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Laryngopedia

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

Laryngopedia By Bastian Medical Media

Multimedia Encyclopedia


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You're viewing encyclopedia entries under N. You can click a different letter above to browse other entries.

Narrow-band illumination

The use of only two narrow wave bands of light (blue and green) during an endoscopic examination, so as to make blood vessels and other tissues in the mucosa more visible. Blood vessels become more visible under narrow-band illumination because both of the wave bands are easily absorbed by hemoglobin in the blood. In addition, the blue and green wave bands in narrow-band illumination each penetrate the tissue to differing degrees, so that blood vessels near the mucosal surface appear as a different color from blood vessels deeper in the tissue.

In the field of laryngology, narrow-band illumination can help an examining clinician to identify the vascular changes that characterize a range of disorders, including recurrent respiratory papillomatosis, capillary ectasia, glottic sulcus, ulcerative laryngitis, and others. It can also help to identify subtle, hazy leukoplakia. The technology, developed by Olympus, is officially called Narrow Band Imaging™. KayPentax offers a different, software-based method for highlighting vascularity and other tissue characteristics, which is called iScan™.


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Nasopharyngeal reflux

The inappropriate entry of saliva, food, or liquid into the nasopharynx during swallowing, usually due to palate weakness or dyscoordination (see palate elevation).



Neck dissection

Neck dissection is a surgical procedure that removes lymph node-bearing tissue in the neck, either because it contains known metastases or is at high risk of containing yet-undetected (i.e., microscopic) metastases. Neck dissection is often combined with removal of the primary tumor. The original neck dissection, today called a radical neck dissection, removes fat and lymph nodes, the jugular vein, and sternocleidomastoid muscle. Later types of neck dissections were devised to reduce the morbidity of this surgery without compromising effectiveness. The commonest variants today are called selective neck dissections; these remove removes fat and lymph nodes from targeted parts of the neck most likely to be involved with metastasis, and tend to spare muscles of the neck, the jugular vein, and cranial nerve 11.



Necrosis

The death of cells or tissue. In laryngology, necrosis is seen most commonly after radiation therapy to the larynx for cancer treatment. Radiation kills the tumor but at the same time damages the blood supply of normal tissue on a permanent basis. Necrosis in this instance is called “radionecrosis.” Or, necrosis could result from trauma (a physical wound) that disrupts blood supply, or occasionally in the context of ulcerative laryngitis, which seems to necrose the superficial layers of the vocal cords. Necrotic tissue typically sloughs off down to viable (living) tissue.


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Neuropathy

Neuropathy, in a basic, practical, and somewhat literal sense means “nerve-ending suffering.” The idea is that the patient’s suffering is from the damaged nerve ending and not from something that is stimulating that nerve ending. In other words, a neuropathic stinging sensation might be arising from misfiring of the sensory nerve ending all by itself, and not in response to, for example, an actual bee sting.

Motor neuropathy involves muscle-supplying nerve fibers.  Motor nerve endings insert into muscle to allow them to contract.  Thus, nerve ending damage would cause weakness.  A person with peripheral neuropathy of the motor (movement) nerves to the lower legs might, for example, develop a slapping walking sound or unsteadiness.

Sensory neuropathy involves damage to nerve endings that provide sensation.  The result can be any number of sensations that all originate in the nerve itself, rather than from an external stimulus.  The person might feel pain, tingling, burning, itching, pins and needles, tickling, and so forth.  The variety of sensations possible likely relates partly to the degree of damage, and also to the many kinds of sensory receptors found in the body.  Different sensory nerve endings are designed to detect pain, change of temperature, vibration, touch, pressure, and so forth.

Neuropathy can follow injury, viral illness, alcoholism, endocrine disorders, certain chemotherapy drugs, diabetes, Herpes zoster (shingles), and other more elusive and undiagnosable causes.  When the cause cannot be found to direct treatment, the disorder is called idiopathic.  General symptomatic treatments are as described below for sensory neuropathic cough.

A special kind of neuropathy is becoming better known in the medical community–Sensory Neuropathic Cough or SNC.  The idea here is that nerve endings supplying sensation to the lining of the mouth, throat, larynx (voicebox), and trachea (windpipe) are neuropathic.  The resulting neuropathic tickle, dry sensation, pinprick, itching, pressure, or dripping sensation initiates a spectrum of responses, depending on urgency of the sensation.  As for that spectrum of responses:  If the sensation is subtle, the individual might only clear the throat or cough once or twice.  When extremely urgent, the sensation might initiate a violent attack of coughing lasting up to several minutes.  The most severe attacks are often associated with turning red, tearing of the eyes, running of the nose, retching or actual vomiting, and even leakage of urine or worse. In some, laryngospasm (sudden locking shut of the throat making breathing difficult and noisy for 30 to 60 seconds) may occur on occasion. After a particularly bad attack of SNC, the individual may feel exhausted; chest wall may hurt.  Public instances of this kind of coughing are humiliating.  Thankfully, many do not cough at night, but some unfortunate people are awakened several times every night to cough, and may be come sleep-deprived and “zombified.”

Treatment of neuropathy:

Treatment of neuropathy in general, and SNC in particular, is always first directed at any known ongoing cause of the neuropathy.  Otherwise, the standard of care involves use of what we call colloquially “nerve ending medicines.”  These typically come from two general classes of drugs:  seizure medications and those used for depression.  Common ones in use are amitriptyline, desipramine, gabapentin or pregabalin, citalopram, effexor, capsaicin spray, and so forth.  Often, physicians help patients work their way through a list of such medications, looking for the one that works best.  Successful treatment may mean dramatic reduction of symptoms, but not necessarily that they are completely abolished.  Some persons must remain on medication indefinitely; others whose cough is virtually abolished for at least a month may successfully taper off medication.  Even in this latter group, a subsequent URI may again “waken the monster” and necessitate resuming medication.



Nonorganic

Nonorganic is a term used to describe an apparently physical disorder that in fact is not arising from the organ or body part but from an abnormality of the use or presentation of that body part. Examples: nonorganic voice disorder, in which the larynx is structurally and neuromuscularly normal, but the sound is absent or very abnormal; nonorganic breathing disorder, tracheal, in which breathing noises made in the trachea mimic asthma; and nonorganic dysphagia, in which swallowing function is normal but factitious events occur during the voluntary phases of swallowing.



Nonorganic “asthma”

Nonorganic “asthma” is another term for nonorganic breathing disorder, tracheal (see that entry for a full definition), a disorder that mimics asthma, but is not asthma.


Photos of Nonorganic “asthma”:






Nonorganic breathing disorder, laryngeal

A nonorganic disorder in which a person’s vocal cords partially or fully close during breathing, which causes noisy breathing. Also called vocal cord dysfunction (VFD) or vocal cord dysfunction (VCD).

The fundamental disorder is not in the mechanism itself, but rather in the patient’s “use” of the mechanism. Consciously or sub-consciously, the patient inappropriately narrows the space between the vocal cords, usually for secondary gain. Unlike with asthma or nonorganic breathing disorder of the trachea, the noisy breathing is mostly heard when the person breathes in (inspiration). Still, on occasion, individuals with this disorder are treated for years as having asthma before this diagnosis is finally made.


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Videos:

Nonorganic Breathing
This video portrays a breathing abnormality that is non-organic / functional.


Nonorganic breathing disorder, tracheal

A breathing disorder, often mistaken for asthma, in which a person induces his or her trachea to narrow, causing wheezing or apparent shortness of breath. The person’s oxygen saturation remains normal, but his or her description of the problem and apparent breathing distress may be quite dramatic; in severe instances, the person may have been intubated and placed in intensive care, based purely upon the “drama”—that is, the person’s distressed appearance and audible noises. The extent of medical intervention prompted by this pseudo-asthma can be remarkable.

How it happens:

The person’s trachea momentarily narrows or collapses, but unlike with tracheomalacia, this narrowing or collapse is not due to any anatomical or physiological disorder of the person’s trachea. Instead, it can be seen as an added capability of the trachea: an unusual, heightened capability of the membranous tracheal wall to flex inward and decrease the caliber of the “pipe.” A person whose trachea has this added capability may figure out how, with inconspicuous excessive expiratory effort—a sort of semi-Valsalva maneuver that isn’t evident to observers—to induce this tracheal or tracheobronchial collapse that creates the wheezing heard by family, friends, or co-workers.

The nonorganic element:

Often, this upper airway wheezing ability can be just a personal quirk (like double-jointedness) that has no particular significance to the person’s life; think of a “wheezy laugh.” Such a case would not be a nonorganic breathing disorder case. In extreme cases, however, a person may begin to use this wheezing ability to masquerade (perhaps sub-consciously) as having asthma, in order to achieve some kind of “secondary gain”; this added element puts a case into the category of a nonorganic breathing disorder. Sometimes, the person does have asthma, but is able to markedly amplify the asthma’s apparent severity by overlaying on it this dramatic nonorganic upper airway wheezing ability.

How it is diagnosed:

If a clinician listens to this person’s breathing with a stethoscope placed over the lung fields, the wheezing can indeed sound exactly like asthma. However, there are some key diagnostic criteria that help the discerning clinician to recognize a case of nonorganic breathing:

  • The wheezing is louder over the manubrium (uppermost part of the sternum) than over the peripheral lung fields.
  • There is a surprising incongruity between, on the one hand, the person’s apparent distress and, on the other hand, his or her objective findings, such as oxygen saturation, pulmonary function tests, blood gas measurement, and so forth.
  • Potent treatments for asthma do not seem to diminish or abolish the wheezing.
  • There appears to be some kind of “secondary gain” (mentioned above). Examples of secondary gain might be simple increased attention from family, healthcare workers, and so forth, or else avoidance of school or work, or an enhancement of the chance of winning a lawsuit, or release from responsibility for losing a competitive race, or the ability to manipulate others who have high levels of empathy combined with low levels of discernment of others’ motivations.







Nonorganic Cough

A persistent cough found not to be infectious, asthmatic, irritative, neurogenic, or the result of drug side effect. Instead, this represents a behavioral disturbance that may be associated with secondary gain. Often this sort of cough is stereotypical and predictable in its manifestations; it is most often seen in young women.



Nonorganic Overlay

Nonorganic overlay refers to a situation in which a person may indeed have an organic disorder, such as laryngitis or asthma, but the symptoms and limitations of the physical condition are in a sense magnified behaviorally so that the disorder seems much more severe than it really is physically. In this scenario, there may be findings sufficient to explain mild hoarseness, but the patient is severely hoarse because of nonorganic overlay. Or, the patient may have mild asthma, but his or her case seems severe because of nonorganic overlay that amplifies the appearance of troubled breathing.



Nonorganic voice disorder

A persistent voice change found not to be infectious, irritative, neurogenic, or the result of drug side effect. Instead, this represents a behavioral disturbance that may be associated with [intlink id=”535″ type=”post”]secondary gain[/intlink]. Often the vocal phenomenology of a nonorganic voice disorder-induced voice change is stereotypical and predictable in its manifestations; it is most often seen in young women.


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Videos:

Nonorganic Voice Loss (or Functional Dysphonia)
In this video, you will see what the larynx looks like when a person with a nonorganic voice disorder makes voice, you will hear the clinician beginning to coax out the patient’s normal voice, and you will hear the patient learning to control this re-discovered normal voice.


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