An open epidermoid cyst occurs when it spontaneously ruptures, but yet not empty all of its contents (keratin). The outline of the partially-emptied cyst may still be very evident, but it usually assumes an oval shape with the long axis oriented anteriorly and posteriorly. If the cyst empties nearly completely, the white oval is no longer seen, but the vocal cord may have a mottled appearance. If the cyst empties completely, a sulcus lined by epithelium remains.

A Case That Clearly Shows the Relationship Between Cyst & Sulcus

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White Lesion on Right Vocal Cord (1 of 6)

This young man is known as vocally exuberant. For some years, he has used his voice socially to the point of hoarseness countless times, including at heavy metal rock concerts. In the past year or so, his hoarseness never went away. In this distant view, a white lesion is seen on his right vocal cord (left of photo).

White Lesion Under Strobe Light (2 of 6)

Under strobe light and with higher magnification, the open phase of vibration shows this lesion as a white nubbin protruding from a fossa.

White Lesion Under Strobe Light (3 of 6)

The closed phase of vibration shows more clearly the depression from which the lesion is protruding.

White Lesion Removed (4 of 6)

After surgical removal and healing, voice is improved though not fully restored. The lesion was granulation and keratosis. It was plucked from the depression without deepening the pre-existing “divot.”

Vocal Cords (5 of 6)

At the open phase of vibration, showing the trough from which the lesion was removed. There is a smaller depression on the left also consistent with vibratory trauma.

Vocal Cords without Lesion (6 of 6)

The closed phase of vibration. Compare with photo 3.

Possible Open Epidermoid Cyst

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Capillary ectasia and white submucosal abnormality (1 of 3)

Left vocal cord (right of photo) has not only overlying capillary ectasia, but a white submucosal abnormality.

Prephonatory view, mtd (2 of 3)

Prephonatory instant shows some muscular tension dysphonia as well.

Open cyst (3 of 3)

Closer view. While an intact epidermoid cyst has a distinct outline, an open cyst develops a more mottled appearance. It may leak intermittently from a tiny dimple or sulcus which is sometimes seen at very close range.

Open Cyst and Sulcus in Same Patient

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Hoarse voice (1 of 4)

A young woman with a history of repeated loud cheering during athletic activities, to the point of hoarseness. She has a sulcus of the right cord (left of photo), and an open cyst of the left ( right of photo). Openings from sulcus and cyst are indicated by dotted lines.

Cyst + sulcus (2 of 4)

Narrow band light. The lateral lip of a sulcus is often bordered by a prominent capillary as seen here. An open cyst assumes an elliptical shape in the anteroposterior direction. It fails to empty completely because the opening draining it is smaller than the diameter of the cyst.

Closed phase (3 of 4)

Closed phase of vibration, strobe light.

Open phase (4 of 4)

Open phase of vibration.

Open Cyst and Sulcus; Normal and Segmental Vibration

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Margin swelling (1 of 6)

Breathing position of the vocal cords of a very hoarse actor. Note the margin swelling of both sides. The white material on the left vocal cord (right of photo) is keratin debris emerging from an open cyst. Find the sulcus of the right vocal cord (left of photo) which is more easily seen in the next photo.

Narrow band light (2 of 6)

Further magnified and under narrow band light. The right sulcus is within the dotted outline. Compare now with photo 1.

Open phase, strobe light (3 of 6)

Under strobe light, open phase of vibration at A3 (220 Hz). The full length of the cords participate in vibration.

Closed phase, same pitch (4 of 6)

At the same pitch, the closed phase again includes the full length of the cords.

Segmental vibration (5 of 6)

At the much higher pitch of C5 (523 Hz) a “tin whistle” quality is heard and only the anterior segment (at arrows) is opening for vibration. The posterior opening is static and not oscillating, as seen in the next photo.

Closed phase (6 of 6)

The closed phase of vibration involves only the tiny anterior segment of the vocal cords, at the arrows. The posterior segment is not vibrating and is unchanged.

Open Epidermoid Cyst-Sulcus

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Chronic hoarseness (1 of 4)

This woman suffers from chronic hoarseness. Note the relatively normal left vocal cord (right of photo) but that the right side has a whitish lesion at the margin. Equally important is the faint white submucosal collection of keratin indicated by dotted line.

Cyst under narrow band light (2 of 4)

Under narrow band light, the arrow indicates the sulcus opening that allows what was likely an epidermoid cyst to partially empty.

Closed phase (3 of 4)

Under strobe light, closed phase also shows a slight “divot” at the opening into the presumed collapsed cyst.

Open phase (4 of 4)

Open phase, showing that the amplitude of vibration (flexibility) of the affected side is understandably less than on the opposite (left) side.
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