R-CPD Esophageal Findings
The details of the following photos may support the R-CPD diagnosis, though they should not be considered diagnostic. Take note that all photos are non-channel scope images; that is, the scope is not able to insufflate (blow in) air. The significance: the esophagus is typically collapsed around endoscopes inserted into them and air is pumped in through a tiny channel in order to gently expand the esophagus so that its walls can be seen. Here, the air the patient cannot belch/evacuate is doing that work for us. And the esophagus remains open for extended time, the full duration of the examination. Four findings are being evaluated and compared with normal esophagoscopy images (also without insufflated air to make the comparison valid):
1) Reflux from the lower esophagus, suggesting damage to the lower esophageal sphincter from constant upward pressure trying unsuccessfully to belch.
2) What we call an “aortic shelf,” meaning that rather than an indentation of the medial circumference of the aorta, dilation of the esophagus drapes its mucosa across the upper surface of the esophagus, making a “horizontal shelf.” Keep in mind again that this is without insufflating any air.
3) Continuous patency with very infrequent, partial “clamping” down of the lumen or, often no closure at all, suggesting that there is sustained opening pressure of unbelchable air and/or that the contractile ability of the esophagus is reduced, in similar fashion to what happens to an overly-distended urinary bladder.
4) Upper esophageal dilation in a medial-lateral axis so that the upper esophagus becomes stretched in an exaggerated “oval” rather than a more gentle oval or even “circle.”
Emerging Esophageal Findings: Series of 5 photos
Abdominal Distention of R-CPD: Series of 3 photos
Dramatic Lateral Dilation of the Upper Esophagus: Series of 3 photos
Dramatic dilation of the esophagus in a person with R-CPD due to buildup of swallowed air that he cannot belch to get rid of. : Series of 2 photos
Inflammation of mucosa caused by cancer-treating radiation. Mucositis is to mucosa as dermatitis is to skin. This inflammation appears reddish with patches of greyish superficial necrosis or ulceration. Typically, radiation mucositis fully resolves four to six weeks after the last radiation treatment.
Prior to start of radiation (1 of 4)
Patient with vocal cord carcinoma, primarily of the right true cord (left of picture). This is before radiation therapy began, so there is not yet any radiation mucositis.
Radiation mucositis, 1 week after radiation (2 of 4)
One week after the end of radiation therapy. The tumor has disappeared. Radiation mucositis is evident from the patches of grey (arrows), which are superficial ulceration.
Radiation mucositis, 4 weeks after radiation (3 of 4)
Almost four weeks after the end of radiation therapy. Note that the mucositis has begun resolving, especially on the right cord (left of picture).
Recurrent Laryngeal Nerve
The recurrent laryngeal nerve is a branch of the vagus nerve that supplies nerve fibers for movement and sensation of the vocal cords. This nerve follows a long course descending from the base of the skull into the chest, where it loops around the aorta (left side) or the subclavian artery (right side), then ascends again in the neck, running posterior to the thyroid gland before entering the larynx. Injury to the nerve at any point along its course may lead to vocal cord paralysis.
Recurrent respiratory papillomatosis (RRP) and other HPV-induced lesions
A disorder in which wart-like tumors or other lesions grow recurrently within a person’s airway. These growths are caused by the human papillomavirus (HPV), and they may occur anywhere in a person’s airway, such as on the vocal cords (by far the most common site), in the supraglottic larynx, or in the trachea. If these growths are removed, they will almost always grow back, or recur; hence, “recurrent respiratory papillomatosis.”
Symptoms and risks of recurrent respiratory papillomatosis:
RRP can be life-threatening in young children, if not carefully followed and treated, since a child’s airway is relatively narrow and can potentially be obstructed completely by the disease’s proliferative growths; moreover, RRP in children tends to grow and recur more aggressively. In adults, RRP will usually only impair voice function (when the growths occur on the vocal cords), though it can also impair breathing in severe cases. Occasionally, RRP can also progress to cancer, and therefore patients found to be at high risk for this (see below) need to be monitored carefully.
Characteristics of the growths:
The growths usually associated with RRP are wart-like tumors, or papillomas, that protrude conspicuously from the surface on which they grow, often in grape-like clusters. These kinds of papillomas are usually seen in patients who have HPV subtypes 6 or 11, which are both lower-risk subtypes for incurring cancer. There are some HPV patients, however, who manifest their HPV infection with subtler, velvety growths within the airway—“carpet-variant” growths, so to speak. Although these “carpet-variant” growths do not have the wart-like appearance of the papillomas typically associated with RRP, there at least a few key points of similarity:
- Both the “carpet-variant” and wart-like growths are lesions that sometimes appear, either independently or together, in patients who have HPV;
- Both the “carpet-variant” and wart-like growths are stippled with polka-dot vascular markings, because each “loop” in the “carpet” or each “grape” in the wart-like cluster has its own fibrovascular core, seen as a red dot;
- Both the “carpet-variant” and wart-like growths can disrupt voice function;
- Both the “carpet-variant” and wart-like growths usually recur if they are removed.
Because of these similarities, we consider these “carpet-variant” growths, even when the sole expression of the infection, to be at least a cousin to RRP, within the family of HPV-induced lesions. Many patients with this “carpet-variant” condition have HPV subtypes such as 16 or 18 that are higher-risk for cancer; such patients need to be monitored with particular care.
Treatment for recurrent respiratory papillomatosis:
The primary treatment for RRP and other HPV-induced lesions is careful, conservative surgical removal of the growths. Because these growths almost always recur, surgery must usually be performed on a repeated basis, as frequently as every few weeks in children, but on average much less often in adults. A common interval between surgeries for adult patients is between every six months and every two years, depending on how quickly the RRP or other HPV-related lesion recurs and impairs the patient’s voice function again. There are also a few medical treatments that have been used in addition to surgery, including, among others, interferon, indole-3-carbinol, intralesional mumps or MMR (measles-mumps-rubella) vaccine, cidofovir, and bevacizumab.
Papillomas: HPV Subtype 11 (1 of 4)
Papillomas at posterior vocal cords, with left side (right of image) much larger than right. This patient has HPV subtype 11.
Papillomas: HPV Subtype 11 (2 of 4)
Closer view, under narrow band illumination, which accentuates the vascular pattern.
Papillomas, removed: HPV Subtype 11 (3 of 4)
Two weeks after microsurgical removal, cidofovir injection, and return of normal voice.
Papillomas: HPV Subtype 6 (1 of 4)
Papilloma, left vocal cord (right of image), standard light. Voice is grossly hoarse. This patient has HPV subtype 6.
Papillomas, removed: HPV Subtype 6 (3 of 4)
After removal and cidofovir injection, normalized larynx. Voice is normal.
Papillomas: HPV Subtype 11 (1 of 3)
Panoramic view, standard light, shows papillomas on the aryepiglottic cord, false cords, anterior face of arytenoid, and at anterior commissure. This patient has HPV subtype 11.
Papillomas: HPV Subtype 11 (2 of 3)
Closer view, standard light, shows more clearly the papillomas on the anterior face of the right arytenoid and at the anterior commissure.
Lesions of HPV Subtype ? (1 of 2)
Under standard light, faint stippled vascularity is seen, along with a general mild inflammatory response (pinkness). Patients like this are often misdiagnosed with acid reflux.
Lesions and papillomas of HPV subtype ? (1 of 8)
At initial diagnosis, as yet untyped for HPV. Multi-focal lesions on both vocal cords.
Lesions and papillomas of HPV subtype ? (2 of 8)
Narrow-band illumination and a different viewing angle better reveal the more subtle lesion on the upper surface of the right cord (dotted circle).
Lesions and papillomas of HPV subtype ? (3 of 8)
Strobe light, open phase of vibration, showing mismatch.
Lesions and papillomas of HPV subtype ?, 1 week after removal (4 of 8)
One week after removal of papillomas, voice is dramatically restored. Strobe light, open phase of vibration. Compare with photo 3.
Lesions and papillomas of HPV subtype ?, 1 week after removal (5 of 8)
Strobe illumination, closed phase. Even in falsetto, oscillatory ability is preserved due to the precise and superficial removal of the papillomas.
Lesions and papillomas of HPV subtype ?, injecting adjuvant (6 of 8)
At three weeks after removal, the patient regards his voice as normal. The patient has neither lesion nor vascular change to suggest any residual or recurrent lesion. Needle in photo (arrow) positioned to inject adjuvant medication in attempt to prevent recurrence. This procedure is done in a voice lab under topical anesthesia, not the operating room.
Lesions and papillomas of HPV subtype ?, after injecting adjuvant (7 of 8)
After both cords have been “inflated” with adjuvant medication. Note the convex, slightly blanched vocal cord margins, due to superficial infiltration of the medication.
Lesions and papillomas of HPV subtype ?, after final adjuvant injection (8 of 8)
Nearly a month later, immediately after the third and final adjuvant injection (hence the blood below the vocal cords). The patient again regarded his voice as completely normal. No sign at this early point of recurrence of papillomas or other HPV lesions. Patients with focal disease as seen in photo 1 of this series not infrequently go into long-term remission or “cure,” though it may be impossible to discern the relative roles of surgery, adjuvants, and the patient’s immune system.
Papillomas: HPV Subtype 55 (1 of 4)
Papillomas of the vocal cords, in a patient with HPV subtype 55, which is intermediate-risk for progressing to cancer.
Papillomas: HPV Subtype 55 (2 of 4)
Same exam, with narrow-band lighting, which accentuates the vascular pattern of the papillomas.
Papillomas, in remission: HPV Subtype 55 (3 of 4)
Same patient, years later, in remission, and with normal voice. No sign of papillomas here or anytime during the prior three and a half years, after meticulous removal and Cidofovir treatment.
Papillomas: HPV Subtype 11 (1 of 2)
Vocal cords, narrow band light, showing papillomas on the upper surface of the anterior vocal cords. This patient has HPV subtype 11.
Papillomas: HPV Subtype 31 (1 of 4)
Standard light, showing lesions on the vocal cords, in particular the stippled vascular pattern we call "HPV effect." The patient's voice was nearly gone, with numerous syllable drop-outs and a very effortful quality. Compare with photo 3.
Papillomas: HPV Subtype 31 (2 of 4)
Closer view, using narrow-band light to accentuate the vascular pattern of "HPV effect." Biopsy and additional testing of these lesions showed squamous papilloma with moderate dysplasia, and HPV subtype 31 was confirmed, which is high risk for eventually causing cancer. After the patient underwent several injections of cidofovir, the lesions persisted but seemed to become more indolent. On compassionate grounds, this fairly young person was then prescribed celecoxib for six months.
Papillomas, in remission: HPV Subtype 31 (3 of 4)
Three years after photos 1 and 2, standard light view. Within two months of the start of celecoxib, voice improved very noticeably, and the "HPV effect" vascularity resolved. Still, it is unknown what roles in this recovery were played by the patient's immune system, the cidofovir, and the celecoxib, respectively.
Obvious lesion not important (1 of 3)
Several months after removal of exuberant papillomas, voice remains quite good, but is becoming a little deeper. The obvious lesion here is not important; the subtle one is the key.
Granuloma (2 of 3)
Narrow band light reveals the spherical lesion to be a granuloma, not papilloma (which would have stippled vascular markings).
Papillomas: HPV Subtype 18 or 45 (1 of 2)
Papilloma growths on the right vocal cord (left of image), standard light. This patient's papillomatosis is caused by HPV, narrowed down to either subtype 18 or 45.
Lesions of HPV Subtype 16 (1 of 3)
Recurring inflammatory and leukoplakic lesions caused by HPV subtype 16. A left vocal cord cancer (right of image) was removed several years earlier, and the patient developed a right vocal cord cancer almost a year later.
Lesions of HPV Subtype 16 (2 of 3)
Slightly magnified view, focusing on the anterior (frontward) ends of the vocal cords. The cords' stippled vascularity, which often accompanies HPV infection, is more apparent here.
Cancer: HPV Subtype 16 (1 of 5)
Cancer, in a patient with HPV subtype 16. The divot and blood seen on the left vocal cord (right of image) are the result of a biopsy performed elsewhere (not by BVI physician) earlier the same day as this examination.
Cancer: HPV Subtype 16, after radiation therapy (3 of 5)
Six weeks after the end of radiation therapy, the tumor is no longer seen. However, part of the left cord (right of image) is missing, due to sloughing of the tumor that had eaten away part of the cord’s normal tissue.
Cancer: HPV Subtype 16, after radiation therapy (4 of 5)
Phonation. Strobe light, open phase of vibration, shows that the margin of the left cord (right of image) is at a lower level than the right’s, due to loss of some of the bulk of the cord where the tumor died and sloughed away.
Papillomas: HPV Subtype 45 (1 of 2)
Papillomas in the supraglottis, left of image. The pink, velvety area of papillomas is outlined by small arrows.
Mid-tracheal papilloma, being treated by thulium laser (1 of 5)
The papilloma is seen attached to the posterior tracheal wall, at the midpoint of the trachea. Note the areas of scarring from prior laser procedures. The dots seen indicate reference points for photo 5.
Mid-tracheal papilloma, being treated by thulium laser (2 of 5)
Using the channel scope, a blue glass fiber is extended from the tip of the scope.
Mid-tracheal papilloma, being treated by thulium laser (3 of 5)
In a closer view, the papilloma has been mostly cauterized using near-contact (not touching) mode.
Mid-tracheal papilloma, being treated by thulium laser (4 of 5)
The papilloma is then penetrated multiple times to deliver laser energy to its base. Some of the papilloma is pulled off by attachment to the fiber, and the remainder will slough off and be swept upwards by the mucociliary blanket (thin layer of mucus being swept upward) within the trachea.
Subtle papillomas, HPV subtype 6 (1 of 3)
After achieving a normal voice through several procedures, the patient came in for reexamination due to the return of mild huskiness. This distant panoramic view with standard illumination does not reveal any obvious papillomas.
Subtle papillomas, HPV subtype 6 (2 of 3)
At close range, using narrow band illumination, a subtle but definite HPV effect is seen. Notice the stippled vascular markings and the faintly increased pinkness at the margins of the cords, indicated by dotted lines.
Two papillomas (1 of 3)
Approximately one month after removal of papillomas and Avastin injection in a man who has battled aggressively-recurring disease caused by HPV, type 6. In this view using narrow band light, only two small papillomas are visible.
Stippled vascularity (2 of 3)
At closer range, careful inspection shows no papilloma (yet), but only the stippled vascularity typical of HPV infection.
Papilloma finding (1 of 4)
This young man had a tonsil problem and normal voice but during the initial head and neck examination was found to have a papilloma in his larynx. Rapid recurrence and spread triggered referral. Note stippled vascularity on masses along the edges of the false vocal cords.
Closed phase (3 of 4)
Under strobe light, closed phase of vibration, the true cords are seen to be uninvolved, and this explains his normal voice.
Left vocal cord lesion (1 of 8)
Middle aged woman with a 6-month history of hoarseness. Note the left vocal cord lesion (right of photo at arrow).
Narrow band light (2 of 8)
At closer range under narrow band light, the stippled vascular pattern suggests that this is HPV-related papilloma. Very tiny secondary lesions may be present at the arrow and ?
One week after removal (3 of 8)
A week after removal (and proof of HPV subtype 6), the left cord (right of photo) shows expected pinkness. The tiny lesion under the right cord (left of photo) “escaped” and appears larger but is still not a verifiable papilloma, nor is the tiny lesion on the upper surface of the right cord (left of photo) at the ?
2 months after removal (4 of 8)
Now 2 months after surgical removal of the original left cord lesion, that cord is healed and without evidence of papilloma. Voice is excellent—can pass for normal—but the tiny lesions previously seen are now verifiably flat papillomas (see stippled vascularity at arrows).
7 months after removal (5 of 8)
Now 7 months after original surgery, voice remains “almost” normal to the patient. Cord margins match well with voicing. Irregular margins are primarily due to overlying mucus.
Papilloma and mucus (6 of 8)
With abduction of the cords for breathing, a papilloma is seen below the margin of the right cord (left of photo at large arrow); the small arrows outline a peculiar “elevated” area that looks to be more than mucus the mucus seen at 'X'.
Stippled vascularity (7 of 8)
At closer range, under narrow band light, the stippled vascular marks further define the papilloma. Note normalized vasculature on the left cord (right of view) where the original papilloma was found. The “battle” of the left cord (right of photo) may have been won…
Papilloma (1 of 8)
Papilloma on right vocal cord (left of photo), proven by biopsy elsewhere. The disease has both a projecting component along with 'carpet-variant' component seen only via stippled vascular marks (within dashed line).
Stippling (2 of 8)
Closer view under strobe light; stippling is seen more clearly. Compare the stippling with the linear capillaries of the opposite cord.
One week after surgical removal (3 of 8)
One week after removal and sub typing (HPV 6) and cidofovir injection. Under narrow band light there is residual bruising but no significant stippling.
Cidofovir injection (4 of 8)
At final office-based cidofovir injection. Blood from the injection is seen, but still no stippling.
Six months after surgical removal (5 of 8)
Six months after removal, papillomas have recurred at the margin of the vocal cord, but not on its upper surface where linear capillaries have replaced stippling.
One week after second removal (6 of 8)
A week after second removal of papillomas and cidofovir injection, with expected inflammation, but no visible remaining stippled vascularity.
4 months later, healed (7 of 8)
4 months later, the vocal cord has long since healed and narrow band light is used to accentuate capillaries. No HPV effect (stippling) is seen.
Chronic hoarseness (1 of 4)
Chronic hoarseness, due to these papillomas, subsequently proven to be caused by subtype 6. Note HPV-effect vascularity.
4 months later (2 of 4)
A second surgery, 5 cidofovir injections (3 in office), and 4 months later, neither papilloma nor HPV vascular effect are seen here, under narrow band light.
8 months from start of treatment (3 of 4)
Now 8 months from the start of treatment, and 5 months since the final (office) cidofovir injection, there remains no evidence of abnormality. This view is under standard light.
"Polyps" diagnosis (1 of 4)
This patient is representative of persons initially diagnosed with "polyps," based upon a view like this one.
Papillomas (2 of 4)
Now we can see that these lesions are papillomas by the powerful visual criterion of vascular stippling aka "HPV vascular effect." Another clue of incorrect diagnosis, even with a distant view, would be the patient's non-match with the vocal overdoer syndrome.
Vascular stippling (3 of 4)
Narrow band light at the same magnification accentuates the vascular stippling. Typical papillomas indicated by arrows, and faint lines online areas of "carpet variant" papillomas.
Chronic hoarseness (1 of 6)
In this distant view, the nature of the abnormality of the right vocal cord (left of photo) is not well seen, and the lesion of the left posterior cord (right of photo) is subtle.
Narrow band light (2 of 6)
Under narrow band light, the two discrete lesions are better identified as being papillomas due to the punctate (dotted) vascular markings.
Higher magnification, narrow band lighting (4 of 6)
Back to narrow band light, to more carefully scrutinize the anterior right vocal cord lesion (left of photo).
Post-operation (5 of 6)
18 months after surgical removal and cidofovir injection, voice is excellent and there is no sign of recurrent papilloma.
Infiltrating anesthetic (1 of 3)
A 27-gauge needle tip is poised to infiltrate local anesthetic lidocaine with epinephrine into the papillomas (within dotted line) located just below the anterior commissure. In a moment, the needle will enter the papillomas at the "X".
Blanching (2 of 3)
The needle is buried and the tissue is blanching due to hydrostatic pressure of the injected fluid. The green dot is for reference with photo 3.
Obstructive papillomas (1 of 4)
This middle aged man has had lifelong RRP due to HPV 11. Primary focus of his recurrences for many years has been the trachea. Prior operative removals under general anesthesia have been challenging and recent work has used the thulium laser in an office setting. The papillomas seen here explain his mild pre-procedure stridor. His tracheal lumen should be approximately the size of the dotted circle.
Local injections (2 of 4)
A needle catheter passed through the channel of the scope is embedded at arrow, and is injecting 1% lidocaine with epinephrine (see blanched area). Numerous areas are similarly injected.
Removal of papilloma (3 of 4)
Here a large chunk of papilloma (stuck to the laser fiber at arrow) is being pulled away.
Reductionistic diagnostic model
A term used somewhat interchangeably with the technology-driven diagnostic model. Reductionism is a theory that all complex systems can be completely understood in terms of their components. Applied to voice disorders, this would suggest that we can understand every voice disorder if we can only make enough measures of various sorts. By extension, proponents of the reductionistic diagnostic model might suggest that if we do not understand a voice disorder completely by the end of a comprehensive set of measures, we need more measures! This model for voice disorder evaluation might be viewed in competition with the integrative diagnostic model used at our practice.
Redundant supraglottic mucosa
An excess of mucosa overlying one or more structures in the larynx above the vocal cords. Mucosa in this area should “fit” snugly, like leggings, but in the case of redundant supraglottic mucosa, the fit becomes more like baggy pants.
Symptoms and treatment:
This redundant supraglottic mucosa most commonly develops on the apex and posterior surface of the arytenoid cartilage. Such mucosa sometimes draws inward during breathing and fills the laryngeal vestibule. In a severe case, inspiration can become noisy (stridor) or even effortful. When symptoms like these become troublesome, the excess mucosal tissue can be removed with endoscopic laser surgery.
Redundant supraglottic mucosa vs. laryngomalacia:
Redundant supraglottic mucosa is similar to the disorder laryngomalacia. In both disorders, supraglottic tissue is pulled into the laryngeal vestibule during breathing and can cause stridor. However, the causes of these symptoms are different. In the case of redundant supraglottic mucosa, the main problem is an excess of overlying mucosa, but in the case of laryngomalacia, the main problem is that the underlying structural tissue, such as that which comprises the aryepiglottic cord and epiglottic cartilage, is abnormally weak or soft.
Redundant supraglottic mucosa: 1 week after surgery (4 of 8)
Same patient, one week after laser peeling of the redundant mucosa. The areas which were addressed include: the upper face of the arytenoid, apical mucosa, aryepiglottic mucosa adjacent to the arytenoid, mucosa from the postarytenoid surface, and even some postcricoid mucosa.
Redundant supraglottic mucosa: 1 week after surgery (5 of 8)
At the peak of rapid inspiration. The aryepiglottic cords are drawn in slightly, but the laryngeal vestibule remains widely open. Compare with photo 3.
Redundant supraglottic mucosa: 1 week after surgery (6 of 8)
Closer view of surgical details, showing that the entire posterior surface of the arytenoids has been denuded. An asterisk marks the edema at the cut edge of the postcricoid mucosa.
Redundant supraglottic mucosa: 7 weeks after surgery (7 of 8)
Same patient, now seven weeks since laser peeling of the redundant mucosa. As the patient rapidly inspires here, the laryngeal vestibule remains widely open. The patient says that she no longer feels a sense of obstruction or hears noise when breathing, even with her chin down. Compare with photos 2 and 3.
Redundant supraglottic mucosa: 7 weeks after surgery (8 of 8)
The areas that were operated on have healed. Compare with photo 6.
Redundant supraglottic mucosa (1 of 8)
This patient said that, when she breathes in (inspires), she hears noise and feels a sense of obstruction, especially if she inspires rapidly or with her chin down. She had found it necessary to use CPAP while reading with chin down, for example. Here, the patient is breathing quietly, with chin in neutral position, “looking at the horizon.” The vocal cords are abducted, the laryngeal vestibule is open, and there is no breathing noise.
Redundant supraglottic mucosa (2 of 8)
Upon request, with her head position unchanged, the patient begins to inspire rapidly. As she inspires, supraglottic tissue (of the arytenoids and aryepiglottic cords) is drawn into the laryngeal vestibule, and harsh breathing noise is heard. This indrawn tissue, which is redundant mucosa, partially obscures the view of the still-abducted vocal cords (dotted lines).
Redundant supraglottic mucosa (3 of 8)
At the peak of rapid inspiration. The vocal cords are still fully abducted (dotted lines) but almost completely obscured by the indrawn mucosa. In addition to the rushing sound, there is also a low-pitched fluttering or rumbling sound, caused by vibration of the leading edge of the indrawn supraglottic mucosa. “B” marks this blurred, vibrating mucosal margin.
See polypoid degeneration. Also known as smoker’s polyps.
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, BEFORE surgery (1 of 4)
Even during quiet breathing, the convexity of the vocal cord margins (dotted lines show where normal margins would be) reveal the presence of smoker's polyps.
Smoker's polyps, BEFORE surgery (2 of 4)
During inspiratory phonation: the polyps are drawn inward and are easier to see.
Smoker's polyps, AFTER surgery (3 of 4)
Two months after surgery, during quiet breathing. The vocal cord margins are now straight.
Smoker's polyps, AFTER surgery (4 of 4)
During inspiratory phonation: the margins are drawn into a mildly convex contour, but far less than preoperatively. The patient's voice is also much improved, albeit the occasional syllable dropouts due to recentness of surgery (listen to this patient's voice samples in the audio section of the encyclopedia entry).
Smoker’s polyp / Reinke’s edema (1 of 2)
Quiet breathing, under standard light. The edematous mucosa is not yet evident.
Smoker’s polyps / Reinke’s edema (1 of 3)
This patient is a long-term smoker, and also is talkative. Her voice has been gradually deepening for years. Here, with the vocal cords in abducted breathing position, one can only see somewhat underwhelming, broad-based, low-profile swelling, along with some hazy leukoplakia in the mid-cord.
Smoker’s polyps / Reinke’s edema (2 of 3)
Phonation. Again, there is only very low-profile, broad-based convexity of the margins, and again, the hazy leukoplakia in the mid-cords.
Smoker’s polyps / Reinke’s edema (3 of 3)
Elicited inspiratory phonation. Now, one can see that, contrary to the appearance in the prior two views, this patient in fact has moderate-sized “smoker's-type” polyps, aka Reinke’s edema. The increased mass explains the virilization of the sound of this woman’s voice.
Smoker’s polyps in various “poses” (1 of 4)
Vocal cord abduction for breathing, during expiratory phase. Left polyp (right of photo) appears to be the only finding. This is in a middle aged smoker with several years of gradually deepening / masculinized and now rough voice. The black dot and white "X" are reference points, facilitating comparisons with the other photos.
Smoker’s polyps in various “poses” (2 of 4)
At the beginning of elicited rapid inspiration, showing the polyp beginning to be displaced from upper surface to the margin. That is, previously-unseen polypoid tissue (at "X") is now indrawing from upper surface of the right cord (left of photo) as well, and margin has become convex rather than straight as it was in photo 1.
Smoker’s polyps in various “poses” (3 of 4)
The left-sided polyp (right of photo) is now displaced below the margin of that cord. The right polyp (left of photo) is now fully displaced/ indrawn to the margin of the right cord (left of photo).
Convexed vocal cords (1 of 4)
Abducted, breathing position. Note that the margin of both vocal cords is slightly convex. See dotted line for normal, perfectly straight margin
Inspiratory phonation (2 of 4)
Inspiratory phonation in-draws the mild Reinke’s edema (smoker’s type polyp formation).
Open phase, faint translucency (3 of 4)
Strobe illumination, at E4 (approximately 330 Hz), mostly open phase.
(1 of 5)
Six years after vocal polyp removal elsewhere. As a result of continued smoking, the voice is deep and rough, and an obvious recurrent/residual "smoker's" polyp is seen on the right vocal cord(arrow, left of photo). The patient "hates" her rough and masculine voice quality.
(2 of 5)
Inspiratory phonation is elicited to "pull" the redundant tissue medially, revealing a lot of Reine's edema of the left vocal cord, too. The dotted lines show the ellipse of mucosa that will be removed during surgery. Mucose will be preserved at the margins and the gelatinous lateral within the polyps will be suctioned away if liquid, and dissected away if fibrotic.
(3 of 5)
A week after surgery. The dotted lines show the extent of mucosal excision--an area that will take a few weeks to re-mucosalize. Since this was a polyp "reduction," though hoarse this early post, she has a "functional" voice. There should be no alarm if patients are aphonic for a week or even a few weeks while inflammation resolves.
(4 of 5)
At two months post, the patient is very pleased and says the improvement to voice is "large." Here, it appears there may be some residual Reinke's edema especially of the left vocal cord (right of photo) judging by the slightly convex margin.
(5 of 5)
With inspiratory phonation, the residual submucosal edema is made obvious, especially on the left. This was (as intended) a polyp "reduction" approach, rather than polyp "removal" as the latter is too hard on voice, and it is not possible to "put back" if too much tissue is taken. Here, there is no stiffness, and if desired, more can be removed. Of course, since the patient is so pleased with her voice, no further treatment is needed.
Relative voice rest
A reduction in a person’s amount and manner of voice use. When we suggest relative voice rest for patients, we sometimes tell them to think of using “vocal prudence,” or to use their voice only for the “business of life,” but not for pleasure-talking or purely social interaction. Some use a concept such as “you can talk for five minutes out of every 30.” Still others use the 7-point talkativeness scale and ask a person to be a “1” or a “2,” where 1 is “Clint Eastwood” and 7 is a life-of-the-party, highly sociable person.
Resources for R-CPD, The Inability to Burp
Here is a centralized, tabulated source of resources for patients who cannot burp, who have R-CPD (retrograde cricopharyngeus dysfunction, also known as “no-burp). After treating 550 patients (as of June, 2021), we have learned that people find useful information on a somewhat random basis. In case it helps, here is our suggested sequence, if you are just discovering what might be causing your daily misery caused by inability to burp, gurgling, bloating, flatulence, hiccups, etc.
- Watch Dr. Bastian’s YouTube video, Can’t Burp? This May Explain Why.
This is a comprehensive introduction to the major and lesser symptoms of R-CPD (Inability to burp). It is also one of the best places to begin for family and friends who are struggling to understand your condition.
- Read the initial peer-reviewed article on this condition, written by Dr. Bastian and colleague.
The x-ray image on page four shows in a glance, why persons with this condition experience such daily misery:
- Read Dr. Bastian’s additional articles:
- Partial Cricopharyngeal Myotomy for Treatment of Retrograde Cricopharyngeal Dysfunction
- The Long-term Efficacy of Botulinum Toxin Injection to Treat Retrograde Cricopharyngeus Dysfunction
- Efficacy and Safety of Electromyography-Guided Injection of Botulinum Toxin to Treat Retrograde Cricopharyngeus Dysfunction
- Check out our entry on R-CPD
- See us in the news:
- Feel encouraged by online communities:
- Watch no-burpers post-op videos on TikTok:
- Read the stories of other no-burpers:
A syndrome caused by laryngeal dystonia in which the larynx’s breathing function is affected. Laryngeal dystonia much more commonly affects the voice (spasmodic dysphonia) rather than breathing, but occasionally it affects only breathing, or both breathing and voice.
Individuals afflicted with respiratory dystonia may have difficulty inhaling air through a glottis closed by adductory spasms, or may be able to inhale without difficulty but then to find it hard to breathe out, as the victim of involuntary breath-holding.
AD SD (1 of 2)
This man has adductory spasmodic dysphonia. He also struggles to breathe because his vocal cords do not remain open as shown here when he breathes in, but instead intermittently spasm briefly to a closed or nearly-closed position, such as seen in photo 2.
Involuntarily adduction (2 of 2)
An example of an involuntary partial closure. Instead of remaining open as in photo 1, they involuntarily adduct to a partially closed position. The patient feels the sudden restriction of his ability to inspire and he also makes an involuntary inspiratory noise. An example of the phenomenology of respiratory dystonia can be heard in the audio clips below.
Retrograde Cricopharyngeus Dysfunction (R-CPD)
Inability to belch or “burp” (Also known as Retrograde Cricopharyngeus Dysfunction, or R-CPD for short) occurs when the upper esophageal sphincter (cricopharyngeus muscle) loses its ability to relax in order to release the “bubble” of air. The sphincter is a muscular valve that encircles the upper end of the esophagus just below the lower end of the throat passage. If looking from the front at a person’s neck, it is just below the “Adam’s / Eve’s apple” and more specifically, directly behind the cricoid cartilage.
If you care to see this on a model, look at the photo below. That sphincter muscle relaxes for about a second every time we swallow saliva, food, or drink. All of the rest of the time it is contracted. Whenever a person belches, the same sphincter needs to let go for a split second in order for the excess air to escape upwards. In other words, just as it is necessary that the sphincter “let go” to admit food and drink downwards in the normal act swallowing, it is also necessary that the sphincter be able to “let go” to release air upwards for belching.
People who cannot release air upwards are miserable. They can feel the “bubble” sitting at the mid to low neck with nowhere to go. Or they experience gurgling when air comes up the esophagus and is blocked by a non-relaxing sphincter. It is as though the muscle of the esophagus continually churns and squeezes without success. The person so wants and needs to burp, but can’t. Sometimes this can even be painful. Such people often experience abdominal bloating as the air must make its way through the intestines before finally being released as flatus.
For people who experience this problem to the point of discomfort and reduced quality of life, here is one approach: First, a videofluoroscopic swallow study, perhaps with effervescent granules. This establishes that the sphincter works normally in a forward (antegrade) swallowing direction, but not in a reverse (retrograde) burping or regurgitating fashion. Along with the symptoms described above, this establishes the diagnosis of retrograde-only cricopharyngeus dysfunction (non-relaxation).
Second, a treatment trial involving placement of Botox into the malfunctioning sphincter muscle. The desired effect of Botox in muscle is to weaken it for at least several months. The person thus has many weeks to verify that the problem is solved or at least minimized. The Botox injection could potentially be done in an office setting, but we recommend the first time (at least) placing it during a very brief general anesthetic in an outpatient operating room. That’s because the first time, it is important to answer the question definitively, that is, that the sphincter’s inability to relax when presented with a bubble of air from below, is the problem.
For a few months at least, patients should experience dramatic relief of their symptoms. And, early experience suggests that It may be that this single Botox injection allows the system to “reset” and the person may never lose his or her ability to belch. Of course, if the problem returns, the individual could elect to pursue additional Botox treatments, or in a truly severe case, might even elect to undergo endoscopic laser cricopharyngeus myotomy.
Photos of the cricopharyngeus muscle:
R-CPD and esophageal dilation: Series of 3 photos
Esophageal Findings: Series of 3 photos
Abdominal Distention of R-CPD: Series of 3 photos
What the Esophagus Can Look Like “Below A Burp”: Series of 3 photos
A diode pumped solid state laser made by LisaLaser of Germany, with a wavelength of approximately 2 microns. This is a very recent addition to the armamentarium of laryngology, because it allows laser energy to be delivered via a solid glass fiber. This enables use of the laser with flexible endoscopes while the patient sits in a chair, rather than requiring general anesthesia and an operating room. To our knowledge, our practice acquired the second RevoLix laser for laryngological use in the U.S.
Rheumatoid nodules are white, fibrous submucosal nodules located on the vocal cords. They are sometimes described as “bamboo nodes,” because of the medial to lateral orientation of the submucosal lesion. Rheumatoid nodules in other areas of the body (elbows, knuckles, etc.) are almost always seen in the context of rheumatoid arthritis. In the larynx, they seem to occur with other auto-immune disorders, and sometimes as the first manifestation of an autoimmune disorder, before the patient has any other symptoms besides hoarseness.
The other entity in the differential diagnosis would be an epidermoid cyst, though distinguishing between the two is usually fairly simple on visual criteria alone. The key features for epidermoid cysts is that they are spherical rather than being oriented in a medial-to-lateral direction. If an epidermoid cyst begins to leak its contents, its shape can also become oval or oblong, but the axis of the submucosal white mass is anterior to posterior. Other distinguishing features of rheumatoid nodules are that they are routinely bilateral and sometimes even multiple as seen in some of the photo series below.
Photos of rheumatoid nodules:
Woman with hoarseness (1 of 4)
Woman in middle age with very noticeable hoarseness. Standard light view not highly revealing.
White submucosal markings (2 of 4)
At very high pitch, one can see edge irregularity especially on the left side (right of photo). Note in addition faint white submucosal markings.
Submucosal lesions (3 of 4)
Under strobe light at high pitch, the medial-to-lateral white submucosal lesion on the left vocal cord (right of photo) is indicated by dotted lines. Additional mottled areas are not marked.
Remission from Crohn's (4 of 4)
At this high pitch, there is an independent vibrating segment involving the area of the brackets. A scratchy, diplophonic voice quality is heard at this pitch. Based upon these findings and additional questions, the patient revealed that she considers herself to be in remission from Crohn's Disease, after having been on Remicade and prednisone a year earlier.
Standard light, submucosal lesions seen (1 of 4)
Young middle-aged woman with chronic severe hoarseness. In abducted (breathing) position under standard light, one can see irregular margins but more importantly, whitish submucosal lesions with the classic appearance of rheumatoid nodules.
Narrow band light, accentuated capillaries (2 of 4)
Under narrow band light, the overlying capillaries are accentuated, and submucosal masses remain obvious.
Strobe light, nodules (3 of 4)
During open (breathing) position, but under strobe light, another view of these classic, multiple, medial-to-lateral “bamboo” nodules.
Submucosal mass (1 of 4)
This young woman has abandoned her strong avocational interest in singing years earlier due to chronic and apparently unresolvable hoarseness. Speaking voice can pass for normal. Consistent with submucosal pathology, her swelling checks become abruptly (rather than gradually) impaired as she sings up the scale. Even in this breathing position, the left vocal cord (right of photo) appears to have a whitish submucosal mass.
Open phase (2 of 4)
At F#4 (370 Hz) under strobe light, open phase of vibration. The lesion remains indistinct.
Much higher pitch (4 of 4)
At the much higher pitch of E5 (659 Hz), the mucosa is stretched and thinned so that the lesion is much more visible (right of photo). This is likely a rheumatoid nodule. The only other oval submucosal white lesion is an open epidermoid cyst, but the axis of the oval is always anterior-posterior rather than medial-lateral.