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

Laryngopedia By Bastian Medical Media

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Literally, “elephant skin.” Used in laryngology to refer to rough or thick mucosa. Most often seen in the interarytenoid area and is thought to be indicative of acid reflux or, sometimes, chronic bacterial infection. Pachyderma does not typically affect the voice, though the underlying cause of the pachyderma can (e.g., chronic inflammation from acid reflux or chronic bacterial laryngitis). In such a case, the true vocal cords themselves appear intensely red.

Pachyderma, caused by laryngitis sicca: Series of 3 photos

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Heaped up Mucosa (1 of 3)

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

Pachyderma (2 of 3)

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

Stippled Vascular Markings (3 of 3)

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

Acid Reflux Laryngitis

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interarytenoid pachyderma

Acid reflux laryngitis (1 of 2)

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

Acid reflux laryngitis (2 of 2)

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

Elephant skin: Series of 1 photo

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Elephant skin (1 of 1)

The namesake of this phenomenon of rough or thick mucosa: elephant skin!


A structure which serves as both the roof of the mouth and the floor of the nasal cavity and nasopharynx. The palate has two parts: the hard palate and the soft palate. The hard palate, which is the anterior two-thirds of the palate, begins just behind the upper central teeth and is made up of bone. The soft palate, which is the posterior one-third of the palate, is made up of muscle; the soft palate is therefore movable, and it elevates to help with swallowing and speech.

Palate deviation

A phenomenon in which, when the palate is lifted, the midline deviates to the normal side and the weak side droops. Palate deviation is seen in individuals who have paresis or paralysis of a hemi-palate due to Vagus nerve injury or dysfunction. It can be observed from either the oral cavity or nasopharynx view; subtle cases sometimes seem easier to see from the nasopharynx view.

Photos of palate deviation:

Palate Elevation

Lifting of the soft palate so that its edge rests against the posterior pharyngeal wall, functionally separating the nasopharynx and oropharynx. Palate elevation occurs with each swallow to keep food or liquid from entering the back of the nose. It also occurs during speech with any non-nasal sounds (in English, all sounds except for “n,” “m,” and “ng”), keeping the sounds non-nasal by keeping air from passing out through the nose.


Palate paralysis

Loss of motion of the muscle in the soft palate, so that the palate does not properly elevate. Normally, the soft palate elevates to seal the nasopharynx when swallowing or when pronouncing any non-nasal sounds (in English, all sounds except for “n,” “m,” and “ng”). However, if the vagus nerve is damaged high in its course, near the base of skull, then the palate on that side can lose its ability to lift, and it remains down during the aforementioned tasks.

A patient with palate paralysis might experience not only hypernasality (speech resonance quality resembling that heard with cleft palate) but also nasal regurgitation, especially of liquids (“water comes out my nose when I swallow”), and also nasal emissions (a slight hissing sound that comes through the nose when the person produces strong consonants).


Paralytic falsetto

See obligatory falsetto.

Paralyzed Vocal Cords

See vocal cord paralysis, unilateral and vocal cord paralysis, bilateral.

Parkinson’s Disease-Related Voice Change

Voice change that accompanies Parkinson’s disease (PD) typically has two components. One component is a change to the “inner engine” of the voice. It is as if the inner motivation or vitality of communication or voice is damped down; think of the “motor” being limited mostly to “idle” rather than “first, second, third, and fourth” gears. When coaxed or even goaded to produce more vigorous voice, a person with advanced PD may find it hard to impossible (depending upon severity) to increase loudness. If the average person can “choose” vocal loudness settings of 1 through 5, it is as though levels 2 through 5 become inaccessible to the person with PD.

A second component of PD-related voice change is that the larynx becomes weak and atrophied. This is not surprising, since any body part will tend to atrophy if it is never used in a vigorous way. The phenomenology of PD-related voice change is that the voice is overly quiet and soft-edged, and though speech does not tend to become slurred, it can lose its crispness of articulation, and the pace of speech may diminish.


Voice Building:

Voice Building (shorter version):

PCA-only paresis

Weakness or paralysis of the vocal cord’s posterior cricoarytenoid (PCA) muscle, but with normal function of the vocal cord’s other muscles. The PCA muscle abducts (lateralizes) the vocal cord for breathing. The following are indicators of PCA-only paresis:

  • Movement: The vocal cord closes normally for voicing, but it does not abduct for breathing. It remains motionless at the midline.
  • Position and appearance: Position is normal during phonation, but the vocal cord does not open (lateralize) for breathing. Because the cord does not appear to move (it adducts or closes normally, but from an already-adducted position), PCA-only paresis is often mistaken for complete vocal cord paralysis—TA (thyroarytenoid), LCA (lateral cricoarytenoid), and PCA. Key points of difference between PCA-only paresis and complete paralysis are that, in the former case, the tip of the vocal process is in a normal medial position and the vocal cord has normal bulk and tone.
  • Appearance during voicing (under strobe lighting): Completely normal, because the adductors of the cord (TA and LCA muscles) are intact. Hence, as with a normal cord, there is no flaccidity or asymmetry of vibration.
  • Voice quality: Entirely normal. Many individuals are told this is due to “compensation” of the opposite cord, but actually it is because the muscles used for voicing (TA + LCA) are intact.

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




Pedunculated, meaning attached by a stalk; the opposite of sessile.


Pemphigus vulgaris (Pemphigoid) is the result of one’s immune system attacking healthy cells in the skin rather than foreign invaders. It creates blisters or sores on the skin which are prone to rupturing and infection. Though it is a skin disease, it often has laryngeal manifestations, which can make it difficult to swallow or eat.

Bullus pemphigoid is different than pemphigus vulgaris in that the blisters do not rupture as easily, making infection less likely. It also may have laryngeal manifestations. It is, however, more rare than pemphigus vulgaris.

The cause of either disease is unknown.


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chronic low-grade sore throat

Textbook chronic sore throat (1 of 4)

This man has a chronic low-grade sore throat. Note the ulcerated areas especially along the right side of the tip of the epiglottis. Surrounding mucosa also appears erythematous. This picture is classic for laryngeal pemphigoid and visual criteria for diagnosis are extremely strong.
ulcerated areas

Closer range (2 of 4)

At closer range under narrow band light, compare and contrast the ulcerated areas (U) with the inflammatory surround (I).

Four months later (3 of 4)

Four months later, the patient has since developed “blisters” on his back. Biopsy at that site was consistent with pemphigoid. Compare this to photo 1 to appreciate that the pattern of the lesions has changed slightly as is typical for pemphigoid.
vascular pattern

Pattern at closer range (4 of 4)

At much closer range under narrow band light, the stippled “autoimmune” kind of vascular pattern is better seen.

Perimenopausal Voice Change

Perimenopausal voice change is a syndrome that seems to be related to the effect on voice of declining estrogen levels. Some women seem to escape this problem almost entirely; others experience pronounced symptoms. When severe, the affected woman will note the following: (1) upper range is either lacking, or extremely effortful; (2) there is paralaryngeal discomfort and muscular tension when she attempts to sing in the upper range; (3) there is a tendency to sing flat in the upper range. May be counteracted with varying degrees of success through vocal exercise and/or estrogen replacement therapy.

Pharyngeal deviation

Pulling of the posterior pharyngeal wall to one side, as sometimes seen when a patient performs the “pharyngeal squeeze.” This finding accompanies paresis or paralysis of the constrictor muscles of one side of the pharynx. In these cases, elicitation of the pharyngeal squeeze will reveal that the pharyngeal wall pulls to the normal (non-paralyzed) side. On the normal side, one will typically see bulging of normally functioning muscle to fill one pyriform sinus; meanwhile, the other pyriform sinus will appear capacious and almost dilated. The midline pharyngeal raphe, which joins the pharyngeal constrictor muscles, moves far to the normal side. A person with these findings normally experiences considerable swallowing difficulty, with pooling of saliva or ingested materials, particularly in the pyriform sinus on the paretic or paralyzed side.


Pharyngeal Paralysis

The pharynx (loosely “throat”) has a “foodway” function to convey food and liquid from the mouth to the esophagus. It also serves as part of the “airway,” also from mouth into the larynx and trachea. These foodway/airway functions are kept separate so food and liquid do not enter the airway towards the lungs. At the moment of swallowing, vocal cords clamp firmly together and epiglottis drops over the entrance of the larynx to divert food and liquid into the esophagus. During each swallow, lasting perhaps a second, breathing is briefly suspended. Once the food/liquid has gone by, the larynx re-opens and breathing resumes.

A thin sheet of muscle surrounds the pharynx, and squeezes to narrow the pharynx and help to propel swallowed material. That contraction lasts for approximately one second, each time the person swallows. The muscle is innervated bilaterally by the pharyngeal branch of the vagus nerve and so one side or both sides can be paralyzed by tumor, fracture at the base of the skull, viral injury, etc.

This diagnosis is often overlooked, because clinicians may not be clear on how to make the diagnosis. The best way is to obtain a clear panoramic view of the laryngopharynx as seen in the photo series below, and ask the patient to produce a very high pitch. This maneuver “recruits” contraction of the pharynx outside of the act of swallowing and allows the examiner to see clearly the difference in the contraction of the two sides. The paralyzed side is pulled to the non-paralyzed side, again as seen below.

Some with unilateral pharynx paralysis can compensate and continue to swallow (with limitations). Others are completely unable to surmount the impediment of this kind of paralysis.


A dilated outpouching from the normal contour of the pharynx.


Pharyngocutaneous fistula

The leaking of saliva outside of the pharynx (“throat” part of the swallowing passage) through a defect in the pharyngeal mucosa lining. This may occur transiently in up to 20% of persons who have undergone total laryngectomy, with the sixth postoperative day the peak time of incidence. Prior radiation therapy seems to increase the risk of fistulization.

Traditionally, the treatment was to make a midline incision directly, insert a penrose drain, and then use pressure dressings. Modern treatment uses suction drains to control salivary leakage and allow the rest of the skin flap to adhere to the neck1. Then, the drain is removed, shortened, and replaced a series of times to allow the tract to close from top to bottom.

  1. Bastian RW, Park AH. Suction drain management of salivary fistulas. Laryngoscope. 1995;105(12 Pt 1):1337-41. 

Pharynx Contraction

Contraction of the pharyngeal constrictor muscles that surround the throat. Or, the “pharyngeal squeeze.” It is the primarily the middle and inferior constrictor muscles that contract. When these muscles contract, they tense and narrow the pharynx. This action is particularly important for swallowing.

The pharynx also contracts when a person produces voice above a certain pitch in his or her range. The threshold for pharynx contraction depends in part on a person’s sex and age, and in women with peri-menopausal voice change (a condition in which they lose some capability and comfort in their upper vocal range), the pharynx will contract at a much lower pitch than otherwise expected. Thus, a clinician trying to diagnose peri-menopausal voice change can endoscopically view a patient’s pharynx and elicit different vocal tasks to see if the voice’s “muscular ceiling”—where the pharynx begins to contract—has lowered or not.


Phases of swallowing

The different phases that together make up the act of swallowing. Actually, swallowing is a rapid and seamless act, and dividing that act into distinct phases is somewhat arbitrary. But one simple scheme for the phases of swallowing, among many that have been codified, would be:

Phases of swallowing:

  1. Oral preparatory phase: food is masticated (chewed), mixed with saliva, and then “gathered” into a softened mass (called a bolus) between the tongue and palate.
  2. Oral transit phase: the bolus is sent posteriorly toward the base of the tongue. This sending of the bolus is a volitional (technically conscious) action, though it may be performed without really thinking about it.
  3. Oro-pharyngeal phase: the bolus arrives at the base of the tongue and triggers the swallow reflex, which is non-volitional, or automatic.
  4. Pharyngeal phase: the bolus travels down from the base of the tongue past the closed and elevated larynx and to the entrance of the esophagus. This is a continuation of the automatic swallow reflex.
  5. Esophageal phase: the cricopharyngeus muscle relaxes to allow the bolus into the upper esophagus, from where it is passed downward by waves of muscle contraction through the lower esophageal sphincter (LES) and into the stomach. All of the muscular action in this phase is also non-volitional.

Swallowing Trouble 101
This video gives an overview of how swallowing works, how it can sometimes go wrong (presbyphagia or cricopharyngeal dysfunction), and possible ways to treat those problems (swallowing therapy or cricopharyngeal myotomy).


Phonation is the process of making vocal sound by bringing vocal cords together while a stream of pulmonary air passes between them, causing them to vibrate. Roughly, this means to “make voice.”

Phonatory Arrest

A phonatory arrest is a manifestation of spasmodic dysphonia, a part of its phenomenology, in which the voice suddenly “chokes off” in the middle of an intended sound, causing a brief instant of silence before the voice starts again.

Phonatory gap

When the vocal cords fail to close during phonation. A phonatory gap may be seen in patients who have muscle tension dysphonia, vocal cord paresis or paralysis, loss of tissue, or vocal cord flaccidity.

In addition, however, a phonatory gap occasionally occurs in patients who have none of the above conditions. In this type of case, the patient will struggle with onset delays, but delays that “pop” followed by relatively clear voice rather than the scratchier or hoarser-sounding onset delays associated with vocal cord mucosal swelling. Also, if asked to perform our vocal cord swelling checks, such a patient will tend to struggle more with the “Happy birthday” task than the descending staccato task (the opposite is true for patients with mucosal swelling).


Phonatory insufficiency

When the vocal cords cannot close sufficiently or vibrate adequately to produce a serviceable voice. An inability to close is usually evidenced by air-wasting phenomenology.

This phonatory insufficiency could have one of several causes. It could be due to the loss of part or all of one or both vocal cords, such as after removal of a vocal cord cancer. Or it could follow prolonged intubation and resulting pressure necrosis of the posterior ends of the vocal cords 1. Another possibility might be scarring of the anterior joint capsule of the cricoarytenoid joints, also as a complication of prolonged endotracheal intubation due to grave illness. Yet another cause might be vocal cord paralysis or paresis. The latter problems not only interfere with the cords’ ability to close, but also make the affected cord flaccid, so that it blows out of the way too easily, further wasting the air stream.

When a person with any of these causes of poor vocal cord closure tries to produce voice, maximum phonation time is typically reduced, because only a fraction of the air pushed up from the lungs is converted to sound, with the remainder of the air quickly “wasted.”

The second main category of phonatory insufficiency, in which the vocal cords cannot vibrate adequately, is seen in a person with stiff or scarred vocal cords. Such a person may not waste air, but just be unable to produce other than a harsh whispery sound, because the stiffened vocal cords (now more like thick leather rather than like, as is normal, plastic wrap overlying a thin layer of jello) cannot vibrate as freely or at all.


  1. Bastian RW, Richardson BE. Postintubation phonatory insufficiency: an elusive diagnosis. Otolaryngol Head and Neck Surg. 2001; 124(6): 625-33. 

Pill dysphagia

Difficulty or inability to swallow pills. For some individuals with pill dysphagia, swallowed pills may tend to lodge in the person’s vallecula, due to presbyphagia. For others, swallowed pills may tend to lodge at the level of the cricopharyngeus muscle, due to cricopharyngeal dysfunction. Yet other individuals may experience pill dysphagia from childhood, perhaps due in part to fear, such that the person cannot commit to swallowing a pill without gagging at the prospect.


Where voice is concerned, pitch refers to the highness or lowness of a tone, perceived through the sense of hearing, that correlates with the [intlink id=”331″ type=”post”]fundamental frequency[/intlink] or rate of vibration of the vocal folds.

Polypoid Degeneration

Diffuse swelling of the vocal cords, due to build-up of edema fluid within the mucosa. Polypoid degeneration is also referred to as Reinke’s edema or smoker’s polyps. This condition is most often seen in long-term smokers who are also somewhat talkative. In other words, polypoid degeneration is rare in talkative non-smokers and also rare in taciturn smokers.

Symptoms of polypoid degeneration:

Polypoid degeneration tends to virilize (masculinize) the quality and capabilities of the voice, and this effect is most noticeable in women. Also, in more severe cases, polypoid degeneration can induce involuntary inspiratory phonation or a fluttering, almost snoring sound during sudden inhalation.

Appearance of polypoid degeneration:

Polypoid degeneration typically appears as pale, watery bags of fluid attached to the superior surface and margins of the vocal cords. In less severe cases, the swelling might be more subtle, but if the patient is instructed to inhale while making voice, then the polypoid tissue will be drawn away from the cords into the glottic aperture, giving each vocal cord margin a convex contour and thereby becoming more noticeable (see two such examples in the photos below).

Treatment for polypoid degeneration:

The patient is encouraged to give up smoking. Short-term voice therapy can help in some cases, reducing the turgidity of the polypoid tissue and thereby improving the voice to a small but noticeable extent. However, the polypoid degeneration itself is permanent, so if the voice quality remains unacceptable to the patient even after voice therapy, then surgery is necessary.

For surgery on polypoid degeneration, it was once common to strip away the polypoid tissue, but this approach often leads to an unacceptably high-pitched, thin-sounding, and husky voice. A better method is to reduce the tissue more conservatively, potentially leaving some fractional residual polypoid tissue. This way, although the voice might remain mildly virilized, it also retains a richer and more effortless quality.

Audio with photos:

Voice sample of a patient with smoker’s polyps, BEFORE surgery (see this patient’s photos just below):

Same patient, two months AFTER surgery (the occasional syllable dropouts are due to the recentness of surgery):



Smoker’s Polyps (aka Polypoid Degeneration or Reinke’s Edema)
This video illustrates how smoker’s polyps can be seen more easily when the patient makes voice while breathing in (called inspiratory phonation). During inspiratory phonation, the polyps are drawn inward and become easier to identify.


Pontocaine is the chemical name for the most common topical anesthetic used at our practice to anesthetize the nasal passage in preparation for passage of the flexible videoendoscopy or fiberscope. When applied topically, pontocaine numbs the mucosa for between 15 and 30 minutes.


Pooling occurs when a person’s swallow does not successfully send the entire mass of food or liquid into the esophagus, so that some or all of the material remains in the hypopharynx. In such cases, the material commonly pools in the vallecula and pyriform sinuses. It can also cling to the base of the tongue or the pharyngeal walls. Pooling is often caused by presbyphagia, and its occurrence may put a patient at risk of aspiration.

Popping Onset

A popping onset refers to the sudden start of the voice after a little hiss of air, but once the voice begins, it is very clear. It doesn’t sound like laryngitis, or scratchy like one would hear after a nodule popping onset.

Positive/ Negative Practice

This behavioral treatment is prescribed primarily for patients with nonorganic voice disorders. A patient with a nonorganic voice disorder has been diagnosed with aberrant voice production due to the abnormal use of a normal mechanism, often due to stress or some sort of secondary gain. She or he may have been ‘stuck’ with the abnormal voice for months to years, or may lurch between normal and abnormal voice production on an apparently involuntary basis. To help patients first “find” their normal voices, the clinician guides the patient through a variety of vocal elicitations such as: a yell, glissando, siren, or vocal fry. All of this may be with or without clinician digital manipulation of the laryngeal framework.

After preliminarily ‘settling in’ the patient’s reestablished normal voice, the clinician quickly asks the patient to alternate between the re-established normal voice and the old abnormal voice. First, the patient alternates upon clinician cue, again optionally with or without digital manipulation, and then the patient demonstrates the ability to switch between the two kinds of voice production at the sentence level, and then every few words, and then word-by-word. The positive and negative practice demonstrates mastery / control over the abnormal/ nonorganic voice production.

If possible, this process should occur with patient, clinician, and family/ friends in attendance. Other doctors, speech pathologists, pulmonologists, and allergists who may have previously attempted to help the patient using medical rather than behavioral treatments should also be made aware of the nature of the patient’s diagnosis, the purely behavioral approach to it, and the idea that behavioral intervention to resolve this problem completely should not normally exceed three visits to a speech pathologist, to avoid his or her becoming a co-dependent or source of secondary gain.

Listen to a few demonstrations below:

Post-Radiation Telangiectasia

Atypical dilation or formation of capillaries (typically seen in the laryngopharynx) as a mid- or long-term response to radiation. These are a benign but sometimes impressive-looking tissue change. Often, post-radiation telangiectasia does not appear until a year or more following the end of the course of radiation.


Post-surgical laryngitis

Post-surgical laryngitis is inflammation of the larynx, not from infectious organisms, but from irritation caused by a surgical procedure. By analogy, think of the redness around a knuckle that has an abrasion but is not infected. Post-surgical laryngitis is typically transient and lasts only a few days following surgery. A typical time of recovery after nodule surgery is about four days, which explains why the suggested time of complete silence after surgery is four days, with gradually increasing amounts of voice use beginning on postoperative day four or five.

Post-swallow hypopharyngeal reflux

Refers to when, shortly after a person swallows, some swallowed material returns from below the esophageal entrance back up into the hypopharynx. This finding is an almost certain diagnostic indicator of cricopharyngeal dysfunction, usually with an associated Zenker’s diverticulum.

If this reflux occurs during a videoendoscopic swallowing study, the clinician will see that, though there may be little to no hypopharyngeal residue immediately after the swallow, a moment later some swallowed material (e.g., blue-stained applesauce or water) reappears and wells up in the post-arytenoid area and into the pyriform sinuses. If this reflux occurs during a videofluoroscopic swallowing study, the clinician will see barium remaining in the Zenker’s sac and, immediately after each swallow, moving back upward into the hypopharynx.



Toward the back side of a person’s body. For example: the heel is posterior to the toes. The opposite of anterior.

Posterior Commissure

The flat, front-facing surface of the glottic aperture that lies between the vocal cord posterior ends. When the vocal cords are in abducted (breathing) position, the posterior commissure is at its widest, since the cords’ posterior ends are spread furthest apart from each other. When the vocal cords have come together into adducted (voicing) position, the posterior commissure is essentially just the point of contact between the posterior ends of the cords.

In individuals who have acid reflux or other inflammatory conditions, the mucosa at the posterior commissure may thicken (pachyderma).

See also: anterior commissure.

Posterior commissuroplasty

An endoscopic procedure performed for individuals who have difficulty breathing, due to either bilateral vocal cord paralysis or bilateral vocal cord fixation. These individuals’ vocal cords are immobile or fixed in a mostly closed position, which inhibits breathing and often causes noisy inspiration.

In a posterior commissuroplasty, the clinician uses a carbon dioxide laser to take small divots from the posterior ends of both vocal cords. These divots create more space between the cords so that, during breathing, air can pass through more easily. This procedure can avoid the need for a tracheotomy. It also preserves the voice’s functionality better than a transverse cordotomy typically does.


Posterior Pharyngeal Wall

The posterior pharyngeal wall is the back wall of the swallowing passage. The upper part of the posterior pharyngeal wall can be seen when one looks through an opened mouth, beyond the soft palate, uvula, and tonsils. There is a layer of mucosa, then muscle, and then the bodies of the cervical vertebrae.

Postoperative Voice Use

Voice Use Following Vocal Fold Micro-Surgery in Singers

During the first 4 days following surgery–NO TALKING. During this time communicate instead using a dry erase board, pencil and paper or sign language. You may attempt to do gentle “gliding sounds” throughout your range every few hours for a few seconds, of course expecting to be hoarse! Your surgeon or speech pathologist will demonstrate what is meant by this. Day 4 following surgery (which begins week one of voice use): you may begin limited voice use according to the table below:

Note that we use a 1 through 7 scale to designate amount of talking. On this scale, 1 = someone who is quiet, introverted, and says little. 7 = someone who is sociable, extroverted, and who by nature talks a lot.

Quality of Talking Quality of Singing (if you sing)
WEEK ONE (days 4 through 11)
Be a “2.” This means minimal voice use to get the “business of life” done. Perhaps 5 minutes of talking for any 30 minute period of the day.
Vocalize gently 5 minutes twice a day. Begin to establish baseline for your “swelling tests.” (If needed, see also instruction sheet on this subject.)
WEEK TWO Be a “3.” Simple conversations. Up to 10 minutes within A 30 minute period. Vocalize gently up to 15 minutes twice a day. Be sure to check “swelling tests” at least 2 x per day.
WEEK THREE Be a “4.” Limit talking to 15 minute stretches with a 15 minute rest period. Vocalize up to 20 minutes three times per day. Swelling tests!
WEEK FOUR Be a “5.” Near-normal amounts of voice use but continue to beware of overdoing it! Twenty minutes of talking should be followed by some “down time.” Vocalize/sing up to 30 minutes 3 x per day.
WEEK FIVE Continue to use voice at near-normal amounts, but with a sense of prudence and caution in noisy environments. Begin to resume normal rehearsal and practice schedule, but not exceeding 90 minutes per day. It is critical that you perform swelling tests every morning and evening and compare to your baseline performance of these tasks.
WEEK SIX and beyond PUBLIC PERFORMANCE MAY RESUME Normal rehearsal and practice schedule. Continue twice-daily swelling tests, especially if you are innately a “six” or “seven.”


Literally, “old age larynx.” The term presbylarynx is used to signify vocal cord changes (and, by extension, vocal limitations) that accompany aging. Typically, these vocal cord changes include bowing of the cords, atrophy, flaccidity, and sometimes reduced wetness and lubrication of the vocal cords. The symptoms of these changes include foggy or weak voice quality, difficulty being heard in noisy places, and decreased vocal endurance.

Such findings are by no means universal in older individuals, however, and some of these changes may be resisted with vocal conditioning exercises. Moreover, some “presbylarynx” changes can be seen in individuals who are only 40 or 50, due to disuse of the voice or familial predisposition. For these reasons, presbylarynx does not seem to be a very useful term; instead, a precise description of the patient’s vocal cords seems to be more useful.



Presbyphagia is a term used to describe swallowing difficulty of the sort that can be associated with the aging process: the process of swallowing as a whole is inefficient and reduced in vigor. Common findings include globally (as opposed to focally) reduced muscle bulk, often seen in vocal cords and not just pharyngeal wall musculature; globally reduced strength of contraction of the pharynx; and tendency for retention or pooling of a part of swallowed food or liquid in the vallecula or pyriform sinuses. Presbyphagia may be associated with cricopharyngeal dysfunction and, when severe, aspiration.


Swallowing Trouble 101
This video gives an overview of how swallowing works, how it can sometimes go wrong (presbyphagia or cricopharyngeal dysfunction), and possible ways to treat those problems (swallowing therapy or cricopharyngeal myotomy).


Literally, “old age voice.” See also presbylarynx. As with presbylarynx, to describe precisely the voice’s capabilities, limitations, and aberrations seems much more useful than to use this term.

Primary Treatment

Primary treatment refers to the first or main treatment of a condition. Example: An individual with larynx cancer may have surgery as primary treatment; later, radiation therapy might follow as an additional treatment.

Projected voice

A voice that is perceptibly “thrown” or “called out,” as when talking to a group of 20 or more people. A clinician might ask a patient to project the voice during the vocal capability battery in order, for example, to reveal weakness not evident or only slightly apparent at normal speaking voice volume, to detect vocal inhibition, or to unmask a nonorganic voice disorder.


A disorder that mimics asthma but is not asthma. One such disorder is nonorganic breathing disorder, tracheal.


Puberphonia is the inappropriate persistence of higher-pitched prepubertal voice long after puberty and normal voice change. Also called mutational falsetto. Such individuals maintain something like their high-pitched, childhood voice by speaking in falsetto register.

The cause of puberphonia is never known with precision. Some think the condition arises more often in men whose voices mutate to the normal and mature male quality suddenly and precipitously, dropping abruptly into the bass or bass-baritone range. It is as though the person isn’t given time to adapt to the new sound of the voice. Some individuals with puberphonia can produce normal voice on request, but consider it “ugly,” or even their “monster voice.” Others need considerable coaching to find the normal voice. Once convinced by voice experts that the “monster” voice actually sounds great and is the “normal” one, most individuals can adopt the new voice fairly rapidly. The process of normalization typically involves only two or three sessions of speech/voice therapy, provided the therapist is highly experienced and voice therapy-qualified.


Falsetto vs chest registers at the same pitch—this is worth careful study: Series of 6 photos

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Falsetto register (1 of 6)

A 20-something man with puberphonia. Here, in distant view, he is in falsetto register at F#3 (185 Hz). His low falsetto is, by the way, remarkably stable and capable. Compare the vibratory blur with the next photo.
Firmer closure

Chest register (2 of 6)

At virtually the same pitch, but now in chest register. Firmer closure (and longer closed phase of vibration explains the more-adducted blur as compared with photo 1.
Falsetto, open phase

Falsetto, open phase (3 of 6)

Now back to falsetto register under strobe light, and with better magnification. This is open phase of vibration also at F#3. Note the single, thinned "leading edge" of each fold.
Falsetto, "closed" phase

Falsetto, "closed" phase (4 of 6)

Closed phase at the same pitch isn't in fact fully closed, and the "closed" phase of vibration is also shorter than in photo 6.
Open phase of vibration

Chest, open phase (5 of 6)

Open phase of vibration at the same pitch, but in chest register. Note the fatter, grey vocal cord margin. Compare with photo 3.
Closed phase

Chest, closed phase (6 of 6)

Closed phase still in chest register is fully closed and it takes longer for the vocal cords to part for the next vibration; that is, the closed phase of vibration is longer. Tighter closure and longer closed phase explain why the blur between the cords seen in photo 2 is different than in photo 1.

Pulmonary function tests (PFTs)

A set of tests that evaluate the mechanical and functional capabilities of the lung and airways. PFTs may non-invasively investigate breathing problems, establish severity, assess risk for general anesthesia, and help determine whether a patient is a candidate for conservation cancer surgery.

Pulse register

Vocal fry is the name given to a quality of sound produced at low pitch (generally below 90 Hz, or around E2 or F2 in musical notation). Vocal fry is produced in what some call pulse register, as compared with chest and falsetto registers.

Pyriform sinus

Pyriform sinus refers to the pear-shaped fossa (Latin for “trench”) just lateral to the laryngeal entrance. Its medial surface is the aryepiglottic cord; laterally it is bounded by the thyroid cartilage, and posteriorly by the low posterior pharyngeal wall. The pyriform fossas and post-arytenoid area together constitute the “swallowing crescent,” which channels swallowed material just before it enters the esophagus, behind the larynx.

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