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 (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.”

Closer view (2 of 5)

At closer range, a little more detail is seen.

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 (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 (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 (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).

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.

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.

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.
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