A closed sac originating from a formerly open and functioning laryngeal saccule. An analogy for a saccular cyst is a velvet bag used to hold coins which has its opening cinched shut by a drawstring. The mouth of the saccule becomes blocked, and mucus secreted within the saccule cannot escape through the normal opening in the anterior ventricle. This closed sac gradually expands, causing the false cord and aryepiglottic cord to bulge; the sac can further expand over the top of the thyroid cartilage and into the neck.
Anterior Saccular Cyst, before and after Removal
20 Years after Saccular Cyst Removal!
Anterior Saccular Cyst
Bilateral Anterior Saccular Cysts
Removal of Lateral Saccular Cyst, Endoscopic Approach
Removal of Lateral Saccular Cyst, External Approach
Lateral saccular cyst, external approach: Series of 1 photo
Saccular Cyst with Extensive Oncocytic Metaplasia
Polyp or Cyst?
Anterior Saccular Cysts, Swellings, and Mucus: What’s the Main Issue?
Anterior Saccular Cysts as Incidental Finding
A sarcoma is a malignant tumor that originates in mesenchymal tissue. Mesenchymal tissue comprises muscle, bone, fat, connective tissue, blood vessels, and cartilage. If, instead, a malignancy originates in lining or covering tissues—which includes skin, bronchial tubes, the lining of the mouth, throat, and gastrointestinal tract, and breast and salivary gland ducts—then that tumor is called a carcinoma.
Carcinomas are far more common than sarcomas, and sarcomas involving the larynx are rare, with chondrosarcoma (“chondro-” refers to cartilage origin) heading the list. The clinicians at our laryngology practice have seen hundreds of carcinomas in their career, but probably no more than 20 sarcomas.
Photos of Sarcoma
Refers to fibrous tissue that remains after healing of an injury. In laryngology, leaving trauma out of the picture, scarring is most often seen in the context of surgery, radiation, or prolonged use of an endotracheal tube. If a wound is created, such as after removing a superficial vocal cord cancer, the tissue that results after complete healing is not as flexible as normal tissue would be; the scarred area typically does not vibrate well, or at all. Sometimes progressive fibrosis occurs after radiotherapy. It is thought that the reduced blood supply and lowered tissue oxygen level caused by radiation damage to microvasculature leads to the gradual replacement of tissue with fibroblasts, because they can tolerate lower tissue oxygen levels.
Breathing Tube Injury—A Rare Complication of Intubation for General Anesthesia
Conclusion: While we try to explain abnormality due to one cause, here, the patient has a mucosal injury and paresis of right TA and LCA muscles, which can also follow intubation. This explains why the initial postop voice was so weak and whispery, and also the rapid partial improvement. This voice will likely continue to improve and be very functional as a speaking voice. Fortunately, this person is not a singer, as clarity especially in upper notes, will likely be remain impaired even after full recovery.
Advantage gained from holding on longer than necessary to an illness—be it organic or nonorganic. At our practice, the phenomenon of secondary gain is most commonly seen in nonorganic voice and breathing (tracheal or laryngeal) disorders. An example might be that a person consciously or subconsciously maintains “laryngitis” after the initial organic infection has resolved, for the secondary gain of being excused from school or work. In this case the loss of voice is “worth it” as compared with the “gain” achieved. The secondary gain may have to do with attention, avoiding a responsibility, punishing or controlling another person, or possibly other issues.
Sedation is a state of reduced excitement or anxiety induced by the administration of sedative agents such as lorazepam (Ativan) and diazepam (Valium). At our practice, we occasionally administer lorazepam, given orally a couple of hours before a procedure, to allay anxiety.
In the normal larynx, segmental vibration occurs when both chest and falsetto (head) registers are produced by vibration of the anterior 2/3 of the vocal cords. The posterior 1/3 is “inhabited” by the arytenoid cartilage and does not vibrate.
In certain pathological circumstances such as displayed in the photo sequences below, only a small part of the vocal cords vibrates.
This segmental vibratory phenomenon is typically seen in vocal cords that are damaged—such as by vocal nodules, polyps, cyst, scarring, etc. In such persons, upper voice is typically particularly impaired, until, as the person continues to try to ascend the scale, suddenly a crystal-clear “tin whistle” kind of voice emerges and may continue upwards to very high pitches.
Some in the past have talked about flagelot, flute, bell, or whistle register. We suspect that this was in the days before videostroboscopy and at least in some cases may have been segmental vibration.
The best way to determine if what sounds like a “tin whistle” upper voice extension is due to segmental vibration is by videostroboscopic examination during that kind of phonation. The other way is for the individual to produce their “tin whistle” kind of voice very softly and then try to crescendo. If full length vibration, smooth crescendo will be possible. If segmental, there will be a sudden “squawk” as the vocal cords try to go (unsuccessfully) from segmental to full-length vibration.
Segmental Vibration Compared to Full-length
Whistle Register or Tin-whistle Segmental Vibration?
Search not Only for Nodules, but Also for Segmental Vibration and Look at the Posterior Commissure for MTD
Sulcus and Segmental Vibration
Open Cyst and Sulcus; Normal and Segmental Vibration
Tiny Vibrating Segment Gives Tiny Tin Whistle Voice
Sensory Neuropathic Cough
A chronic cough disorder that is thought to have a neurogenic cause. Sensory neuropathic cough (SNC)1 is also sometimes referred to as a cough caused by “laryngeal sensory neuropathy,” or is sometimes grouped within the more general category of “refractory chronic cough.”
Symptoms of sensory neuropathic cough:
A person with SNC may cough dozens to hundreds of times per day, often also waking up at night to cough. A few of these daily coughing attacks may become violent and last 30 seconds to several minutes. The person’s eyes may tear up and the nose may run; the person may gag or throw up; the person may leak urine, or worse; a few of our patients have even broken one or more ribs during a violent coughing attack.
A key characteristic of SNC is that a coughing attack is typically, though not always, preceded by an abrupt sensation in the throat; this sensation may be described as a “tickle,” a “sudden dry patch,” “like inhaling a powdered doughnut,” “dripping mucus,” or something else.
Possible explanation for sensory neuropathic cough:
SNC is thought to be a relative to neuralgia, like post-herpetic neuralgia (persistent pain long after an outbreak of shingles has resolved), or even diabetic neuropathy (“I feel bees stinging my feet”), except that the sensations felt by SNC patients are not painful. With SNC, it may be that the nerve endings in a person’s throat have become damaged, so that they “misfire” and cause this cough-provoking tickling or similar sensations.
Treatment for sensory neuropathic cough:
These kinds of medications may help to reduce or abolish a person’s coughing by diminishing the nerve-ending “misfires” caused by SNC. In our experience, patients sometimes need to work through more than one of these neuralgia medication options, at varying dosage levels, before they arrive at a satisfactory degree of relief. Another treatment option that can be tried is capsaicin. For more about treatment, see our second video below.
Interview with a SNC patient:
Second interview with a different SNC patient:
SNC and throat clearing of 36 Years’ duration:
Fourth interview with a different SNC patient:
SNC cough phenomenology: different than that of pneumonia, asthma, or acid reflux!
Note: Some aspects of these patient’s experiences are atypical; not every patient has the same experience with SNC.
Bruise caused by cough: Series of 2 photos
Bruising from sensory neuropathic cough
Vocal cord bruising from coughing
Bastian RW, Vaidya AM, Delsupehe KG. Sensory neuropathic cough: a common and treatable cause of chronic cough. Otolaryngol Head and Neck Surg. 2006; 135(1): 17-21. ↩
Jeyakumar A, Brickman TM, Haben M. Effectiveness of amitriptyline versus cough suppressants in the treatment of chronic cough resulting from postviral vagal neuropathy. Laryngoscope. 2006; 116: 2108-2112. ↩
Bastian ZJ, Bastian RW. The use of neuralgia medications to treat sensory neuropathic cough: our experience in a retrospective cohort of thirty-two patients. PeerJ. 2015; 3:e816. ↩
Ryan NM, Birring SS, Gibson PG. Gabapentin for refractory chronic cough: a randomized, double-blind, placebo-controlled trial. Lancet. 2012; 380(9853): 1583-9. ↩
Attached completely at the base and without an intervening stalk; the opposite of pedunculated.
Shattered vibration is a chaotic kind of vibration in which there may be several independent segments vibrating erratically to create a characteristic sound quality. May be seen, for example, in an individual who has vocal cords that are not symmetrical with respect to vocal cord mass, flaccidity, and tension, and that are not “of one piece” within themselves, so that a fold may have two different vibratory patterns within itself.
The cycle-to-cycle variability of the period amplitude of vocal cord vibration. Shimmer is used as one of the measures for the micro-instability of vocal cord vibrations. Given that shimmer may vary dramatically with changes of voice production within the same voice, and also that a given shimmer measurement is non-specific to any particular voice disorder, this measure is considered superfluous to the integrative diagnostic model. Shimmer is therefore not used routinely at our practice.
A highly inert silicone rubber that has wide use for medical applications. The term silastic comes from the combination of the words silicone and plastic.
Laryngologists commonly place silastic implants into flaccid, paralyzed vocal cords in order to plump and firm them up so that they can serve as better partners to the non-paralyzed cord. See also: medialization laryngoplasty.
Extrusion of Vocal Cord Implant
Singing voice qualified
Singing voice qualified, when used to refer to a speech pathologist or physician, means that the clinician has personal knowledge of the expected phenomenology and capabilities of the voice, including those only encountered in the singing voice. Typically, this kind of qualification comes from personal voice training and singing experience on the part of the clinician.
Single Modality Treatment
Single modality treatment refers to a situation in which only one treatment modality is chosen from among several options available for that disease process. This is in contrast to combined modality treatment or even multi-modality treatment.
An uninterrupted sound that begins very low in a person’s vocal range and ascends to a very high pitch, sometimes the highest possible pitch that person can produce. A single siren could also go from low to high and back to low one or more times without interruption. A clinician might ask a patient to perform a siren during the vocal capability battery in order to assess pitch range capability or even vocal skill.
SLAD-R (Selective laryngeal adductor denervation-reinnervation). This procedure was introduced by Dr. Gerald Berke of UCLA in the late 1990’s. It is a surgical option for adductory spasmodic dysphonia. The concept is to sever the anterior branch of the recurrent laryngeal nerve. This denervates the spasming laryngeal adductors (particularly thyroarytenoid and lateral cricoarytenoid muscles). The squeezed, strained quality and/ or “catching, cutting out, stopping” of the voice are replaced initially with an extremely breathy and weak voice. This initially weak voice is analogous to what one might sound like after a Botox injection that is far too high a dose. To return strength to the voice, a branch of the ansa cervicalis nerve that normally supplies some relatively “unimportant” neck muscles is anastomosed (connected) to the severed nerve. It takes 3 months to a year for tone to begin to return to the adductory muscles. Since the “unimportant” neck muscles were not affected by the dystonia, the hope is that the new nerve supply to the laryngeal muscles may not be affected by dystonia.
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 and after Surgery
Smoker’s Polyps / Reinke’s Edema
Smoker’s Polyps with Leukoplakia
Smoker’s Polyps / Reinke’s Edema
Smoker’s Polyps in Various “Poses”
Smoker’s Polyps and Thulium Laser
Reinke’s (smoking-related) edema and how to see it: Series of 4 photos
Smoker’s Polyps with Two Explanations for Bruising
Smoker’s Polyp Reduction Improves Voice Even Though the Larynx Result May not be “Pretty”
Spasmodic Dysphonia: Definition and Treatments
A non-life-threatening neurological disorder in which the muscles of the larynx involuntarily spasm and interfere with the voice. Spasmodic dysphonia (SD) is a focal dystonia, in this case involving the larynx—i.e., laryngeal dystonia. Laryngeal dystonia typically affects the voice, but can occasionally also affect breathing (respiratory dystonia). The term spasmodic dysphonia refers specifically to voice-affecting laryngeal dystonia.
Adductor vs. abductor:
There are two main variants of spasmodic dysphonia (SD). In the first variant, adductor SD (AD-SD), the vocal cords are pressed together excessively, intermittently cutting off words or giving the voice a constant strangled quality; this variant comprises 90% of the cases of SD. In the second variant, abductor SD (AB-SD), the vocal cords are abruptly and momentarily pulled apart while talking, causing the voice to drop out completely or down to a whispery, breathy sound. There are some cases in which a person has both of these variants: this is called mixed AB-AD SD.
Classic vs. tonic:
Another distinction that can be made is between classic variant and tonic variant cases of SD. In classic variant SD, the spasms cause phonatory arrests—that is, while the person is speaking, intermittent words or syllables are choked off (with AD-SD) or drop out (with AB-SD). In tonic variant SD, the spasms are more continuously sustained, so that the voice continuously sounds either strained (with AD-SD) or breathy (with AB-SD), but without any actual phonatory arrests. Because the presence of phonatory arrests is the symptom most often associated with SD, tonic variant SD goes undiagnosed or misdiagnosed far more frequently than does classic variant SD.
Treatment for spasmodic dysphonia:
There is no definitive “cure” for SD, but for most patients, periodic injections of Botox™ into the muscles of the larynx help a great deal, if there is optimal dosage and placement. These injections relax the malfunctioning muscles of the larynx, thereby minimizing the spasms and their impact on the voice. The effect of an injection typically lasts a few months, and then another injection is needed. For those having difficulty getting good results with Botox™ therapy, see our video below “Spasmodic Dysphonia: When Botox Disappoints.”
The leading surgical treatment currently offered for SD, Selective Laryngeal Adductor Denervation-Reinnervation, can be an option for individuals with the AD-SD variant. However, no treatment for SD works satisfactorily for all. The history of each of the several surgical treatments for SD always includes some failures.
Speech therapy is another treatment sometimes suggested for SD. While there are strong and even passionate individual proponents of speech therapy, the consensus view is that speech therapy is not expected to substantially improve the voice’s capabilities or reduce spasms other than perhaps in the therapy room1. A brief course of speech therapy can be very helpful for patient education and perhaps a search for sensory tricks. Much confusion surrounds this subject, because individuals who have a nonorganic voice disorder can be mistakenly diagnosed with SD, and nonorganic voice disorders are routinely “cured” with speech therapy alone.
Adductory Spasmodic Dysphonia
Abductor Spasms, Worsened by Cognitive Loading
Laryngology 401: PCA-only Paresis, but the Actual Voice Problem Is Spasmodic Dysphonia
Remarkable Task-Specificity of Spasmodic Dysphonia
Assessment of Vocal Phenomenology Protects from Visual Red Herrings
Ludlow CL. Treatment for spasmodic dysphonia: limitations of current approaches. Curr Opin Otolaryngol Head Neck Surg. 2009; 17(3): 160–165. ↩
An individual who has a graduate degree (master’s or doctorate) in speech-language pathology. After successful completion of the CFY (clinical fellowship year), a speech pathologist may work behaviorally with a wide variety of conditions that affect breathing, voice, and swallowing.
Some speech pathologists are generalists, potentially working within the same day with: a child whose speech is not clear; a person who is trying to recover clear speech after a stroke; a singer with vocal nodules; and an elderly person who is aspirating when she swallows. A speech pathologist’s activities may be divided between evaluation (including by use of the videofluoroscopic swallowing study or videostroboscopy to assess the voice) and therapy or treatment – teaching and coaching the patient in ways that improve their voice, breathing, and swallowing.
At our practice, our speech pathologist is singing voice qualified, working nearly exclusively with voice and breathing disorders. Adjunct speech pathologists from Good Samaritan Hospital are typically involved with our patients who have swallowing disorders.
Spirometry measures the breathing capacity of the lungs using an instrument that measures expired lung volumes and flow-volume curves.
Squeezedown (of the voice)
Stenosis in the airway can be the result of prolonged endotracheal intubation, external trauma such as gunshot wound, crush injury, or tracheotomy, an inflammatory or auto-immune process, surgical resection of part of the airway for tumor, or other causes. Persons with airway stenosis will note a reduced capacity for exercise. Often the clinician hears noisy breathing on inhalation, especially when the patient is asked to fill the lungs quickly. Esophageal stenosis gives symptoms of difficulty swallowing solids more so than liquids.