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Laryngopedia

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

Laryngopedia By Bastian Medical Media

Multimedia Encyclopedia


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Saccular Cyst

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.


Photos:







Lateral saccular cyst, external approach: Series of 1 photo

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Lateral saccular cyst external approach

Lateral saccular cyst, external approach (1 of 1)

The hemostat in the lower photo points to the upper part of the thyroid cartilage. The neck of the sack is being followed over the top of the cartilage and between the thyroid cartilage and soft tissue, to its origin at the ventricle.







Sarcoma

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:




Scarring

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.



Secondary Gain

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

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.



Segmental Vibration

In the normal larynx, 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.


Photos:









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:

Many individuals with SNC have found relief through use of a neuralgia medication, such as amitriptyline,2, desipramine3, gabapentin4, pregabalin, oxcarbazepine, and others.

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.


Audio:

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.

Photos:

Bruise caused by cough: Series of 2 photos

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Bruised vocal cord caused by violent coughing

Bruise caused by violent coughing (1 of 2)

A person with violent sensory neuropathic coughing may injure the vocal cords, as illustrated by this bruise, right vocal cord (left of photo).
Closer view of bruise

Closer view of bruise (2 of 2)

Closer view of bruise, with small collection of white mucus in the middle.

Bruising from sensory neuropathic cough

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subglottic bruise

Bruising from SNC (1 of 1)

This individual occasionally coughs to the point of hoarseness. Particularly noteworthy is the subglottic bruise (arrow, dotted line) caused by profound Valsalva-retching kind of coughing. The rest of the right cord (left of photo) is also bruised.

Vocal cord bruising from coughing

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bruising over the vocal processes

Bruise from coughing (1 of 3)

This man had an episode of aggressive coughing a week earlier. Note the bruising over the vocal processes, which receive the major collisional force during coughing.
Pre-phonatory instant

Pre-phonatory instant (2 of 3)

The vocal processes are approaching the point of touching (contact would occur gently with onset of talking and more aggressively with coughing).
moderately-severe vocal cord bowing

Phonation (3 of 3)

Vocal cords are now in full contact. Note the unrelated moderately-severe vocal cord bowing.

Hemoptysis

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sensory neuropathic cough

SNC patient (1 of 6)

A very worried patient with sensory neuropathic cough has scheduled a return appointment. On arrival she states that she cannot rest due to a trace of hemoptysis a week earlier. What begins as a simple upper aerodigestive tract examination represented by this view of her normal nasopharynx is easily expanded…
base of tongue, hypopharynx, and laryngeal vestibule

Panoramic view (2 of 6)

Detailed inspection of base of tongue, hypopharynx, and laryngeal vestibule, represented by this panoramic view, also show no abnormality. And the examination can continue…
upper trachea

Lidocaine (3 of 6)

Simple instillation of lidocaine into the trachea allows this view into the upper trachea.
carina

Carina (4 of 6)

And this view, with the carina in clear view.
right mainstem bronchus

Right mainstem bronchus (5 of 6)

Deep inside right mainstem bronchus and…
Left mainstem bronchus

Left mainstem bronchus (6 of 6)

...into left mainstem bronchus also reveal no lesions and no “trail of blood.” Simple watchful waiting for more hemoptysis is acceptable to the patient. CXR is optional in the near-term.

Videos:

Sensory Neuropathic Cough, Part I: Coughing That Won’t Go Away
Sensory neuropathic cough is a chronic cough condition that does not respond to the usual treatments. Many individuals who have been coughing for years find relief from treatment with “neuralgia” medications.
Sensory Neuropathic Cough, Part II: Medications
In this video, Dr. Bastian introduces potential medications to treat sensory neuropathic cough.

  1. 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. 

  2. 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. 

  3. 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. 

  4. Ryan NM, Birring SS, Gibson PG. Gabapentin for refractory chronic cough: a randomized, double-blind, placebo-controlled trial. Lancet. 2012; 380(9853): 1583-9. 



Sessile

Attached completely at the base and without an intervening stalk; the opposite of pedunculated.



Shattered vibration

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.



Shimmer

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.



Silastic

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.

[intlink id=”407″ type=”post”]Laryngologists[/intlink] commonly place silastic implants into flaccid, [intlink id=”493″ type=”post”]paralyzed vocal cords[/intlink] 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.


Photos:




Silent aspiration

Aspiration that does not provoke an expected, normal response of coughing or throat clearing. Silent aspiration suggests a very high risk of aspiration pneumonia.



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.



Siren

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

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.


Photos:



Videos:

One Man’s Experience Over Time with SLAD-R
SLAD-R is a surgical alternative to ongoing “botox” injections for treatment of adductory spasmodic dysphonia. The surgery involves intentionally cutting the nerves that close the vocal cords for voice and reconnecting a different nearby nerve supply (reinnervating the nerves). This surgery requires the patient’s willingness to endure an extremely breathy voice for many months after the procedure, while awaiting reinnervation.


Smoker’s Polyps

Diffuse swelling of the vocal cords, due to build-up of edema fluid within the mucosa. Smoker’s polyps are also referred to as Reinke’s edema or polypoid degeneration.


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):


Photos:





 

Reinke’s (smoking-related) edema and how to see it: Series of 4 photos

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Abducted, breathing position of vocal cords

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

Inspiratory phonation (2 of 4)

Inspiratory phonation in-draws the mild Reinke’s edema (smoker’s type polyp formation).
Open phase, faint translucency

Open phase, faint translucency (3 of 4)

Strobe illumination, at E4 (approximately 330 Hz), mostly open phase.
Closed phase, faint translucency

Closed phase, faint translucency (4 of 4)

Note again in closed phase.



 


Videos:

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.


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.


Photos:









Spasmodic Dysphonia: A Peculiar Voice Disorder
Dr. Robert Bastian reviews the various types and subtypes of spasmodic dysphonia (SD). Numerous voice examples are included, along with video of the vocal folds. SD is a rare neurological disorder caused by laryngeal dystonia, and it interferes with the smooth functioning of the voice. Tiny spasms of the vocal folds may cause the voice to catch or cut out, strain or squeeze away, and sometimes to drop momentarily to a whisper.
Spasmodic Dysphonia: When Botox Disappoints
In this video, Dr. Bastian discusses common problems with Botox treatment for spasmodic dysphonia (SD) and offers clear, practical advice to increase the effectiveness of these treatments.
2014 NSDA 25th Anniversary Symposium
In this video, Dr. Bastian leads a panel discussion on Spasmodic Dysphonia.

  1. Ludlow CL. Treatment for spasmodic dysphonia: limitations of current approaches. Curr Opin Otolaryngol Head Neck Surg. 2009; 17(3): 160–165. 



Speech Pathologist

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.

 

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Spirometry

Spirometry measures the breathing capacity of the lungs using an instrument that measures expired lung volumes and flow-volume curves.



Squeezedown (of the voice)

A vocal phenomenology term coined to refer to adductory spasms that do not “complete” all the way to a phonatory arrest. Virtually exclusively a manifestation of spasmodic dysphonia.




Stenosis

Abnormal narrowing of a passageway in the body. At our practice, stenosis typically refers to narrowing in the breathing passage, such as for narrowing in the glottic, subglottic, or tracheal areas.

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.


Photos of Stenosis:

































Videos of Stenosis:

Tracheal Stenosis: Before and After
In this video, trachea (windpipe) blockage causes shortness of breath until the narrowed segment is removed. You will see views of the trachea before and after surgical repair.

Post-Radiation Hypopharyngeal Stenosis
People with larynx or pharynx (voice box or throat) cancer often undergo radiation therapy as part of their treatment regimen. An uncommon complication is stenosis (narrowing, scarring) of the entrance to the upper esophagus at the junction of the throat and esophagus. This video provides an example of this disorder.


Straight tone

Sustaining the voice on a steady pitch and loudness, without any vibrato. In the vocal capability battery, straight tone is elicited during a sustained tone to assess the stability of the voice, and to discover whether or not there are any neurogenic findings of lack of control, “involuntary glitches,” tremor, or the like.



Stridor

Stridor is a harsh, wheezy, or rough respiratory sound most often heard on inspiration to indicate laryngeal, subglottic, or tracheal partial obstruction or stenosis. Compare with involuntary inspiratory phonation.



Stripping of Vocal Cords

An older term in the lexicon of laryngology, now passing out of use. The idea of stripping the vocal cords is to grasp the mucosa superficially, and then to “peel” it, along with whatever pathology might be present. The thought was that the mucosa would re-grow and be more normal.

With more modern concepts of the crucial importance of the mucosa and, particularly, the need for it to be loosely attached to underlying layers of the cords, the practice of stripping has been discredited in favor of more precise removal of otherwise irreversible lesions.



Stroboscopy

To look at something using strobe rather than continuous illumination. At our practice, we use strobe lighting to allow apparent slow motion videodocumentation of the vibration of the vocal folds. When, for example, the vocal folds produce the pitch of “middle C,” they vibrate at 252 hertz, or cycles, per second; hence, under ordinary illumination, this rapid vibration of the vocal folds is a blur. Under a common setting for the stroboscope, however, the vocal folds appear to be vibrating at just 2 cycles per second, regardless of the actual rate of vibration, which allows the vibratory dynamics to be observed.



Subglottic stenosis

Subglottic stenosis is narrowing just below the vocal cords, in the lowest part of the larynx and immediately above the first tracheal ring. Examples of causes include scarring from a breathing tube used during a long ICU stay, Wegener’s Granulomatosis (aka Granulomatosis with polyangiitis), and idiopathic subglottic stenosis (aka limited Wegener’s Granulomatosis).


Photos of subglottic stenosis:

Subglottic stenosis, after treatment

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Subglottic stenosis

Subglottic stenosis, before treatment (1 of 2)

Subglottic and high tracheal stenosis, inflammatory, idiopathic (Lab).
Subglottic stenosis

Subglottic stenosis, after treatment (2 of 2)

Same patient, a few days after dilation and steroid injection (Lab).










Subglottis

The lower part of the larynx, from just below the free margin of the vocal cord to the upper end of the trachea.



Submucosal Fibrosis

A disorder in which the attachment of the mucosa to the underlying vocal ligament appears to thicken and toughen, yet without creating any protrusion, such as one sees with nodules or polyps. The mucosa thereby becomes less flexible. Think of satin turning into canvas of a similar thickness.


Photos:







Superior

Toward the upper end of a person’s body. For example: the head is superior to the feet. The opposite of inferior.



Superior Laryngeal Nerve (SLN) Paralysis

Paralysis of one of four main nerves serving the larynx, and two of the four if the paralysis is bilateral. SLN paralysis may be idiopathic or perhaps the result of neck surgery. The SLN internal branch supplies sensation to the interior of the upper part of the larynx; the external branch supplies motor innervation to the cricothyroid muscle.

Individuals with SLN paralysis, whether unilateral or bilateral, seem to compensate for the sensory deficits, provided that motor swallowing abilities are intact. On the other hand, they have symptoms of loss of upper voice and poor vocal projection. These two symptoms are easily verified by clinician elicitation and judgment of response.



Supportive Treatment

Supportive treatment is treatment aimed at providing comfort or reducing the problem, but not necessarily curing it.



Supraglottic Cyst

A retention-type cyst of the supraglottic structures not manifesting as either an anterior or lateral saccular cyst. With a supraglottic cyst, the duct of a single gland is thought to become obstructed and to thereby retain secretions. By contrast, with a saccular cyst, the mouth of the laryngeal saccule becomes obstructed.

Photos:




Supraglottic laryngectomy

Supraglottic laryngectomy is one type of partial laryngectomy, in which the upper part of the larynx is removed, for a tumor that does not involve the vocal cords. The ventricles are the dividing line between glottic and supraglottic tumors. Due to the higher risk of metastasis to neck nodes, supraglottic laryngectomy as primary treatment is usually combined with neck dissection.



Supraglottic phonation

Making voice by means of supraglottic vibration rather than glottic (true vocal cord) vibration. The supraglottic tissues used for vibration can vary between individuals. Vibrating tissue can be the false vocal cords (false cord phonation), aryepiglottic cords, or apical arytenoid mucosa.

Supraglottic phonation may become necessary if the vocal cords are absent or scarred to the point of being unable to vibrate. Examples might include larynx trauma, partial laryngectomy with loss of one or both vocal cords or an inability to bring them close enough together to be entrained into vibration, or progressive radiation damage (radiation fibrosis), usually many years after treatment for cancer.


Photos:





Supraglottic swallow

A swallowing technique in which a person coughs right at the end of a swallow to help prevent any swallowed food or liquid from going down into the airway. This technique is especially useful for individuals who have undergone a supraglottic laryngectomy, because the upper part of the larynx (epiglottis, aryepiglottic cords, false cords, etc.) has been removed and can no longer help to shield or divert swallowed material.

For each and every swallow, the person will do as follows: first, finish chewing; then, hold the food or liquid in the mouth and fill the lungs with air; then, with the food or liquid still in the mouth, hold his or breath; then, swallow forcefully and, without hesitation, cough immediately on the tail end of the swallow. At our practice we call this technique a “swallowcough,” to signify that the cough occurs using pent-up air from the lungs, and not air drawn in between the swallow and the cough.



Supraglottic web

When either the false folds or aryepiglottic folds adhere to each other. This supraglottic web narrows the laryngeal vestibule and distorts the normal contours of the larynx. This is an uncommon diagnosis, and is usually either a complication of cancer-treating radiation therapy or else is the result of trauma, such as from a gunshot wound or severe blunt trauma to the larynx that causes fracture and tears the mucosa.

See also: glottic web.


Photos:




Supraglottis

The upper part of the larynx, from just above the vocal cord to the tip of the epiglottis.



Surgical results: before and after photos

Vocal polyps:








For more info: Vocal polyps


Vocal nodules:








For more info: Vocal nodules


Cancer:









For more info: Cancer


Capillary ectasia:





For more info: Capillary ectasia


RRP:





For more info: Recurrent Respiratory Papillomatosis


Vocal cord paralysis/paresis:








For more info: Paralysis or Paresis


Stenosis:






For more info: Stenosis


Other:















[Gallery not found]




[Gallery not found]





Sustained Phonation

Sustained phonation is a part of the vocal capability battery in which the patient is asked to sustain a sung tone as steadily as possible, so as to detect tremor, or other kinds of vocal instability.



Swallowing Evaluation and Treatment

What we try to accomplish during an initial consultation:

1. Obtain your general medical history
2. Understand your “swallowing experience” and the symptoms that bother you
3. Examine your palate, tongue, pharynx, and larynx because they comprise your “equipment” for swallowing
4. Study your swallowing function during an office-based videoendoscopic swallow study (VESS) because it is typically the best evaluation of the “propulsive” side of swallowing, that is, the oral and pharyngeal phases.
5. Review images from an xray-based videofluoroscopic swallow study (VFSS) because it is the better procedure to best understand the “receptive” side of swallowing both anatomically and functionally. That is, the cricopharyngeus muscle (aka upper esophageal sphincter), a Zenker’s diverticulum if present, and esophageal transit. These x-ray images may be available from:

a. A CD of this study you bring to the initial appointment from your prior workup elsewhere. In this case, we suggest you load the disc into your home computer
b. A CD of a VFSS done earlier in the day by per-arrangement at nearby Good Samaritan Hospital
c. A CD of a VFSS performed after the initial consultation at nearby Good Samaritan Hospital (if possible to arrange), and then brought back for review later that day

After all the above, we can usually describe in detail your issue is primarily propulsive or the “pitcher” of swallowing, or the “catcher” or receptive side (cricopharyngeus muscle and esophagus) – or both. Depending on the specifics of your case, we may suggest swallowing therapy, cricopharyngeus myotomy, or both.

Swallowing Therapy

If the main problem is with strength and organization of food and liquid propulsion (what we often call by the shorthand term “presbyphagia” in older adults), the primary approach is teaching/training. The evaluating physician may give tips and pointers and as appropriate, swallowing therapy provided by a speech pathologist may be recommended. Exercises for tongue, cheek, and throat muscles, head position, swallowing techniques, and careful food choices are some of the topics covered during swallowing therapy.

Cricopharyngeus Myotomy

If a major issue is non-relaxation of the cricopharyngeus muscle and “the catcher won’t open his glove”, cricopharyngeus myotomy (CPM) is often an option. The following is a summary of important information to know about CPM.

1. To reduce the likelihood of a complication called subcutaneous emphysema, it is crucially important that if you need to cough or sneeze in the first three days after surgery, this must be done with mouth wide open. Your surgeon will demonstrate how to do this and you should practice this many times at home before the day of surgery so that it is “second nature”.
2. Surgery is performed at nearby Good Samaritan Hospital, under general anesthedia.
3. We ask your permission for both endoscopic (through the mouth) and trans-cervical (through a neck incision) myotomy, even though the majority of procedures are done endoscopically. The trans-cervical operations are typically for the one of ten whose anatomy will not permist endocopic visualization.
4. Immediately upon waking, there will be discomfort from a very sore throat, often rated by patients as between 5 and 8 on a 10-point scale, and also the annoying discomfort of a tube in your nose.
5. That tube in the nose is placed in the operating room while you are asleep and is used to create gentle suction in the area of the surgery.
6. The day of surgery, we usually allow sips of liquids. The tube in your nose cannot be removed until you are able to swallow quite well around it. Most often the tube is removed the morning after surgery. In the uncommon event that a person is still unable to swallow by the next morning, the suction tube going through the nose can be repositioned to serve as a feeding tube. That occurs mostly in people who not only have cricopharyngeus dysfuntion (for which we are doing surgery) but also poor propulsion or “prebyphagia”. That is, both “pitcher” and “catcher” of swallowing are impaired.
7. Usual discharge is the morning after surgery whether we have done the endoscopic or trans-cervial approach. The suction tube is removed early in the morning of the day of surgery, to give time to verify ability to swallow liquids before going home.
8. IF you are unable to swallow around the suction tube, you would stay one or more additional days. This occurs in approximately one of five patients.

The great majority get through this procedure uneventfully. It is unpleasant due to the sore throat and initial tube in the nose, of course.

The risks of surgery overlap between endoscopic and trans-cervical methods of surgery:

For both approaches:

*a chipped or dislodged tooth (very uncommon)
*infection including rare mediastinitis (a severe central chest infection)
*anesthesia complications
*postoperative bleeding

For the endoscopic (through the mouth) approach, an added potential complication: subcutanrous emphysema (blowing air into the tissues of the neck, face, upper chest, etc. causing swelling for days)

For trans-cervical (neck incision) approach: vocal cord paralysis, or rarely a fistula (short-term leakage of saliva)



Swallowing Phenomenology

Swallowing phenomenology are manifestations that are observable during the videoendoscopic swallowing study (VESS) or videofluoroscopic swallowing study (VFSS) and that convey key information about a person’s swallowing function. This phenomenology may be visual or audible findings in or around the person’s swallowing passageway, or may be observations of the person’s general behavior.



Swallowing Therapy

Swallowing therapy is typically provided by a speech-language pathologist (and, more informally and adjunctively, by other healthcare professionals). General areas of teaching might include: choosing wisely which food types and consistencies to eat; swallowing maneuvers such as tucking the chin, double swallow, effortful swallow, head turning, and supraglottic swallow; and direct exercises for the tongue, pharynx, palate, and larynx.

Videos:

https://youtu.be/_dBPKBg8jXM
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).


Swelling checks

Vocal tasks that reveal the vocal phenomenology of mucosal disturbances of the vocal cords.1 These mucosal disturbances may be vocal nodules, vocal polyps, vocal cysts (e.g., epidermoid cysts or mucus retention cysts), or others.

These vocal tasks incorporate high frequency (pitch), very low intensity (loudness), and sometimes rapid onset and offset of the voice. The two swelling checks used almost exclusively at our practice are the first phrase of “Happy Birthday” and a five-note descending staccato. For both of these vocal tasks, the individual should produce the voice in a tiny “boy soprano pianissimo” kind of production; this tiny dynamic is insisted on because getting even a little louder tends to conceal the problem. Women should focus on the C5-C6 octave (~523 Hz to ~1046 Hz).

Signs of swelling check positivity include onset delay, breathiness that gets worse as one ascends the scale, and loss of expected upper range, as understood by a singing voice-qualified clinician. Note that a small gap between the vocal cords can also cause onset delay and breathiness, but differences in performance between the two can help to indicate whether the problem is swelling or a gap.


Videos:

Vocal Cord Swelling Checks
In this video, Dr. Bastian introduces and demonstrates two swelling checks: two simple vocal exercises that can be used to help detect the early signs of vocal cord injury. He also discusses the physiology of vocal cord injury and explains how to make the best use of these swelling checks in your daily routine.

  1. Bastian RW, Keidar A, Verdolini-Marston K. Simple vocal tasks for detecting vocal cord swelling. Journal of Voice. 1990; 4(2): 172-83. 



Symptom Complex

The aggregate of symptoms associated with a diagnosis, in the case of our practice, relating to a voice, swallowing, or airway disorder. Certain symptom complexes are virtually diagnostic for the disorder involved. Example: The symptom complex of vocal cord paralysis often includes air wasting, coughing on liquids, difficulty coughing up sputum (due to the non-percussive nature of the cough), and generalized fatigue experienced as a result of sustained voice use.



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