Multimedia Encyclopedia
TA + LCA Paresis
Weakness or paralysis of both the thyroarytenoid (TA) and lateral cricoarytenoid (LCA) muscles of one vocal cord, but with normal function of that cord’s posterior cricoarytenoid (PCA) muscle. The TA muscle “inhabits” the vocal cord and normally provides bulk and internal tone to the cord. The LCA muscle helps to bring the vocal cord to the midline for voice production and, more specifically, to bring the “toe” of the arytenoid cartilage to the midline. The following are indicators of TA + LCA paresis:
- Movement: Position is normal during breathing, but the vocal cord does not move closer than the intermediate position for voicing. In other words, it is further lateral than the paramedian position one would see with paralysis of all three muscles: TA + LCA + PCA.
- Position and appearance: Due to the TA paralysis, the margin of the cord is slightly concave, the ventricle is capacious, and the conus area below the free margin is lacking in bulk. Due to the LCA paralysis, there is lateral turning of the vocal process. This lateral turning is seen best in low voice, and is a little less apparent with very high voice.
- Appearance during voicing (under strobe lighting): Flaccidity as indicated by increased amplitude of vibration; the lateral excursions become exaggerated and the mucosal wave increases. One may also see chaotic fluttering. The gap between the cords is particularly large because of the unopposed lateral pull of the intact PCA muscle. TA and LCA paresis is often mistaken for complete vocal cord paralysis (TA + LCA + PCA). To avoid this mistake, the examiner must notice this lateral position. The examiner can also try to make any such lateral pulling more evident by asking the patient to inhale sharply or, better yet, to sniff, which exaggerates the abductory movements of the patient’s vocal cords.
- Voice quality: Exceedingly weak and air-wasting. After successful medialization, the obligate falsetto and luffing may disappear, while some of the breathy-pressed quality may persist.
Other variants of vocal cord paresis include LCA-only, TA-only, PCA-only, and IA-only (interarytenoid muscle).
Photos of TA + LCA paresis:
Visual Cues of Paresis Validated by their Change with Recovery!
Paresis, TA + LCA, before and after Placement of an Implant
Paresis, TA + LCA, before and after Injection of Voice Gel
TA + LCA Paresis
Paresis, TA + LCA, with Recovery
Paresis, TA + LCA, before and after Medialization
TA + PCA-only Paresis
Telescope Panoramic Views are Routinely not Adequate for Assessing Paresis!
Classic TA + LCA-only Paresis, Right Vocal Cord
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.
PCA working; TA and LCA Are not in this Paresis Subtype
TA-only Paresis
Weakness or paralysis of the vocal cord’s thyroarytenoid (TA) muscle, but with normal function of the vocal cord’s other muscles. The TA muscle “inhabits” the vocal cord and normally provides bulk and internal tone to the cord. The following are indicators of TA-only paresis:
- Movement: The vocal cord opens normally for breathing and closes normally for voicing.
- Position and appearance: Position is normal. Typically, the margin of the cord is slightly concave, the ventricle is capacious, and the conus area below the free margin is lacking in bulk.
- Appearance during voicing (under strobe lighting): Closure at the posterior commissure is complete and symmetrical bilaterally. Under strobe light, one sees flaccidity as indicated by increased amplitude of vibration; the lateral excursions become exaggerated and the mucosal wave increases. One may also see chaotic fluttering.
- Voice quality: Weak and air-wasting and often indistinguishable from a case of complete vocal cord paralysis—TA, LCA (lateral cricoarytenoid), and PCA (posterior cricoarytenoid).
Other variants of vocal cord paresis include LCA-only, TA + LCA, PCA-only, and IA-only (interarytenoid muscle).
Photos of TA-only paresis:
Paresis, TA-only
Paresis, TA-only: before and after an Implant
TA-only Paresis before and after Voice Gel Injection
Just Bowing? No, TA-only Paresis
“Mostly-TA” Paresis
TA-only Paresis, before and after Recovery
Another TA-only Paresis
Arytenoid Mismatch Makes for Gravelly Voice Quality Is Hard to Fix in Some Cases of Vocal Cord Paralysis
One could medialize more aggressively posteriorly on the left, hoping to raise the level of the cord, but often attempts to compensate for arytenoid mismatch such as that seen here are only modestly successful. Arytenoid superstructure is not useful for assessment of match; instead, the examiner should judge match at the vocal processes.
Vocal Cord Atrophy Goes Away when Nerve Supply to the Thyroarytenoid Muscle Returns
Talkativeness Scale
At our practice, we use a 7-point interval scale upon which the patient and family will rate the patient’s degree of talkativeness.
(1) signifies an individual who is unusually quiet and uncommunicative;
(4) represents an averagely talkative person;
(7) describes someone who is unusually extroverted and even a “life of the party” type.
Notably, persons with mucosal injuries (e.g., vocal nodules) are almost invariably (6) or (7); the exception might be a person whose occupational demands on the voice are truly extreme.
Technology-driven diagnostic model
A term used somewhat interchangeably with the reductionistic diagnostic model. The idea of a technology-driven diagnostic model is that technology is generally the answer to difficult diagnostic dilemmas. The hope is also looking to make voice diagnosis more “scientific” or “objective.” Inherent to the technology-driven model is the idea that the disorder will be better understood if only we can make enough measures of various sorts. By extension, if we don’t understand a voice disorder completely by the end of a large battery of measurements, we need more measures. While the clinicians at our practice make use of state-of-the-art technology, the integrative diagnostic model is preferred.
Teflon
A synthetic material, polytetrafluoroethylene, most popularly associated with non-stick cooking pans. Until 25 or so years ago, it was common to treat paralyzed vocal cords by injecting a paste of Teflon particles deep within the cords. It was an effective treatment for its time, but it occasionally caused granuloma formation and required late debulking.
Today, injected materials such as hyaluronic acid gel or hydroxyapatite particles suspended in hyaluronic acid are typically used instead for temporary or somewhat permanent rehabilitation. For permanent rehabilitation of permanent paralysis, surgically implanted silastic wedges are used most often, though other materials are also used optionally.
Photos:
Teflon Bulge, before and after Removal
Posterior Commissure Synechiae
Audio with photos:
Interview:
The patient describes original problem with Teflon granuloma/ overinjection, and the improvement after debulking Teflon.
Teflon Bulge, before and after Treatment
Thin Liquids
The prototype is water. Other examples include black coffee and apple juice. There is little consistency or viscosity to thin liquids, making them difficult to manage when there is an issue with bolus control or inability to close the larynx fully when swallowing, as with unilateral vocal cord paralysis.
Thyrohyoid Syndrome
A little-known inflammatory condition of the lateral thyrohyoid ligament and nearby tissues in the neck. The connective tissues in this area comprise in practical terms a floating “joint” that attaches the larynx to the hyoid bone. Inflammation of unknown cause can lead to a syndrome similar to tennis elbow, so that the point of attachment becomes chronically sore. Thyrohyoid syndrome is also known as hyoidynia, hyoid bursitis, or lateral thyrohyoid ligament syndrome.1
A patient with this condition typically (but not always) has a history of placing stress on this connective tissue in his or her profession or activities—trumpet playing, for example. Diagnosis is confirmed with finger or thumb pressure to find a point of acute tenderness over the greater horn of the hyoid bone and sometimes the upper border of the thyroid cartilage. The clinician may find it helpful also, by way of comparison, to apply gentle pressure on the submandibular gland or carotid artery so as to confirm that the point of tenderness is truly greatest at the lateral thyrohyoid ligament, hyoid bone, or thyroid cartilage.
Treatment of thyrohyoid syndrome is typically supportive and may include reduction of percussive or aggressive use of voice, non-steroidal anti-inflammatory drugs, or (by far most effective) an injection of 0.5 ml of Kenalog 40 mg per ml at the lateralmost point of the hyoid and upper border of the thyroid cartilage2, requiring care and experience, as this is just anterior to the carotid artery. This injection may cause soreness on top of the thyrohyoid syndrome pain for a day or two, followed by considerable, if not complete, relief for about three weeks. After this time, pain may return, though not usually to the original level. In some cases a single injection suffices; in others, a series of three injections, performed three or four weeks apart, is more effective.
Sinha P, Grindler DJ, Haughey BH. A pain in the neck: lateral thyrohyoid ligament syndrome. Laryngoscope. 2014;124(1):116-8. ↩
Kunjur J, Brennan PA, Ilankovan V. The use of triamcinolone in thyrohyoid syndrome. British Journal of Oral and Maxillofacial Surgery. 2002;40:450-451. ↩
Tonic Variant Spasmodic Dysphonia
A variant of spasmodic dysphonia (SD) in which the spasms (and their effect on the voice) are sustained rather than intermittent. Tonic variant spasmodic dysphonia is to be distinguished from classic variant SD.
Individuals with a tonic variant of adductor SD have a sustained strained-sounding voice. Individuals with a tonic variant of abductor SD have a voice that is more or less continuously breathy. Tonic variant SD goes undiagnosed or misdiagnosed far more frequently than does classic variant SD.
Photos:
“Pure” tonic-variant adductory Spasmodic Dysphonia
Audio:
Four subtypes of adductor SD, tonic variant :
Non dysphonic variant
Cry variant
Stage whisper variant
Vocal fry variant
Topical Anesthesia
Topical anesthesia refers to the loss of sensation confined to mucosal surfaces (as when pontocaine, benzocaine, or lidocaine is applied to the surface).
Torus Mandibularis
Torus mandibularis is a benign bony growth on the medial surface (tongue side) of the mandible or jaw bone. Also known as mandibular torus. Mandibular tori are usually seen on both the left and right sides (bilaterally). They often require no treatment unless they interfere with denture fitting.
In laryngology, mandibular tori come to attention because, when large, they can make it difficult or impossible for the clinician to gain a view of the vocal folds during microlaryngoscopy. That difficulty arises because during a microlaryngoscopy, the floor of the mouth is normally compressed by the laryngoscope to allow the scope to angle anteriorly at the viewing end, but mandibular tori, being composed of bone, do not compress.
Photos:
Total Laryngectomy
The ultimate surgical option for larynx cancer, in which the entire voice box is removed. Options used to avoid total laryngectomy are endoscopic laser surgery; partial laryngectomy; radiation; and chemo/radiation. Today, total laryngectomy is most often a salvage procedure, performed after failure of the initial treatment. It is still, however, a good primary option for very advanced tumors not likely to respond to chemo/radiation.
Photos:
Go Straight to Total Laryngectomy, or Give Thulium Laser a Chance?
How a Sphincter Works
Trace aspiration
Aspiration to a very limited degree, in which perhaps no more than a few drops or particles of liquid or food material enter the airway. If a person only has occasional trace aspiration, there is no real risk of aspiration pneumonia, especially if the person responds with coughing.
Trachea
The trachea, or windpipe in layman’s terminology, begins on its upper end just below the larynx and extends inferiorly into the chest where it splits into the right and left mainstem bronchi; delivering inspired air to the right and left lungs, respectively.
The tracheal rings comprise approximately two-thirds of the circumference of the trachea, anteriorly and laterally. The remaining posterior one-third “membranous” tracheal mucosa is the anterior surface of the “party wall” it shares with the esophagus.
Photos:
Benign Bony Growths in the Trachea Called Tracheobronchopathia Osteochochondroplastica!
Less Severe Case of Tracheobronchopathia Osteochochondroplastica
Trachea, with Tracheotomy Tube
Tracheal Resection and Reanastomosis
Tracheal Resection and Reanastomosis is a surgical procedure for tracheal stenosis in which the damaged, narrowed segment of the trachea is removed and the healthy remaining trachea is sutured back together.
Photos:
Tracheal Stenosis, before and after Tracheal Resection and Primary Reanastomosis
Tracheal Deformity and Stenosis, before and after Repair
Tracheal Stenosis and Collapse
A Fenestrated Trach Tube Allows Voicing when there Is Stenosis
Does this Person Really Need Tracheal Resection? Let’s see…
Tracheoesophageal Party Wall
The membranous shared wall between the trachea and esophagus. The tracheoesophageal party wall is also known as the membranous trachea. This membranous wall makes up one-third of the trachea’s circumference; the other two-thirds is bolstered and stiffened by cartilaginous rings. These stiff cartilaginous rings help to keep the trachea open, whereas the membranous wall has some flexibility and may momentarily bulge into and narrow the tracheal passageway, as during a cough or a Valsalva maneuver.
Photos:
Rumbling Vibration of the Tracheoesophageal Party Wall can make Coughing Sound “Infectious and Productive” when it isn’t
Tracheoesophageal Party Wall with Wheezing
Tracheoesophageal Voice Prosthesis (TEP)
A device that is placed in the wall that separates the trachea and esophagus in order to enable a total laryngectomy patient to make voice. The tracheoesophageal voice prosthesis (TEP) uses a one-way valve to let air pushed up from the lungs to pass through from the trachea and enter the esophagus, causing the walls of the esophagus to vibrate as a new voice, but without letting food or liquids to pass through the other way, from the esophagus to the trachea.
The need for a TEP:
A patient who undergoes a total laryngectomy procedure will have the entire larynx removed and the end of the trachea redirected to an opening—called a stoma—created in the front of the neck. The result is that the patient can now breathe through this stoma, but would be unable to make any voice, because the larynx (voice box) is gone, and the air for voicing that once passed up through the larynx, causing the vocal cords to vibrate and thereby making voice, now simply exits the trachea at the stoma. Such a patient can obtain an alternate voice by using a TEP device.
The placement of a TEP:
In order to place a TEP device into the wall that separates the trachea and esophagus (the tracheoesophageal party wall), a puncture must first be made, into which the device can fit. This puncture can be made during the laryngectomy procedure (primary tracheoesophageal puncture) or else afterward in a separate procedure (secondary tracheoesophageal puncture), typically some weeks after the laryngectomy. Some clinicians prefer to place the device itself as part of the primary puncture. Others first place a catheter to hold the puncture open and allow for tube feedings while the pharynx heals, and then they place the actual device in an office setting 10 days or more later.
The use of a TEP:
When a patient with a TEP device wants to speak, he or she must momentarily cover the stoma in the front of the neck, so that air coming up from the lungs is redirected through the TEP and into the esophagus to make voice. Some patients will simply cover the stoma as needed with their thumb, if their stoma is normally left entirely open, or is only concealed from view with a small, unobtrusive, breathable cloth. More commonly, however, the patient’s stoma is fitted with a housing, into which is placed a heat and moisture exchanger (HME); in these cases, the HME, which looks like a flat, plastic button, can be pushed as needed to block the stoma and enable voicing. Whatever the case, speaking with a TEP device is a learned skill and requires training through speech therapy.
Photos:
TEP: Series of 4 photos
TEP voicing: Series of 4 photos
TEP’s that want to become buried: Series of 4 photos
How the one-way flapper valve works in a TEP prosthesis: Series of 3 photos
Tracheomalacia
Flaccidity of the trachea, due to injury or congenital defect, such that the tracheal passageway fails to stay open at its normal diameter, especially during inspiration. In adults, tracheomalacia is most commonly seen after a prolonged intubation in which the endotracheal tube balloon was (sometimes necessarily) over-inflated and, consequently, exerted too much pressure on the tracheal rings, damaging and thereby weakening them; infection can also exacerbate this weakening of the tracheal rings. Intubation is a less common cause of tracheomalacia now, however, since the advent years ago of high-volume, low-pressure endotracheal tube and tracheotomy tube cuffs. In neonates, tracheomalacia can be congenital or a sign of incomplete development of the trachea.
Tracheomalacia should be distinguished from nonorganic breathing disorder, tracheal, which differs from tracheomalacia in that the tracheal collapse which occurs is functional or volitional, and is sometimes used to amplify asthmatic wheezing, or to masquerade as asthma, in each case for secondary gain.
Photos:
Tracheal Hyperflexibility
Tracheotomy
Photos of Tracheotomy:
Nuances of Endotracheal Tube Injury
This woman with high-risk comorbidities of diabetes and obesity, was in ventilated in ICU more than a month for pulmonary complications of Covid-19 infection. She had an orotracheal tube in place for 3.5 weeks, and then a tracheotomy tube was placed. Now at her first visit a year later, she remains tracheotomy-dependent, and is told she has bilateral vocal cord paralysis (disproven in the following photo series).
The plan here is posterior commissuroplasty, followed by placement of a smaller trach tube and a trial of plugging. If plugging is tolerated during the day, she will need a sleep study with it plugged at night, given the tracheomalacia and her obesity.
Tracheotomy Dependence
Tracheotomy dependence is the state of having no choice but to breathe through a tracheotomy tube, because of an obstruction of the normal “pathway” for breathing, through nose and/or mouth, through the larynx, and only then into the trachea. Tracheotomy dependence may occur because part or all of the larynx has been removed, e.g., for cancer, or because of severe scarring or inflammation.
Tracheotomy Tube
A tracheotomy tube is a device that is surgically placed into the trachea low in the neck, with its tip well inside the trachea and its other end anchored to a faceplate that sits on the surface of the neck. A tracheotomy tube allows an individual to breathe directly from the neck opening into the trachea as an alternative to normal breathing through the nose and/or mouth. “Trach” is the colloquial term used by clinicians to refer to a tracheotomy tube.
A fenestrated tracheotomy tube allows voicing when there is stenosis
Nuances of Endotracheal Tube Injury
This woman with high-risk comorbidities of diabetes and obesity, was in ventilated in ICU more than a month for pulmonary complications of Covid-19 infection. She had an orotracheal tube in place for 3.5 weeks, and then a tracheotomy tube was placed. Now at her first visit a year later, she remains tracheotomy-dependent, and is told she has bilateral vocal cord paralysis (disproven in the following photo series).
The plan here is posterior commissuroplasty, followed by placement of a smaller trach tube and a trial of plugging. If plugging is tolerated during the day, she will need a sleep study with it plugged at night, given the tracheomalacia and her obesity.
Traditional diagnostic model (for voice disorders)
The traditional diagnostic model (for voice disorders) is the method of diagnosis used up to recent decades, and still by far the most prevalent model worldwide. Here, the clinician collects a patient history and then proceeds directly to mirror examination, or possibly one using the fiberscope. Unfortunately, many diagnoses may be missed due to missing information. See also: the integrative diagnostic model for voice disorders.
Translucent Polyp
Some polyps are covered by mucosa that is opaque. Some are filled with blood (hemorrhagic polyp). On the other hand, some have a thin and delicate mucosa, and a watery content that is not transparent, yet transmits some light. Unlike a blister, which they could be construed as resembling, and which typically resolves itself, most translucent polyps end up requiring surgery for their resolution.
Photos of Translucent Polyps:
An Extreme Example of Protective Fibrosis Deposits
The Mucosa’s Expression of Injury Varies
Translucence of a Polyp to the Point of Near-Transparency
Transnasal esophagoscopy (TNE)
Transnasal esophagoscopy (TNE) is a diagnostic procedure that involves passing a slender, flexible videoendoscope through a topically anesthetized nasal passage into the back of the nose, down past the larynx, and through the whole length of the esophagus. Formerly, esophagoscopes were much larger in diameter than the newer scope. This makes passage of the scope relatively pain-free so that topical anesthesia is all that is required. Occasionally, anxious patients are slightly sedated for the procedure; more commonly, sedation is not needed and, in this latter instance, the patient may not only drive to the examination, but drive back to work or home afterwards.
Transverse cordotomy
Transverse cordotomy is a surgical procedure on the posterior part of the vocal cord, first described to our knowledge by Dr. Haskins Kashima of Johns Hopkins University many years ago. The procedure is done for bilateral vocal cord paralysis, or for glottic stenosis caused by injury and resultant scarring of the vocal cords together. Typically, an individual undergoes this procedure because of tracheotomy dependence or because of marked exercise intolerance. The procedure is performed endoscopically, using the laser to make an incision across the posterior end of the most damaged or least functioning vocal cord. Inherent to this problem, and to this solution, is the idea that one trades away a little bit of voice to gain a little bit better airway.
Treatment for Sensory Neuropathic Cough
Instructions:
Begin with the medication marked with the large “X.” If, over time, the first prescription fails to provide adequate benefit, you will of course let us know this during a phone or encrypted email followup communication. At that point, we would create a new prescription that you would pick up at your pharmacy. You will follow the same procedure, if necessary, for a third medication if the first two do not reduce cough sufficiently. (see Voice Mail and Portal Email Instructions, below).
_______ Option 1: Amitriptyline (Elavil) OR Desipramine (Norpramin): begin with 10 mg 2 hours before bed.
Notes:
1. If grogginess occurs, this often resolves if you persist in taking the medication for two weeks.
2. If you experience some response, but less than 80% reduction of your symptoms, please double to 20 mg. (2 pills) 2 hours before bed.
3. If there is still less than 80% reduction, you may increase step-wise up to 80 mg. (8 pills) 2 hours before bed.
4. If you have afternoon “breakthrough” coughing, you may try adding 10 or 20 mg (1 or 2 pills) at noon.
5. Please leave voicemail or encrypted email for your doctor 14 days after beginning,
as instructed below at *.
______ Option 2: Gabapentin (Neurontin): 300 mg (1 pill) at bedtime for 3 days; then 300 mg noon and bedtime for three days; then 300 mg breakfast, mid-afternoon and bedtime for 3 days; then breakfast, lunch, dinner, and bedtime (300 mg 4 times per day for a total of 1200 mg per day). You may increase slowly in like manner to as much as 600 mg (2 pills) four times a day, assuming side effects allow.
Notes:
1. You must “taper on” and “taper off” this medication as described above.
2. Side effects are dramatically different between individuals. Some experience none in spite of high dose; a few notice significant side effects with even one pill per day.
3. Main side effect is sleepiness, or a mild feeling of being “drunk.” Also occasionally swelling of feet.
4. To minimize side effects, take the medication with food.
5. If you cannot tolerate side effects, back off to the next lower dose and maintain until you are tolerating the medication well, then try to increase again by one pill.
6. Please leave voicemail or encrypted email for your doctor approximately 14 days after beginning, as instructed below at *.
______ Option 3: Citalopram (Celexa): Start at 20 mg (1 pill) every evening. After one week, increase to 2 pills (40 mg)
*Notes:
1. You must “taper on” and “taper off” this medication, and do not make sudden large changes in dose.
2. Main side effects include drowsiness and dry mouth.
3. Please leave a voicemail for your doctor 7-10 days after beginning, as instructed below.
*Voicemail Instructions:
Information we need from you each time you call/email:
a. Your name (Please spell).
b. Name of medication and how long you have been taking it.
c. Your current dose level.
d. What % reduction of symptoms you are experiencing.
e. Side effects, if any.
f. Daytime and evening phone numbers.
g. Any other comments you wish to make, or questions you have.
Sample Voicemail: “This is John Doe, I’ve been on the amitryptyline 10 days. I increased to 50 mg (5 pills) each evening. My symptoms are diminished by 50%. Side effects are: ________________. My phone numbers are_______________ and _____________. I’d like to know what to do next.”
Trial Therapy
The use of a variety of brief therapy approaches during the initial diagnostic encounter to assess the vocal phenomenology that results, and also to see what changes of voice production appear to be possible for the patient, versus which ones seem not to be, due to physical limitation or nonorganic interference.
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