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Scarring

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.

Tube Injury—A Rare Complication of Intubation for General Anesthesia

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inflamed vocal cord

Inflamed vocal cord (1 of 5)

This patient had severe voice change after intubation for a 2-hour surgical procedure. She says voice was 100% before surgery and she awakened at 15%, a whisper with a bit of voice mixed in. Fortunately, across six weeks she has recovered partially to “70%.” The right cord (left of photo) looks “inflamed.”
Close view of the vocal cords

Closer view (2 of 5)

At closer range, a little more detail is seen.
Scarring from intubation tube

Scarring from intubation tube (3 of 5)

Under narrow band light, it appears that there is scarring of that fold likely from a laceration upon insertion of the tube. (She was told intubation was difficult.) A key finding, however: the right vocal process is turned slightly laterally, suggesting weakness of the LCA muscle.
Mucosal Injury

Mucosal Injury (4 of 5)

Under strobe light, closed phase of vibration, it is almost as if there is loss of mucosa upper surface of right cord.
Flaccidity of right vocal cord

Flaccidity of right vocal cord (5 of 5)

Open phase of vibration shows flaccidity of the right cord, with a much larger lateral excursion / amplitude of open phase on the right (left of photo).

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.

Supraglottic (above the vocal cord) Scarring as a Result of Radiotherapy

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Supraglottic Scarring

Supraglottic Scarring (1 of 4)

This man was treated with radiotherapy for an early vocal cord cancer, approximately 35 years prior to this examination. For those 35 years, his breathing has been slightly noisy, and he feels mild restriction of exercise tolerance. Here, you see an arch-like scar above the posterior end of the vocal cords (dotted line).
Supraglottic Scarring

Hoarseness caused by radiation effects (2 of 4)

The vocal cords can come together fully when he makes voice; his mild hoarseness is therefore not due not to the scar band, but instead to reduction of vibratory flexibility of the surface tissue of the vocal cords due to radiation effects.
Supraglottic Scarring

Cords don’t close completely (3 of 4)

In this closer view, one can also appreciate that the vocal cords do not separate to as wide a “V” as would be normal, and this is the main explanation of the harsh inspiratory noise and slight prolongation of time to fill his lungs with forced inspiration. Note as well additional evidence of radiation damage (scar band) at the arrow.
Supraglottic Scarring

Normal caliber trachea (4 of 4)

A view is obtained of his (normal caliber) trachea, to make certain that there is not an additional reason for his noisy breathing.

Scarring Diverts Swallowed Materials Directly into the Larynx

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Post tonsillectomy

Post tonsillectomy (1 of 4)

A young woman struggles to swallow after extensive cauterization of severe bleeding after tonsillectomy elsewhere. The arrows here show the path food and liquid should follow to get into the esophagus (opening indicated by flat oval).
epiglottis is tethered to base of tongue

Closer view (2 of 4)

Closer view shows that the epiglottis is tethered to base of tongue at the dotted line. Furthermore, the “ski jump” scar appears to be ready to divert swallowed material directly into the larynx ( arrow) rather than into the pyriform sinus at *.
chute into the larynx

The “chute” (3 of 4)

A closer view shows even better the “chute” into the larynx.
Abnormal diversion

Abnormal diversion (4 of 4)

While swallowing blue-colored water, arrows indicate the normal path on the left (right of photo) and the abnormal diversion into the larynx on the right (left of photo). The patient manages, but must swallow carefully, especially since the epiglottis cannot invert since it is scarred to the base of tongue as shown in photo 2.

VESS Findings after Radiotherapy

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narrowing of the pharyngeal wall from radiation scarring

Narrowed pharyngeal wall (1 of 7)

After radiation and chemotherapy for larynx cancer several years earlier. Note the dry secretions. There is narrowing of the pharyngeal wall (dotted line) due to radiation scarring.
post-swallow residue

Swallowing applesauce (2 of 7)

After the second bolus of blue-stained applesauce. The propulsive ability (“pitcher of swallowing”) is inadequate, leaving a lot of post-swallow residue.
cleaned esophagus with bits of blue applesauce

After sipping water (3 of 7)

After three sips of blue-stained water, much of the applesauce has been washed away.
swallowing crescent

Gravity aiding in swallowing (4 of 7)

Additional water washes nearly all of the residue in the “swallowing crescent” away–mostly by gravity as seen in the next photo.
wallowing crescent opens down to the cricopharyngeus muscle

Lifting larynx (5 of 7)

Each swallow looks like this. The pharynx “bird swallow” mechanism lifts larynx forward so that the swallowing crescent opens down to the cricopharyngeus muscle, indicated by double dotted lines. (PC = post-cricoid.)
cricopharyngeus muscle bulge

A closer look (6 of 7)

At closer range, the cricopharyngeus muscle bulge is seen more clearly, along with the small opening into the esophagus.
Blue-stained water flowing into the esophagus

Gravity aiding again in swallowing (7 of 7)

Blue-stained water flowing into the esophagus mostly by gravity.

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