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Laryngopedia

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

Laughing

Posted on March 28, 2016 by Dr. Robert Bastian

Ever wonder how we laugh?

https://vimeo.com/160649997

VESS of the laryngopharynx during laughter
VESS Recorded at Bastian Voice Institute

https://vimeo.com/166868972

Laughing that can be seen and heard!
In this video, Dr. Bastian looks into the esophagus via VESS.

Supraglottic Phonation

Posted on April 14, 2014 by Dr. Robert Bastian

Supraglottic phonation is 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:

False Cord Phonation

False cord phonation due to flaccid true cords: before false cords begin to vibrate — False cord phonation due to flaccid true cords (2 of 5): before false cords begin to vibrate

Strobe light reveals an unusually wide amplitude of vibration, denoting flaccidity of the true vocal cords.

False cord phonation due to flaccid true cords: after false cords begin to vibrate — False cord phonation due to flaccid true cords (4 of 5): after false cords begin to vibrate

When asked to produce louder voice, the false cords begin to participate in vibration, and a rough, gravelly superimposed “ godfather” quality arrives. Notice that the true cords are in at least partial open phase of vibration.

Supraglottic Phonation

Closed phase (3 of 6) — Supraglottic phonation (3 of 6)

Under strobe illumination. With assistance of topical anesthesia, during high pitched phonation, is the only “true vocal cord voice” this patient can achieve. This is the “closed” phase of vibration, though of course the glottis is not truly closed as one can see from the persistence of the black glottal gap.

False Cord Phonation

Posted on February 21, 2014 by Dr. Robert Bastian

False cord phonation is making voice by vibrating the false vocal cords. This kind of phonation is unlike normal phonation or voice-making, which uses the true vocal cords.

This produces a much deeper, rougher voice quality than normal phonation. It is purposefully used in certain kinds of vocal performance, such as Tibetan chant or heavy metal screaming. It can also occasionally serve as an alternate voice for a person whose true cords are unable to vibrate—due, for example, to their surgical removal or to scarring. It can also be produced concurrently with true cord phonation to produce a “Louis Armstrong” effect.

Photos:

True and False Cord Voice

Thin and weak voice (1 of 4)

This man has a thin and weak voice, often with a superimposed gravelly, rough quality. In this view, false cords, marked with dotted lines, obscure the true cords and their vibration is indicated by blurred margins.

True cords during closed phase (2 of 4)

At much closer range under strobe light, the true cords are approximated during the closed phase of vibration. The false cords should remain lateralized throughout voice production (but don’t).

Flase cords during open phase (3 of 4)

From same viewing position, but during open phase of vibration, showing very “wide” amplitude of vibration caused by flaccidity. The false cords are beginning to come together.

False cords during phonation (4 of 4)

Withdrawing the scope slightly, one can now see the false cords have completed their vibratory closure, explaining the superimposed rough quality. The arrow points to where true cords are, hidden in darkness below the false cords.

True and False Cord ‘Godfather’ Voice

Bowing (1 of 4)

The true cords are together posteriorly but with major bowing seen at the pre-phonatory instant, to explain the husky, weak quality of voice.

Closed phase (2 of 4)

As a result of the need to compress together the weak true cords, false cords also overcompress. This is closed phase of true cords; false cords have not yet reached midline as they are vibrating more slowly than the true cords.

False cord phonation (3 of 4)

Now the false cords have come into contact but below them the true cords have begun their open phase of vibration. We hear the husky, weak true voice with the superimposed rough, gravelly false cord phonation.

True and False cords in open phase (4 of 4)

The true cords are at maximum open phase with enormous lateral excursions typical of flaccid cords. False cords are also at open phase, but as shown in photos 2 and 3, they are vibrating at a lower frequency and out of phase with the true cords.

True and False Cords Vibrate Mostly in Tandem (in phase)

True cords vibrate (1 of 4)

At relatively high pitch, only the true cords vibrate. This is closed phase, under strobe light.

Open phase of vibration (2 of 4)

Open phase, same pitch.

True and false cords, closed phase (3 of 4)

At low pitch, where false cord phonation is facilitated. Both true and false cords are in closed phase of vibration (though the true cords are obscured by the false cords).

True and false cords, open phase (4 of 4)

Both true and false cords are simultaneously in open phase of vibration.

Another Voice Without Vocal Cords

Hemilaryngectomy (1 of 4)

After removal of the anterior larynx (hemilaryngectomy) for cancer that recurred after radiation therapy. Though not well seen here, the vocal cords are surgically absent. The black dot seen is for orientation to the next photo. A = arytenoid; E = epiglottis.

Within the larynx (2 of 4)

A view within the larynx. Note again that vocal cords are surgically absent, with only the arytenoid cartilages remaining at the level of the cords. The black dot, on the left arytenoid cartilage, orients to the prior photo. The dot is on the right vocal process.

"Wolfman Jack" voice (3 of 4)

The patient is about to produce his rough, “Wolfman Jack” voice but the arytenoid mounds have not yet started to vibrate.

Arytenoid vibration (4 of 4)

Aggressive voice use brings arytenoid mounds into vibration (notice blurring). With time and practice, this kind of supraglottic voice can serve moderately well, but it is always difficult to be heard in competition with background noise.

Audio:

True cord phonation

False cord phonation

True and false cord phonation

Laryngeal Vestibule

Posted on December 9, 2013 by Dr. Robert Bastian

The “airspace” above the level of the vocal folds that is bounded by the posterior surface of the epiglottis, the medial surfaces of the aryepiglottic folds, and the anterior faces of the arytenoid cartilages.

Tracheoesophageal Party Wall

Posted on November 1, 2013 by Dr. Robert Bastian

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

Tracheobronchial cough vibration (1 of 2)

Patient with SNC who is treated for presumed infection because of her congested rumbling “productive-sounding” cough. The "X" marks the same place in this photo and the following photo.

Tracheoesophageal Party Wall with Wheezing

Abducted breathing position (1 of 5)

Normal laryngeal entrance, with vocal cords in abducted (breathing) position.

View of mid-trachea (2 of 5)

View in normal mid-trachea. Note that the cartilaginous rings make up approximately 2/3 of the circumference and that the membranous trachea (upper photo at 'X') is more flat.

View just above the carina (3 of 5)

View just above the carina, where the distal trachea splits into left and right mainstem bronchi. Anterior take-off of carina at the 'X'. The straight line delimits the membranous (flexible) tracheal wall.

Wheezing begins (4 of 5)

With Valsalva maneuver to accentuate patient’s functional expiratory wheezing. Note that the membranous tracheal and bronchial walls bulge inward on a functional basis to narrow the airway. Wheezing begins to be heard. The 'X' again marks the anterior take-off of the carina. Compare with Photo 3.

Left bronchus blocked (5 of 5)

As bulging inward continues, the left mainstem bronchus is particularly blocked. This explains why, on auscultation of the chest, wheezing sounds louder on the left than the right. Compare with photos 3 and 4.

Posterior Commissure

Posted on October 30, 2013 by Dr. Robert Bastian

The flat, front-facing surface of the glottic aperture that lies between the vocal cord posterior ends. When the vocal cords are in abducted (breathing) position, the posterior commissure is at its widest, since the cords’ posterior ends are spread furthest apart from each other. When the vocal cords have come together into adducted (voicing) position, the posterior commissure is essentially just the point of contact between the posterior ends of the cords.

In individuals who have acid reflux or other inflammatory conditions, the mucosa at the posterior commissure may thicken (pachyderma).

Anterior Commissure

Posted on October 30, 2013 by Dr. Robert Bastian

The point at which the vocal cords are joined together, which is at the most anterior end of each cord. Compare this with the posterior commissure.

Photos of the Anterior Commissure:

Capillary Ectasia with Vocal Nodules

Subtle Papillomas and the Importance of A Motivated Examination

Standard light, HPV-6 infection (1 of 4)

Breathing position, standard light in a young woman with longstanding HPV-6 infection. Voice remains quite good, many months after her last microsurgery with cidofovir injection. The only obvious “lesion” is posterior right cord (left of image) but the characteristic punctate vascular marks are not seen. The black lines are purely for use to orient photo 4.

Stobe light, vocal cord margin irregularity (2 of 4)

With such a clear voice, this prephonatory instant under strobe light reveals a surprising degree of vocal cord margin “serpentine” irregularity. Black lines again support orientation with photo 4.

Narrow band light, vascular marks seen (3 of 4)

At very close range and also using narrow band light, the tiny punctate vascular marks are seen in the lesion first seen in photo 1. Faint vascularity like that demonstrated here can be a correlate of relatively stable, inactive disease, which has clinically been the case here.

Narrow band light, papilloma formation (4 of 4)

This narrow band view includes only the anterior half of the vocal cords from the black lines of photos 1 and 2 to the anterior commissure (at x). Inside the faint circles, note the vascular markings that suggest papilloma formation to explain the serpentine margin.

Hypopharynx

Posted on October 30, 2013 by Dr. Robert Bastian

Hypopharynx is the inferior-most part of the pharynx, made up of the pyriform sinuses, the lowest part of the posterior pharyngeal wall, and the post-arytenoid/post-cricoid areas.

Reflux Into Hypopharynx, Characteristic of Cricopharyngeal Dysfunction

Hypopharynx Pooling After Swallow

Cervical Osteophyte

Pyriform Sinus

Posted on October 30, 2013 by Dr. Robert Bastian

Pyriform sinus refers to the pear-shaped fossa (Latin for “trench”) just lateral to the laryngeal entrance. Its medial surface is the aryepiglottic cord; laterally it is bounded by the thyroid cartilage, and posteriorly by the low posterior pharyngeal wall. The pyriform fossas and post-arytenoid area together constitute the “swallowing crescent,” which channels swallowed material just before it enters the esophagus, behind the larynx.