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Laryngopedia

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

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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:

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 (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

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: 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.

Vocal Cord Paralysis, Before and After Medialization

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: 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 (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: 5 months after medialization (9 of 12)

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

Extrusion of Vocal Cord Implant

Paresis, TA + LCA, Before and After Medialization

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 (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

the right cord is paramedian, while the left cord is widely abducted — 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:

https://youtu.be/IYlzcyHE9TY

Injection Medialization for Vocal Cord Paresis (https://youtu.be/IYlzcyHE9TY)

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

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 (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.

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 (4 of 7)

At very close range, the yellowish color typical of amyloid deposits is better seen.

Vocal cords cannot close completely (5 of 7)

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

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:

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

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

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

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.

removed divots on vocal cords — 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:

Mucosal Bridges from Severe Vocal Overuse

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 — 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:

Audio:

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.

https://youtu.be/zit6I7EPMto

Vocal Cord Swelling Checks: A Simple Way to Detect the Early Signs of Vocal Injury (https://youtu.be/zit6I7EPMto)

Photos:

Swelling

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

Indicator Swellings

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

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.

Open phase (3 of 6)

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

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

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).

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

Removal of Mucus Retention Cyst

Removal of cyst (4 of 5)

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

Mucus Retention Cyst

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

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:

https://vimeo.com/77220870

Mucus Retention Cyst: Before and After Surgical Removal (https://vimeo.com/77220870)

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.

https://vimeo.com/77223835

Mucus Retention Cyst II: Before and After Surgical Removal (https://vimeo.com/77223835)

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.