening (arrow) is a little more evident. Note most of all that the distance between the cords at their posterior ends is similar (a little greater in this view due to mucosal displacement of the upper surface of the cords).

Closed phase, distance posteriorly of cords (3 of 5)

In a more distant view under standard light at A5 (880 Hz) that shows the posterior vocal cord separation more clearly during phonation (note blurring caused by vibration).

Two weeks post-surgery, MTD (4 of 5)

Two weeks after successful surgery to remove the right sulcus (left cord margin elevation undisturbed pending verification of restored right cord oscillatory ability). The prephonatory instant at A5 (880 Hz), shows that the posterior commissure separation is virtually identical to preoperatively, proving that the MTD posturing abnormality, and not only the sulcus, is a primary issue for this voice.

Re-posture vocal mechanism (5 of 5)

Still under standard light as in photo 4, phonation (and blurring of the margins) has begun and both cords vibrate well. Upper range has been extended by this surgery, but breathiness throughout the range is still evident. The remaining challenges are to re-posture the vocal mechanism, and then consider smoothing the left cord margin (right of photo), depending upon residual limitations caused by it, and patient needs.

MTD and Postoperative “Gap Memory”

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Prephonatory instant (1 of 6)

Nodules and severe MTD. This is prephonatory instant, standard light at low pitch (C4, or approximately 262 Hz).

Phonatory blur (2 of 6)

A moment later, with phonatory blur, also under standard light.

Post-op, persistant gap (3 of 6)

Eight days after removal of the nodules. Prephonatory instant at a much higher pitch (E5, or approximately 659 Hz). Notice the persistent gap. Slight irregularities will model away with time.

Large gap (4 of 6)

A moment later, with phonatory blur. The large gap remains evident.

Strobe light (5 of 6)

E5 but now under strobe light at “closed” phase which is of course not at all closed due to the MTD.

Strobe light, open phase (6 of 6)

Open phase. This person has an excellent surgical result but will need considerable work to bring the cords into full approximation.

MTD Briefly Abolished with Creaky Voice

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Breathing position (1 of 6)

This choral teacher/ singer is troubled by breathiness and short phrase length. Here during quiet breathing, the vocal cords do not appear to be injured.

MTD posturing (2 of 6)

This photo is characteristic of her entire range: Classic MTD posturing abnormality with poor posterior closure.

Gap (3 of 6)

Strobe light, closed phase of vibration at G4 (392 Hz) shows persistent posterior commissure gap.

Open phase (4 of 6)

Open phase of vibration also at G4.

Creaky voice (5 of 6)

The patient has been requested to produce creaky voice, again at G4. In closer view of closed phase, she successfully closes the posterior commissure, though voice quality is not ideal. Compare with photo 3.

Open phase (6 of 6)

Open phase of vibration, still at G4 with creaky voice. Compare with photo 4.

Mind the GAP!

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Bilateral vocal cord swellings (1 of 5)

Young mezzo-soprano with “fuzziness” in her sound. In this abducted, breathing position, one can see bilateral vocal cord swellings, at the arrows.

MTD gap (2 of 5)

Pre-phonatory position for E5 (659 Hz) under standard light. The swellings are more clearly seen, but the MTD gap is enormous and greater than would be needed to accommodate the swellings.

Phonatory blur (3 of 5)

Phonatory blur as she sings E5. Large gap remains.

Vocal processes (4 of 5)

Under strobe light, closed phase of vibration at A-flat 5 (831 Hz). The arrows indicate vocal processes widely separated. The points of these two arrows should instead touch.

Surgery? (5 of 5)

Still at A-flat 5, open phase, with wide separation of the posterior cords. Surgery would improve this voice a lot, but other than the occasional ‘self-correcting’ individual, would not fix this large MTD gap.

Indicator Lesions and MTD

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Breathy voice (1 of 6)

Distant view at the prephonatory instant in young female singer. There is a wide gap between the cords. The explanation for this gap is not immediately evident, but the voice is breathy.

Phonation (2 of 6)

Phonation has started with margin blurring, and the sense of extra space between the cords remains.

Open phase (3 of 6)

Strobe light, open phase of vibration at B4 (494 Hz)

Closed phase (4 of 6)

Closed phase of vibration, still at B4. Note the incomplete closure posteriorly caused by MTD. Arrows indicate the vocal processes.

Open phase, indicator lesions (5 of 6)

Open phase of vibration, strobe light, at F#5 (740 Hz). Here, the subtle indicator lesions are seen more clearly; vocal cord margins are not perfectly straight.

"Closed" phase, MTD (6 of 6)

“Closed” phase of vibration is not really closed and the vocal processes do not come into full closure, again consistent with MTD.

Quasi-Muscular Tension Dysphonia: the Real Thing Is Usually Throughout the Range

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Seemingly normal vocal cords (1 of 7)

Normal-appearing vocal cords in young singer plagued by inconsistency of capability, effortfulness, breathy voice quality in middle and lower range.

Good approximation (2 of 7)

At the high pitch of G5 (784 Hz), vocal cords come into fairly good approximation, including posteriorly, at the arrows.

Muscular tension dysphonia (3 of 7)

In low voice C4, during phonation (blur, under standard light), the posterior cords separate (arrows) into the posture of muscular tension dysphonia, with breathy quality. None of the photos so far are adequate, however, to evaluate posterior commissure.

Breathiness (4 of 7)

Under strobe light, at C#4 (277 Hz), closed phase. Note the large separation between the vocal processes, responsible for breathiness.

Open phase (5 of 7)

Still at C#4, but open phase of vibration.

Closed phase (6 of 7)

At the high pitch of F5 (698 Hz), closed phase, note that the vocal processes come into approximation, and there is no breathiness.

Approximated vocal processes (7 of 7)

Again at F5, closed phase isn’t quite closed, but note again that vocal processes remain approximated.

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.

MTD: Vocal Cord Posture and Pharynx Recruitment Often Come Together

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Phonation, A3 (1 of 4)

Middle-aged soprano with loss of upper voice, and tremendous strain attempting to make it. Here producing A3 (below middle C), the pharynx is relatively uncontracted and makes a long broad arch (see line).

Pharynx contracted (2 of 4)

At only middle C (~262 Hz), the pharynx is already surprisingly contracted and is beginning to close the pyriform sinuses and "hug" the larynx.

Maximum contraction (3 of 4)

Truly remarkably, at just A4 (~440 Hz) the pharynx is practically maximally contracted, and the patient experiences paralaryngeal aching trying to make a pitch a full octave below what should be possible for her.

"Closed" phase (4 of 4)

"Closed" phase of vibration at G4 is not closed, in classic "MTD" fashion, and the vocal processes indicated by dotted lines should be completely together but are not.

MTD at A Distance and Up Close

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Posterior gap (1 fo 6)

In a somewhat distant view under standard light, the findings of MTD are seen but not clearly. Note that at the prephonatory instant, the gap between the vocal cords becomes gradually wider as it travels posteriorly (to the upper part of the photo).

Phonation (2 of 6)

Now during phonation (note blurring), the vocal cords are still separated posteriorly.

Strobe light, closed phase (3 of 6)

At a more appropriate distance and under strobe light at G4 (~392 Hz), closed phase of vibration. The vocal processes remain separated.

Strobe light, open phase (4 of 6)

Open phase of vibration, at the same pitch, same vocal process separation.

Closed phase (5 of 6)

Closed phase of vibration at D5 (~587 Hz). Note that the vocal cords are longer, and look again at the vocal processes.

Open phase (6 of 6)

At open phase of vibration, also at D5, the MTD remains obvious.

Self-correcting MTD

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Swellings (1 of 5)

This is a young soprano opera singer with significant margin swellings bilaterally. The dotted lines indicate what would be the normal margins. The upper voice is very impaired and swelling checks were strongly positive.

Closed phase (2 of 5)

Closed phase of vibration under strobe light at E5 (659 Hz). Early contact of the swellings, and significant gap of MTD posteriorly at the vocal processes (indicated by dots).

Open phase (3 of 5)

Open phase of vibration at the same pitch also shows gap, if anything a little exaggerated.

Post microsurgery (4 of 5)

Six weeks after microsurgical removal of the nodules. Strobe light at G5 (784 Hz). Voice now has "original equipment" capabilities, and swelling checks are normal even to C6 (1047 Hz).

MTD post surgery (5 of 5)

Open phase of vibration still at G5, showing accurate match and bilaterally equal mucosal vibratory excursions. The MTD gap at dots remains, but has partially self-corrected. In some other patients, the gap remains precisely the same after surgery as before, and in that case, necessitates further work with a MTD-qualified voice teacher or speech pathologist.

MTD Phonatory Gap Greater Than Required By Swelling

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Open phase (1 of 2)

Open phase of vibration at A4 (440 Hz). Moderate-sized vocal nodules, but the gap between the vocal processes (at dots) seems wider than the combined projection of the nodules.

Closed phase (2 of 2)

Closed phase of vibration shows that the nodules barely touch. It appears that the MTD gap is greater than would be necessary to accommodate the nodules. After surgical removal, this gap sometimes self-corrects; sometimes it does not, as if the "ghosts" of the nodules remain.

Released to Sing, and A Surprise Explanation for Pain

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Voice major complains of pain (1 of 4)

A soprano voice performance major worked in a summer resort musical theater troupe. By the end of summer she noted mild vocal decline, with increased breathiness, but also a pain left mid-neck. With a history of successful microlaryngoscopy for removal of nodules 3 years earlier, she was concerned that she might have a significant injury, and shouldn't sing for the first few weeks of school. Here, she produces voice under standard light at D5 (587 Hz). Large posterior commissure gap suggests MTD, which can cause a sense of "strain" with voice production, but does not require voice rest.

Open phase (2 of 4)

Under strobe light at B5, open phase, the grey vocal process mucosa (at green arrow) is barely within the field of view, but clinches the diagnosis of MTD. Still, no finding here suggests that voice rest required. Technical work on her MTD is indicated instead.

Closed phase (3 of 4)

"Closed" phase of vibration at the same pitch, and now a subtle, very low profile convexity of the left vocal cord (right of photo) serves as an "indicator lesion" but it is so subtle just 3 days after her singing job ended, that again, mild vocal prudence at most is indicated.

Cause of pain (4 of 4)

Saving the real explanation for focal pain to the end: Here we see the cause of her left-sided mid-neck pain: an "arytenoid perichondritis" sort of lesion, unrelated to voice use, and not requiring voice rest. The patient is relieved that she does not have recurrent nodules, and that she can resume voice lessons to battle her MTD.

Search not Only for Nodules, but Also for Segmental Vibration and Look at the Posterior Commissure for MTD

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Open phase (1 of 4)

In a young pop-style singer, the open phase of vibration under strobe light at C#5 (554 Hz). This magnified view is best to see the large fusiform nodules.

Closed phase (2 of 4)

Closed phase of vibration at the same pitch shows touch closure—that is, that the nodules barely come into contact.

Segmental vibration (3 of 4)

Even when patients are grossly impaired in the upper voice as is the case here, the clinician always requests an attempt to produce voice above G5 (784 Hz), in order to detect segmental vibration. Here, the pitch suddenly breaks to a tiny, crystal-clear D6 (1175 Hz) Only the anterior segment (arrows) vibrates.

Posterior commissure (4 of 4)

A more panoramic view that intentionally includes the posterior commissure to show that the vocal processes, covered by the more ‘grey’ mucosa (arrows), do not come into contact. This failure to close posteriorly is a primary visual finding of muscular tension dysphonia posturing abnormality.

Muscular, not Mucosal Ceiling Diagnosable Even with Distant Views

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Low voice at a distance, pharynx is relaxed (1 of 3)

This very accomplished but “natural” singer is in late middle age and has lost most of her upper range. She has not been ill nor has there been any episode of increased voice use. Low voice (131 Hz) viewed at a distance gives no significant information.

Maximal contraction of pharynx (2 of 3)

Attempted C5 (523 Hz), still distant view. The patient undershoots the pitch and is only able to produce B-flat 4 (466 Hz), and only with effort and muscular strain. Simultaneously, we see maximal contraction of the pharynx, hugging the larynx and obliterating the pyriform sinuses.

Vocal cord swellings are red herrings (3 of 3)

Closer visualization of the vocal cords shows small elevations. They are not the problem; premature pharynx contraction (as seen in photos 1 and 2) reveals that the lowered ceiling of the voice is "muscular" and not "mucosal."


Mycobacterium Abscessus: An Infection of the Larynx

A photo gallery of mycobacterium abscessus infection located on the larynx.

Mycobacterium abscessus: Series of 6 photos

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Mycobacterium abscessus

scarring or extra tissue (1 of 6)

This immunocompromised patient is receiving monthly immunoglobulin infusions and has experienced many months of severe hoarseness. From a distance, one sees what looks like scarring or extra tissue mostly posteriorly.
vascular stippling

Vascular stippling (2 of 6)

Under narrow band light and at closer range, notice the vascular stippling. The initial impression was that this might be a fungal infection such as blastomycosis.
Mycobacterium Abscessus

Enlarged Abnormalities (3 of 6)

A month later, due to delay while optimizing her medical condition for brief general anesthesia, the abnormalities seem to have progressed/enlarged. Voice is even worse, and now the patient has mild symptoms of airway restriction.
A week after surgical debulking

Recovery after surgery (4 of 6)

A week after surgical debulking. Both voice and breathing are much improved.
Inflammatory polyp

Inflammatory polyp (5 of 6)

Six weeks later, airway remains excellent; voice has re-deteriorated due to this inflammatory “polyp.”
thulium laser coagulation

Thulium laser (6 of 6)

Office based thulium laser coagulation in progress…


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