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Laryngopedia

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

Inability to Burp or Belch

Posted on September 26, 2016 by Dr. Robert Bastian

Inability to burp or belch occurs when the upper esophageal sphincter (cricopharyngeus muscle) cannot relax in order to release the “bubble” of air. The sphincter is a muscular valve that encircles the upper end of the esophagus just below the lower end of the throat passage. If looking from the front at a person’s neck, it is just below the “Adam’s / Eve’s apple,” directly behind the cricoid cartilage.

If you care to see this on a model, look at the photos below. That sphincter muscle relaxes for about a second every time we swallow saliva, food, or drink. All of the rest of the time it is contracted. Whenever a person belches, the same sphincter needs to let go for a split second in order for the excess air to escape upwards. In other words, just as it is necessary that the sphincter “let go” to admit food and drink downwards in the normal act swallowing, it is also necessary that the sphincter be able to “let go” to release air upwards for belching. The formal name for this disorder is retrograde cricopharyngeus dysfunction (R-CPD).

People who cannot release air upwards are miserable. They can feel the “bubble” sitting at the mid to low neck with nowhere to go. Or they experience gurgling when air comes up the esophagus only to find that the way of escape is blocked by a non-relaxing sphincter. It is as though the muscle of the esophagus continually churns and squeezes without success.

The person so wants and needs to burp, but continues to experience this inability to burp. Sometimes this can even be painful. Such people often experience chest pressure or abdominal bloating, and even abdominal distention. Flatulence is also severe in most persons with R-CPD. Other less universal symptoms are nausea after eating, painful hiccups, hypersalivation, or a feeling of difficulty breathing with exertion when “full of air.” Many persons with R-CPD have undergone extensive testing and treatment trials without benefit. R-CPD reduces quality of life, and is often socially disruptive and anxiety-provoking. Common (incorrect) diagnoses are “acid reflux” and “irritable bowel syndrome,” and therefore treatments for these conditions do not relieve symptoms significantly.

Approaches for treating the inability to burp:

For people who match the syndrome of:
1) Inability to belch
2) Gurgling noises
3) Chest/abdominal pressure and bloating
4) Flatulence

Here is the most efficient way forward: First, a consultation to determine whether or not the criteria for diagnosing R-CPD are met. Next, a simple office-based videoendoscopic swallow study which incorporates a neurological examination of tongue, pharynx (throat) and larynx muscles and often includes a mini-esophagoscopy. This establishes that the sphincter works normally in a forward (antegrade) swallowing direction, but not in a reverse (retrograde) burping or regurgitating fashion. Along with the symptoms described above, this straightforward office consultation and swallowing evaluation establishes the diagnosis of retrograde cricopharyngeus dysfunction (non-relaxation).

The second step is to place Botox into the malfunctioning sphincter muscle. The desired effect of Botox in muscle is to weaken it for at least several months. The person thus has many weeks to verify that the problem is solved or at least minimized.

The Botox injection could potentially be done in an office setting, but we recommend the first time (at least) placing it during a very brief general anesthetic in an outpatient operating room. That’s because the first time, it is important to answer the question definitively, that is, that the sphincter’s inability to relax when presented with a bubble of air from below, is the problem. Furthermore, based upon an experience with more than 190 patients as of August 2019, a single injection appears to “train” the patient how to burp. Approximately 80% of patients have maintained the ability to burp long after the effect of the Botox has dissipated. That is, long past 6 months from the time of injection.

Patients treated for R-CPD as just described should experience dramatic relief of their symptoms. And to repeat, our experience in treating more than 190 patients (and counting) suggests that this single Botox injection allows the system to “reset” and the person may never lose his or her ability to burp. Of course, if the problem returns, the individual could elect to pursue additional Botox treatments, or might even elect to undergo endoscopic laser cricopharyngeus myotomy. To learn more about this condition, see Dr. Bastian’s description of his experience with the first 51 of his much larger caseload.

Check out our list of resources containing peer-reviewed articles, patient stories and more!

Photos of the cricopharyngeus muscle:

Location of the cricopharyngeus muscle — Cricopharyngeus Muscle (1 of 3)

The highlighted oval represents the location of the cricopharyngeus muscle.

Retrograde Cricopharyngeus Dysfunction (R-CPD) — Cricopharyngeus Muscle (2 of 3)

The cricopharyngeus muscles in the open position.

Contracted Cricopharyngeus Muscle (3 of 3)

The cricopharyngeus muscle in the contracted position.

Esophageal Findings: Series of 3 photos

Esophageal Findings (1 of 3)

A view of the mid-esophagus in a young person (early 30’s). The esophagus is kept open by the patient’s un-burped air. Note the “aortic shelf” at A, delineated by dotted lines.

A bony spur in the spine — Esophageal Findings (2 of 3)

A moment later, additional air is pushed upwards from the stomach to dilate the mid-esophagus even more. A bony “spur” in the spine is thrown into high relief by the stretched esophagus.

dilation of the upper esophagus — Esophageal Findings (3 of 3)

A view of the upper esophagus (from just below the cricopharyngeus muscle sphincter) shows what appears to be remarkable lateral dilation (arrows) caused over time by the patient’s unburpable air. Dilation can only occur laterally due to confinement of the esophagus by trachea (anteriorly) and spine (posteriorly), as marked.

Abdominal Distention of R-CPD: Series of 3 photos

x-ray of Gastric Air Bubble — Gastric Air Bubble (1 of 3)

This abdominal xray of an individual with R-CPD shows a remarkably large gastric air bubble (dotted line), and also excessive air in transverse (T) and descending (D) colon. All of this extra air can cause abdominal distention that increases as the day progresses.

Bloated Abdomen (2 of 3)

Flatulence in the evening and even into the night returns the abdomen to normal, but the cycle repeats the next day. To ask patients their degree of abdominal distention, we use pregnancy as an analogy in both men and women. Not everyone describes this problem. Most, however, say that late in the day they appear to be “at least 3 months pregnant.” Some say “6 months” or even “full term.” In a different patient with untreated R-CPD, here is what her abdomen looked like late in every day. Her abdomen bulges due to all of the air in her GI tract, just as shown in Photo 1.

Non-bloated Abdomen (3 of 3)

The same patient, a few weeks after Botox injection. She is now able to burp. Bloating and flatulence are remarkably diminished, and her abdomen no longer balloons towards the end of every day.

Dramatic Lateral Dilation of the Upper Esophagus: Series of 3 photos

lateral dilation of the throat at C6 of the spine — (1 of 3)

This photo is at the level of (estimated) C6 of the spine (at S). This person has known cervical arthritis, accounting for the prominence. Opposite the spine is the trachea (T). Note the remarkable lateral dilation (arrows) in this picture obtained with with no insufflated air using a 3.6mm ENF-VQ scope. It is the patient’s own air keeping the esophagus open for viewing.

(2 of 3)

At a moment when air from below further dilates the upper esophagus, the tracheal outline is particularly well-seen (T) opposite the spine (S). The “width” of the trachea indicated further emphasizes the degree of lateral dilation, which is necessary because spine and trachea resist anteroposterior dilation.

aortic shelf at the mid-esophagus — (3 of 3)

Just for interest, at mid-esophagus, the familiar aortic “shelf” is seen. Again, this esophagus is being viewed with a 3.6 mm scope with only the patient own (un-burped) air allowing this view.

What the Esophagus Can Look Like “Below A Burp”: Series of 3 photos

Baseline (1 of 3)

Mid-esophagus of a person with R-CPD who is now burping well after Botox injection into the cricopharyngeus muscle many months earlier. The esophagus remains somewhat open likely due to esophageal stretching from the years of being unable to burp and also a “coming burp.”

Pre-burp (2 of 3)

A split-second before a successful burp the esophagus dilates abruptly from baseline (photo 1) as the excess air briefly enlarges the esophagus. An audible burp occurs at this point.

burp in the esophagus — Post-burp (3 of 3)

The burp having just happened, the esophagus collapses to partially closed as the air that was “inflating it” has been released.

Where have no-burpers traveled from?

Swelling Checks to Detect Vibratory (Overuse) Injury to the Surface Tissue (Mucosa) of the Vocal Cords

Posted on September 23, 2016 by Dr. Robert Bastian

https://youtu.be/zit6I7EPMto

Vocal Cord Swelling Checks: A Simple Way to Detect the Early Signs of Vocal Injury (https://youtu.be/zit6I7EPMto)

Definition: Vocal tasks (swelling checks) that detect acute or chronic vocal fold mucosal injury reliably; Secondarily, they can also detect gaps between otherwise normal folds.
Purpose /rationale: To provide persons with a way to detect mucosal trouble for themselves. We are in effect “taking all of the clothes off the mucosa.”
Who they are for: Anyone who uses the voice extensively or vigorously—particularly vocal overdoers.*
What they are not for: Voice training or performance.
When they should be done: When first learning the tasks, they should be done often until the concept of one’s mucosal ceiling is understood (see below). Once both proficiency and ceiling are established, the tests require 20 seconds or less both morning and evening.

TEST I: “HAPPY BIRTHDAY”

In your upper voice range, sing the first phrase of “Happy Birthday” as softly as you can, using a “boy soprano pianissimo.” Resist the temptation to “make it work” by getting louder!
Repeat the phrase at progressively higher pitches.
Verify carefully the pitch at which you falter (onset delays or air escape) or can’t go higher without getting louder. THIS IS YOUR MUCOSAL CEILING PITCH, FOR THIS TASK.
If your mucosa is normal, the “soft voice” and “loud voice” ceilings should be about the same.
If your mucosa is abnormal, the “loud” ceiling should be higher than the “soft.”

TEST II: STACCATO

Sing again “boy soprano pianissimo” using the descending staccato figure so so so so so fa mi re do
(5-5-5-5-5-4-3-2-1; e.g. G-G-G-G-G-F-E-D-C) Attack each note precisely in the middle of the continuum
between an aspirated ho and a coupe de glotte. In other words, lightly, precisely, and with a little bounce.
As for “Happy Birthday,” repeat at progressively higher pitches.
Again carefully verify the pitch at which you experience onset delays or air escape or can’t go higher without getting louder. THIS IS YOUR MUCOSAL CEILING PITCH, FOR THIS TASK.

COMMON QUESTIONS

My mucosal ceiling is higher when I do the staccato exercise than it is when I do “Happy Birthday.” What does that mean?

Though needing verification via careful laryngeal examination, this phenomenon suggests that a small gap between the folds, rather than swelling, is the problem.

My mucosal ceiling is higher when I do the “Happy Birthday” exercise than it is when I do staccato. What does that mean?

Again needing verification, this phenomenon suggests a mucosal disturbance rather than a gap as the explanation.

I can figure out my mucosal ceiling easily enough, but how do I know if it is normal?

This can be answered best at the outset by individuals who can compare your performance with that of hundreds of others to whom they have applied these tests (e.g. laryngologist, speech pathologist, voice teacher). It is also helpful at the beginning to correlate your mucosal ceiling with high quality visualization of the vocal folds.

What if my ceiling isn’t normal as compared to others?

The swelling tests are nevertheless just as valuable! Here’s how: Suppose an individual’s initial mucosal ceiling is abnormal because of small vocal nodules, but the person is happy with the voice’s capabilities. Here, the swelling tests can be monitored to help the individual prevent additional mucosal injury, by not allowing the ceiling to descend any further. A different person whose initial ceiling is abnormal might be unhappy with
perceived limitations due to mucosal injury. Now, ongoing use of the swelling tests can confirm the benefits of medical, behavioral (voice therapy) or, eventually, surgical treatments, because the ceiling will rise with successful treatment. Furthermore, these tests can help to avoid recurrent injury.

What if I notice that my ceiling is abnormal (lower) as compared to my usual?

First, consider recent voice use for the possibility that it was “too much.” If so, and/or if the ceiling
remains lowered on subsequent trials of the tests later in the day, “back off” by reducing voice use
until the ceiling returns to your usual pitch, whether “normal” as compared to other persons or not.
Women: Some may find that the ceiling lowers routinely during pre-menstrual days, but returns to normal in a few days.

Do I need to cancel everything until the ceiling recovers?

This depends on the severity of the lowering of the ceiling. Generally, however, careful strategy concerning amount and manner of voice use during this time will allow the mucosa to recover while you continue to work or perform.

Are there common pitfalls in use of the swelling tests?

First and foremost, is the tendency to adjust how the voice is produced when the voice begins to falter. A singer will, for example, unconsciously get a bit louder or use a slight glottal attack to “make it work,” thereby reducing the sensitivity of the tasks. Another might be to perform them without a pitch reference at hand, so that the value of comparing with one’s known “ceiling” pitch is lost. A third might be to become a bit too obsessive and easily “spooked” with any ceiling change. And finally, comes the tendency to “lose the habit!”

* Vocal overdoer: Defined as an individual with both of the following:

A high propensity to use the voice. Generally, “sixes and sevens” on a 7-point (maximum) intrinsic talkativeness scale.
A high extrinsic opportunity or invitation to use voice, based on family, social, vocational, and avocational considerations.

Foreign Content in the Throat

Posted on August 31, 2016 by Dr. Robert Bastian

Photos:

Closeup, magnified examination finds barbecue brush bristle base of tongue: Series of 4 photos

Pain in throat (1 of 4)

While eating barbecued steak, this person felt a sharp pain deep in her throat. At this visit the next day, she continued to feel a sharp sensation, especially when swallowing. Note the faint dark line at the arrow.

abnormality in the throat — Closer view (2 of 4)

From a slightly closer vantage, the abnormality is seen better.

bristle in the throat — Bristle identified (3 of 4)

At even closer range, the bristle is identified.

bristle stuck in the esophagus — Bristle to be removed (4 of 4)

At this final view, the metallic nature of the foreign body and stuck-on carbonaceous debris can be appreciated. This bristle was removed with cup forceps through a channel scope in an office setting.

Granulomatosis with Polyangiitis (GPA)

Posted on August 11, 2016 by Dr. Robert Bastian

A newer term for the auto-immune disorder previously called Wegener’s Granulomatosis.

Idiopathic Subglottic Stenosis

Posted on August 11, 2016 by Dr. Robert Bastian

A subtype of subglottic stenosis that is inflammatory. One view is that this entity is actually a limited expression of Wegener’s Granulomatosis (aka Granulomatosis with polyangiitis).

Podcast:

Photos:

Idiopathic subglottic stenosis has different levels: Series of 4 photos

dilation of idiopathic subglottic stenosis — Post dilation (1 of 4)

Six months after dilation of idiopathic (inflammatory) subglottic stenosis, the patient has noted only slight deterioration, and breathing ability remains acceptable to her.

closer view of idiopathic subglottic stenosis — Closer view (2 of 4)

At closer range, the inflammatory component appears more evident.

Rich vascular pattern (3 of 4)

The rich vascular pattern accompanying the lesion is seen better and is a visual finding of inflammation.

"Sharing" the airway (4 of 4)

Here, the scope has been passed through the area of maximal narrowing and the patient becomes acutely aware of greater difficulty breathing. "Sharing the airway" is a way of 'measuring' it functionally. Note again the congested capillaries.

Another way to inject idiopathic subglottic stenosis: Series of 3 photos

Idiopathic inflammatory subglottic stenosis (1 of 3)

This patient is about to receive a triamcinolone (steroid) injection into her idiopathic inflammatory subglottic stenosis, while sitting in a chair under topical anesthesia. Dotted circle is for reference with Photo 2.

infused medication into cricoid — Priot to injection (2 of 3)

A needle has been passed through anterior neck skin and its tip rests out of sight, submucosally just inferior to the anterior cricoid ring. Note that the milky white medication has been infused submucosally within the dotted ring.

needle in tracheal wall — Injection (3 of 3)

Here, the 27-gauge needle traverses the trachea in order to inject the posterior tracheal wall. The submucosal white medication appears at the *.

Subglottic stenosis

Posted on August 11, 2016 by Dr. Robert Bastian

Subglottic stenosis is narrowing just below the vocal cords, in the lowest part of the larynx and immediately above the first tracheal ring. Examples of causes include scarring from a breathing tube used during a long ICU stay, Wegener’s Granulomatosis (aka Granulomatosis with polyangiitis), and idiopathic subglottic stenosis (aka limited Wegener’s Granulomatosis).

Photos of subglottic stenosis:

Subglottic stenosis, after treatment

Subglottic stenosis, before and after dilation: Series of 2 photos

Subglottic stenosis, before dilation (1 of 2)
This individual has undergone at least a dozen prior dilations, each of which provides dramatic relief from noisy breathing and exercise intolerance. Here the patient is halfway to needing re-dilation, due to the typical inflammatory stenosis that is seen. Compare with photo 2.

Subglottic stenosis, after dilation (2 of 2)
One week after one of this patient's dilations (with Kenalog injection and topical Mitomycin C), showing a dramatic widening of her airway; compare with photo 1. After a number of years, inflammatory lesions such as this sometimes "burn out," and the interval between dilations increases.

Subglottic / Tracheal stenosis: Series of 4 photos

Subglottic / Tracheal stenosis (1 of 4)
Inflammatory subglottic/tracheal stenosis, thought to be the result of an incomplete expression of Wegener's granulomatosis (no history of trauma).

Subglottic / Tracheal stenosis (2 of 4)
Close view, from vocal cord level.

Subglottic / Tracheal stenosis (3 of 4)
Close view, from just above vocal cords.

Subglottic / Tracheal stenosis (4 of 4)
Close view, showing the inflammatory nature of the stenosis.

Subglottic stenosis, due to Wegener's granulomatosis: Series of 2 photos

Subglottic stenosis, due to Wegener's (1 of 2)
This person has Wegener’s granulomatosis, confirmed by anti-neutrophil cytoplasmic antibodies (ANCA) testing. Here, looking from above the vocal cords, one can see an estimated 50% narrowing of the subglottic and high tracheal passageway.

Subglottic stenosis, due to Wegener's (2 of 2)
Viewed from within the subglottis, one can see more clearly the inflammatory nature of this stenosis. A dotted oval estimates what the normal caliber or width of this airway would be. This patient has been managed with systemic medication, but also occasional dilation, steroid injection, and Mitomycin C application.

Subglottic stenosis, before and after dilation: Series of 5 photos

Subglottic stenosis (1 of 5)
Middle-aged woman with unexplained shortness of breath and noisy breathing, due to this idiopathic inflammatory and very high subglottic stenosis. The patient initially declined dilation due to her anxiety. She also had granularity of the nasal septum and a positive ANCA profile for Wegener’s granulomatosis.

Subglottic stenosis, worsened (2 of 5)
Five months later, the symptoms became intolerable, and the stenosis was noted to be slightly narrower and with a greater posterior component. The patient agreed to dilation.

Subglottic stenosis, worsened (3 of 5)
Same exam as photo 2; this close-up view shows more clearly the inflammatory nature of this stenosis.

Subglottic stenosis, after dilation (4 of 5)
Five days after outpatient dilation, triamcinolone injection, and topical mitomycin C application. The patient’s symptoms have vanished, the harsh inspiratory noise is no longer heard, and the size of the airway, though still not normal, is more than doubled. Compare with photo 2 of this series.

Subglottic stenosis, after dilation (5 of 5)
Same exam as photo 4, close-up view. Intensification of the inflammatory changes of this stenosis are expected so early after dilation. Compare size of the stenosis with photo 3 of this series.

Stenosis before and after dilation for forme fruste Wegener's: Series of 5 photos

Subglottic stenosis (1 of 5)
High-grade subglottic stenosis in a woman diagnosed syndromically with forme fruste Wegener's granulomatosis-related subglottic stenosis. With a narrowing less than 50%, she is very symptomatic. Her breathing is noisy, and her forced inspiration time is about 3 seconds. Compare with photo 4.

Inflammation (2 of 5)
Closer visualization reveals the inflammatory nature of the stenosis.

Flexible scope (3 of 5)
Here the distal chip flexible scope has passed through the narrowing not only to see into distal trachea, but also as a breathing test. The patient becomes very aware of reduced space and this indicates a marginal airway.

Post-dilation (4 of 5)
A week after dilation, triamcinolone injection and mitomycin C application, the patient says breathing is now normal, and forced inspiration time is only a second in duration--normal. Compare with photo 1.

Post-operative bruising (5 of 5)
Closer visualization with early postoperative bruising. The trachea is now easily visible through the larger opening. Compare with photo 2.

Pinhole opening in near-complete subglottic stenosis: Series of 4 photos

Narrowed space for breathing (1of 4)
This man was gravely ill and intubated for several weeks. He is now well, but tracheotomy-dependent. The vocal cords do not abduct fully due to scarring of the cricoarytenoid joints. However, the narrowed space for breathing between the posterior vocal cords is not the main reason he is tracheotomy-dependent, as seen in the next photos.

Looking between the vocal cords (2 of 4)
At closer range, a deep erosion “divot” of the right posterior vocal cord (left of photo at dotted line) is the result of pressure necrosis of the endotracheal tube. Looking between the vocal cords into the subglottic airway, a small white oval is seen (arrow). This is the upper surface of the white plastic tracheotomy tube.

Closer view (3 of 4)
A closer view, again through the vocal cords.

Space between subglottis and trachea (4 of 4)
At yet closer range. The size of this pinhole between subglottis and trachea below cannot measure more than 3 mm. Crico-tracheal resection and re-anastomosis (planned for soon after this examination) is the best option to work towards decannulation.

Difficulty breathing after a 3-day intubation: Series of 5 photos

Noisy, restricted breathing following intubation (1 of 5)
This teenager was intubated for 3 days due to tongue swelling. Breathing became noisy and restricted approximately 6 weeks later. Note that the vocal cords do not abduct fully and there is what appears to be granulation tissue at the posterior commissure (anterior asterisk).

Normal voice (2 of 5)
The vocal cords can come into contact as shown here, consistent with her normal-sounding voice.

At close range (3 of 5)
At very close range within the posterior commissure, a small tract is seen posterior to the "granulation" which is now seen more clearly to be a broad-based synechiae with asterisks marking anterior and posterior limits.

At even closer range (4 of 5)
An even closer view verifies a posterior tract, and this makes it less likely that the cricoarytenoid joints are also injured.

Mucosa-only scar (5 of 5)
This view is taken with the scope passed just between the vocal cords and just anterior to the synechiae and angled directly posteriorly. A small superficial-looking "mucosa-only" scar is seen bilaterally, surrounded by dotted line. It can be confidently predicted that when the synechiae is released, the arytenoid cartilages will likely be able abduct fully.

Open Epidermoid Cyst

Posted on July 19, 2016 by Dr. Robert Bastian

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.

Photos of open epidermoid cyst:

A Case That Clearly Shows the Relationship Between Cyst & Sulcus: Series of 6 photos

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: Series of 3 photos

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: Series of 4 photos

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: Series of 6 photos

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: Series of 4 photos

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.

Indicator Lesions

Posted on December 28, 2015 by Dr. Robert Bastian

Indicator lesions are visual findings of vibratory injury in a person who has no current voice complaints, and whose “swelling checks” are normal.

Background:

Individuals who fit the “vocal overdoer profile” may only notice vocal limitations caused by vibratory injury on an occasional and transient basis. These episodes may be brushed off as insignificant, because they are so brief, and recovery so complete. Even while asymptomatic, however, such individuals may have subtle visual findings of vibratory injury—“Indicator lesions.” Unless discovered during a screening examination for entry to music studies, the individual may be unaware of these findings. What if indicator lesions are found? Suggested responses:

1. Make sure the individual understands that these are indicator lesions and as such constitute a “yellow flag” suggesting at least occasional overuse of voice.

2. Define the “vocal overdoer syndrome” for the person as the combination of and interaction between an expressive, talkative, extroverted personality and a “vocally busy” life. Said another way, there may be both intrinsic, personality-based and extrinsic, vocal commitment based reasons that amount and forcefulness of voice may be excessive. A 7-point talkativeness scale can be used to estimate the intrinsic risk, where “1” represents Clint Eastwood, “4” the averagely talkative person, and “7” the life of the party. The extrinsic risk is addressed by making a list of vocal commitments such as for occupation, childcare, hobbies, social activities, religious practice, athletics/ sports, and rehearsal and performance.

3. Discuss the symptom complex of mucosal injury: a) loss/ impairment of high, pianissimo singing; b) day-to-day variability of vocal clarity and capability; c) a sense of increased effort to produce voice; d) reduced mucosal endurance, or becoming “tired” vocally from amount/ manner of voice use that does not seem to induce this in others; and e) phonatory onset delays—the slight hiss of air that precedes the beginning of the sound, especially if high and soft. Speaking voice hoarseness can be a fairly late and gross symptom of mucosal injury.

4. Talk about managing the amount, manner, and spacing of voice use to reduce unnecessary wear and tear on the vocal cord mucosa.

5. Teach vocal cord swelling checks as a means of detecting even subtle injury. Respond to what they tell you!

Singers are understandably distressed when they discover even the tiniest mucosal swelling such as indicator lesions. That is because for true singers, singing is not just what they do; the term “singer” also defines who they are. So injury threatens both activity and identity. Consequently, discuss indicator lesions with great care and sensitivity. Keep in mind that some doctors speak of “small vocal nodules that do not interfere with singing.” Small nodules that are but a tiny step above indicator lesions, especially when spicule-shaped rather than fusiform, always exact a penalty to the singing voice (see #3 above), but limitations can often be concealed by warming up, and singing more loudly. Singers often say “I have a big voice that doesn’t do pianissimo.” That is, pp becomes p; mp becomes p; mf becomes f; and so forth. Alternatively, the singer considers the missing pianissimo to be a technical fault.

Photos of Indicator Lesions:

Indicator lesions and MTD: Series of 6 photos

Breathy voice (1 of 6)
Distant view at the prephonatory instant in young female singer. There is a wide gap between the cords. The explanation for this gap is not immediately evident, but the voice is breathy.

Phonation (2 of 6)
Phonation has started with margin blurring, and the sense of extra space between the cords remains.

Open phase (3 of 6)
Strobe light, open phase of vibration at B4 (494 Hz)

Closed phase (4 of 6)
Closed phase of vibration, still at B4. Note the incomplete closure posteriorly caused by MTD. Arrows indicate the vocal processes.

Open phase, indicator lesions (5 of 6)
Open phase of vibration, strobe light, at F#5 (740 Hz). Here, the subtle indicator lesions are seen more clearly; vocal cord margins are not perfectly straight.

"Closed" phase, MTD (6 of 6)
“Closed” phase of vibration is not really closed and the vocal processes do not come into full closure, again consistent with MTD.

Indicator lesions: Series of 4 photos

Middle-aged teacher (1 of 4)
Middle-aged teacher who also sings. She is aware of effortfulness to sing; this is hard to interpret because she is pre-menopausal and also not actively singing/ grooming her voice. Extraordinarily subtle margin swellings could easily be overlooked in this view.

Phonatory view (2 of 4)
During phonation at E-flat 4 (311 Hz) with vibratory blurring under standard light. The subtle narrowing of the blurred dark line between the folds could still be overlooked.

Pre-phonatory instant (3 of 4)
Use of the pre-phonatory instant by having the patient do repeated staccato at the same pitch. Here, very small, low-profile, and broad-based swellings can be seen.

Indicator swellings (4 of 4)
At much higher pitch, E5 (659 Hz) and using strobe light. In this view of the open phase of vibration, at high magnification, the rounded “indicator swellings” are seen best.

Vocal Cord Synechia

Posted on December 18, 2015 by Dr. Robert Bastian

Vocal cord synechia is a strand of scar tissue that tethers the vocal cords to each other. It can prevent the vocal cords from opening fully for breathing.

A synechia can also form in other parts of the body. (Note the subglottic synechia shown below.)

Photos:

Vocal Cord Synechia: before, during, and after surgery

Vocal Cord Synechia (1 of 9)

Post-intubation synechia tethers the arytenoid cartilages together. This patient is tracheotomy-dependent.

Vocal cord synechia during surgery — Vocal cord synechia, during surgery (2 of 9)

Operative view of synechia ("v" of the vocal cords is inverted). Notice that the vocal cords are completely approximated because the synechia has bound them together.

Tiny forceps are separating the cords — Vocal cord synechia, during surgery (3 of 9)

Tiny forceps is separating the cords (arrows) and more clearly shows the extent of the synechia.

Vocal cord synechia, during surgery (4 of 9)

Micro-scissors in position to divide the synechia cleanly. For perspective, the blade of the scissors is only a few millimeters long.

Vocal cord synechia, during surgery (5 of 9)

After division of the synechia and topical application of an anti-scarring agent.

Vocal cord synechia after surgery — Vocal cord synechia, after surgery (6 of 9)

Five days after surgery. Vocal cords are able to separate for breathing, and the tracheotomy tube can be removed. Compare with photo 1.

Vocal Cord Synechia, after surgery (7 of 9)

Completely healed larynx after release of synechia. Abduction completely restored.

Vocal cord synechia, after surgery (8 of 9)

As the vocal cords are coming together for phonation (not yet completely adducted).

Ossified synechia resists thulium laser

Tip of glass fiber near the Ossified Synechia — Ossified Synechia, during first laser treatment (2 of 8)

Close-range view of the synechia. The tip of the glass fiber through which laser energy will be delivered is seen just inferior to the synechia.

Laser energy reveals bone underneath — Ossified synechia, during first laser treatment (3 of 8)

As the synechia is divided, a core of bone formation is exposed. More than half of the laser energy has been delivered to this spar of bone, yet it will not yield. The tip of the scope has also been flexed against the synechia to no avail. A second attempt with higher energy laser has been scheduled.

Ossified synechia 4 months later — Ossified synechia, 4 months later (4 of 8)

Four months later. The synechia remains, and there is residual granulation tissue on its undersurface. It's not yet known whether the spar of bone is still present. Compare with photo 2.

Second surgery attempt of thulium laser — Ossified synechia, 4 months later (5 of 8)

Now, with the thulium laser, beginning a second attempt at dividing the synechia.

Thulim laser reveals no bone remaining in ossified synechia — Ossified synechia, 4 months later (6 of 8)

The spar of bone is not found within the synechia (apparently turned to ash during the original procedure four months earlier), and now the scar band is divided. The patient could feel the difference in her breathing immediately.

synechia is now gone 6 months later — Synechia gone, 6 months later (7 of 8)

Six months after the initial laser treatment for this patient's bone-containing synechia. The synechia is now gone, with only a small residual projection remaining, left of photo. The vocal cords also separate more widely, to a wider "V".

Synechia gone, 6 months later (8 of 8)

During phonation. The divots from pressure necrosis of the endotracheal tube remain evident. In spite of them, the patient's voice is excellent.

Vocal cord synechia

Intubation injury, including a subglottic synechia

View of the vocal cords in abducted position — Intubation injury, including a subglottic synechia (1 of 2)

View of the vocal cords, in abducted position, in a patient with voice change after long-term intubation due to brain injury. Injury of the left posterior vocal cord (right of image) can be seen, where pressure from the breathing tube caused an erosion or divot (arrow). The synechia is not yet visible from this viewing perspective.

posterior synechia — Intubation injury, including a subglottic synechia (2 of 2)

Same patient, just below the level of the cords. This synechia, located posteriorly, is additional evidence of breathing tube injury.

Synechia hidden by overhanging arytenoid superstructure

Synechia hidden by overhanging arytenoid superstructure (1 of 4)

Maximum possible abduction of the vocal cords, as seen a few months after an illness that required endotracheal intubation for 3 weeks. This person experienced noisy breathing with any significant exertion.

Synechia hidden by overhanging arytenoid superstructure (2 of 4)

With elicited sudden inhalation the inspiratory air draws the vocal cords together, and the result is involuntary inspiratory phonation.

Synechia hidden by overhanging arytenoid superstructure (3 of 4)

Close-up view of the posterior vocal cords reveal a synechia or scar band tethering the vocal cords to each other and preventing their abduction. This kind of injury can exist in isolation; it can also occur together with cricoarytenoid joint ankylosis.

Synechia hidden by overhanging arytenoid superstructure (4 of 4)

An even closer view of the synechia.

Nasal and inter-arytenoid synechiae, with subglottic stenosis in forme fruste Wegener’s

inflammatory adhesion in left nasal cavity — Nasal cavity (1 of 4)

View in left nasal cavity, showing inflammatory adhesion between septum and turbinate/ lateral wall of nose. Note intense erythema at “e.” Dotted line shows where normal separation would be seen.

adhesion of septum and turbinates — Closer view (2 of 4)

Closer, brighter view, again with dotted line where there should be no tissue bridge, but instead separation between septum and turbinates. This adhesion is asymptomatic, and therefore does not need to be treated.

Panoramic view (3 of 4)

Panoramic view of larynx, showing adhesion between arytenoid cartilages indicated by vertical hashed lines. Horizontal dashed line is for reference with the next photo.

interarytenoid synechia is no longer seen after dilation — Post dilation (4 of 4)

After dilation, the interarytenoid synechia is no longer seen. Subglottic stenosis is present but not shown in this series.

Ulcerative laryngitis and resulting synechia – fixed!

Synechia (1 of 3)

This woman developed a sore throat and lost her voice a week after a chemotherapy treatment for her metastatic breast cancer. Here, 6 weeks later, note the hazy area representing resolving “ulcerative” laryngitis (surrounded by tiny dotted line). There is a synechia attaching the cords together.

slight separation of attached vocal cords — Attempted to detach (2 of 3)

The flexible scope has been used once to “twang upwards” from below in order to detach the cords from each other. At the arrow, slight separation can be seen.

Successfully detached (3 of 3)

Just after the second attempt. That is, for the second time, the scope was passed below the cords, angulated sharply underneath the synechia, and then pulled upwards. The adhesion has been released. Voice is instantly and dramatically restored (though still hoarse, of course).

Posterior Commissure Synechiae

tissue band tethers the vocal cords closer together — Tethered vocal cords (1 of 5)

This man has right vocal cord paralysis and a history decades ago of Teflon injection into the right vocal cord, resulting in posterior commissure synechiae. He is short of breath, partly due to the tissue band and partly because it tethers the vocal cords closer together than they would otherwise need to be as seen in photo 4 after the band is removed. See also photo 5.

Tethered vocal cords (2 of 5)

At closer range.

thulium laser fiber is touching the synechiae — Before laser removal (3 of 5)

The thulium laser fiber (F) is touching the synechiae, with laser energy about to be delivered.

Immediately after laser (4 of 5)

This is just after the thulium laser division of the band using topical anesthesia only, with patient sitting in a chair.

Vocal cords free of synechiae — One month post-op (5 of 5)

A month later, no residue of the synechiae is seen, and the vocal cords can spring farther apart than in photo 1.

Difficulty Breathing After A 3-day Intubation

Noisy, restricted breathing following intubation (1 of 5)

This teenager was intubated for 3 days due to tongue swelling. Breathing became noisy and restricted approximately 6 weeks later. Note that the vocal cords do not abduct fully and there is what appears to be granulation tissue at the posterior commissure (anterior asterisk).

vocal cords come into contact — Normal voice (2 of 5)

The vocal cords can come into contact as shown here, consistent with her normal-sounding voice.

small tract is seen posterior to the granulation — At close range (3 of 5)

At very close range within the posterior commissure, a small tract is seen posterior to the "granulation" which is now seen more clearly to be a broad-based synechiae with asterisks marking anterior and posterior limits.

At even closer range (4 of 5)

An even closer view verifies a posterior tract, and this makes it less likely that the cricoarytenoid joints are also injured.

small superficial-looking scar — Mucosa-only scar (5 of 5)

This view is taken with the scope passed just between the vocal cords and just anterior to the synechiae and angled directly posteriorly. A small superficial-looking "mucosa-only" scar is seen bilaterally, surrounded by dotted line. It can be confidently predicted that when the synechiae is released, the arytenoid cartilages will likely be able to abduct fully.

Videos:

https://youtu.be/yF9pU_CncW4

Vocal Cord Synechia
Vocal cord synechia is a condition wherein a scar band tethers the vocal cords to each other. Therefore, the vocal cords cannot fully open for breathing. This video provides a clear example — using laryngeal videostroboscopy — of a vocal cord synechia.

Recurrent Respiratory Papillomatosis (RRP) and Other HPV-Induced Lesions

Posted on December 18, 2015 by Dr. Robert Bastian

A disorder in which wart-like tumors or other lesions grow recurrently within a person’s airway. These growths are caused by the human papillomavirus (HPV), and they may occur anywhere in a person’s airway, such as on the vocal cords (by far the most common site), in the supraglottic larynx, or in the trachea. If these growths are removed, they will almost always grow back, or recur; hence, “recurrent respiratory papillomatosis.”

Symptoms and risks of recurrent respiratory papillomatosis:

RRP can be life-threatening in young children, if not carefully followed and treated, since a child’s airway is relatively narrow and can potentially be obstructed completely by the disease’s proliferative growths; moreover, RRP in children tends to grow and recur more aggressively. In adults, RRP will usually only impair voice function (when the growths occur on the vocal cords), though it can also impair breathing in severe cases. Occasionally, RRP can also progress to cancer, and therefore patients found to be at high risk for this (see below) need to be monitored carefully.

Characteristics of the growths:

The growths usually associated with RRP are wart-like tumors, or papillomas, that protrude conspicuously from the surface on which they grow, often in grape-like clusters. These kinds of papillomas are usually seen in patients who have HPV subtypes 6 or 11, which are both lower-risk subtypes for incurring cancer. There are some HPV patients, however, who manifest their HPV infection with subtler, velvety growths within the airway—“carpet-variant” growths, so to speak. Although these “carpet-variant” growths do not have the wart-like appearance of the papillomas typically associated with RRP, there at least a few key points of similarity:

Both the “carpet-variant” and wart-like growths are lesions that sometimes appear, either independently or together, in patients who have HPV;
Both the “carpet-variant” and wart-like growths are stippled with polka-dot vascular markings, because each “loop” in the “carpet” or each “grape” in the wart-like cluster has its own fibrovascular core, seen as a red dot;
Both the “carpet-variant” and wart-like growths can disrupt voice function;
Both the “carpet-variant” and wart-like growths usually recur if they are removed.

Because of these similarities, we consider these “carpet-variant” growths, even when the sole expression of the infection, to be at least a cousin to RRP, within the family of HPV-induced lesions. Many patients with this “carpet-variant” condition have HPV subtypes such as 16 or 18 that are higher-risk for cancer; such patients need to be monitored with particular care.

Treatment for recurrent respiratory papillomatosis:

The primary treatment for RRP and other HPV-induced lesions is careful, conservative surgical removal of the growths. Because these growths almost always recur, surgery must usually be performed on a repeated basis, as frequently as every few weeks in children, but on average much less often in adults. A common interval between surgeries for adult patients is between every six months and every two years, depending on how quickly the RRP or other HPV-related lesion recurs and impairs the patient’s voice function again. There are also a few medical treatments that have been used in addition to surgery, including, among others, interferon, indole-3-carbinol, intralesional mumps or MMR (measles-mumps-rubella) vaccine, cidofovir, and bevacizumab.

Photos:

Papillomas, HPV subtype 11, before and after removal: Series of 4 photos

Papillomas: HPV Subtype 11 (1 of 4)
Papillomas at posterior vocal cords, with left side (right of image) much larger than right. This patient has HPV subtype 11.

Papillomas: HPV Subtype 11 (2 of 4)
Closer view, under narrow band illumination, which accentuates the vascular pattern.

Papillomas, removed: HPV Subtype 11 (3 of 4)
Two weeks after microsurgical removal, cidofovir injection, and return of normal voice.

Papillomas, removed: HPV Subtype 11 (4 of 4)
Closer view of left posterior vocal cord, narrow band illumination. Notice that there are a few dot-like vascular marks. These are typical of HPV effect, and may presage recurrence.

Papillomas, HPV subtype 6, before and after removal: Series of 4 photos

Papillomas: HPV Subtype 6 (1 of 4)
Papilloma, left vocal cord (right of image), standard light. Voice is grossly hoarse. This patient has HPV subtype 6.

Papillomas: HPV Subtype 6 (2 of 4)
Same lesion, under narrow band illumination.

Papillomas, removed: HPV Subtype 6 (3 of 4)
After removal and cidofovir injection, normalized larynx. Voice is normal.

Papillomas, removed: HPV Subtype 6 (4 of 4)
Same view, under narrow band illumination.

Papillomas, HPV subtype 11: Series of 3 photos

Papillomas: HPV Subtype 11 (1 of 3)
Panoramic view, standard light, shows papillomas on the aryepiglottic cord, false cords, anterior face of arytenoid, and at anterior commissure. This patient has HPV subtype 11.

Papillomas: HPV Subtype 11 (2 of 3)
Closer view, standard light, shows more clearly the papillomas on the anterior face of the right arytenoid and at the anterior commissure.

Papillomas: HPV Subtype 11 (3 of 3)
Still closer view, to see more clearly the anterior commissure papilloma.

HPV lesions: Series of 2 photos

Lesions of HPV Subtype ? (1 of 2)
Under standard light, faint stippled vascularity is seen, along with a general mild inflammatory response (pinkness). Patients like this are often misdiagnosed with acid reflux.

Lesions of HPV Subtype ? (2 of 2)
Same patient, narrow band light. Now seen is the stippled, HPV-effect kind of vascularity of “carpet-variant” lesions.

Lesions and papillomas of HPV, before and after removal and adjuvant injection: Series of 8 photos

Lesions and papillomas of HPV subtype ? (1 of 8)
At initial diagnosis, as yet untyped for HPV. Multi-focal lesions on both vocal cords.

Lesions and papillomas of HPV subtype ? (2 of 8)
Narrow-band illumination and a different viewing angle better reveal the more subtle lesion on the upper surface of the right cord (dotted circle).

Lesions and papillomas of HPV subtype ? (3 of 8)
Strobe light, open phase of vibration, showing mismatch.

Lesions and papillomas of HPV subtype ?, 1 week after removal (4 of 8)
One week after removal of papillomas, voice is dramatically restored. Strobe light, open phase of vibration. Compare with photo 3.

Lesions and papillomas of HPV subtype ?, 1 week after removal (5 of 8)
Strobe illumination, closed phase. Even in falsetto, oscillatory ability is preserved due to the precise and superficial removal of the papillomas.

Lesions and papillomas of HPV subtype ?, injecting adjuvant (6 of 8)
At three weeks after removal, the patient regards his voice as normal. The patient has neither lesion nor vascular change to suggest any residual or recurrent lesion. Needle in photo (arrow) positioned to inject adjuvant medication in attempt to prevent recurrence. This procedure is done in a voice lab under topical anesthesia, not the operating room.

Lesions and papillomas of HPV subtype ?, after injecting adjuvant (7 of 8)
After both cords have been “inflated” with adjuvant medication. Note the convex, slightly blanched vocal cord margins, due to superficial infiltration of the medication.

Lesions and papillomas of HPV subtype ?, after final adjuvant injection (8 of 8)
Nearly a month later, immediately after the third and final adjuvant injection (hence the blood below the vocal cords). The patient again regarded his voice as completely normal. No sign at this early point of recurrence of papillomas or other HPV lesions. Patients with focal disease as seen in photo 1 of this series not infrequently go into long-term remission or “cure,” though it may be impossible to discern the relative roles of surgery, adjuvants, and the patient’s immune system.

Papillomas, HPV subtype 55, going into remission: Series of 4 photos

Papillomas: HPV Subtype 55 (1 of 4)
Papillomas of the vocal cords, in a patient with HPV subtype 55, which is intermediate-risk for progressing to cancer.

Papillomas: HPV Subtype 55 (2 of 4)
Same exam, with narrow-band lighting, which accentuates the vascular pattern of the papillomas.

Papillomas, in remission: HPV Subtype 55 (3 of 4)
Same patient, years later, in remission, and with normal voice. No sign of papillomas here or anytime during the prior three and a half years, after meticulous removal and Cidofovir treatment.

Papillomas, in remission: HPV Subtype 55 (4 of 4)
Same exam as photo 3, with narrow-band lighting. The vascular dots on the vocal cords are not HPV-related.

Papillomas, HPV subtype 11: Series of 2 photos

Papillomas: HPV Subtype 11 (1 of 2)
Vocal cords, narrow band light, showing papillomas on the upper surface of the anterior vocal cords. This patient has HPV subtype 11.

Papillomas: HPV Subtype 11 (2 of 2)
Tracheal view, standard light, showing scattered papillomas (arrows). The carina is in the distance.

Papillomas, HPV subtype 31, going into remission: Series of 4 photos

Papillomas: HPV Subtype 31 (1 of 4)
Standard light, showing lesions on the vocal cords, in particular the stippled vascular pattern we call "HPV effect." The patient's voice was nearly gone, with numerous syllable drop-outs and a very effortful quality. Compare with photo 3.

Papillomas: HPV Subtype 31 (2 of 4)
Closer view, using narrow-band light to accentuate the vascular pattern of "HPV effect." Biopsy and additional testing of these lesions showed squamous papilloma with moderate dysplasia, and HPV subtype 31 was confirmed, which is high risk for eventually causing cancer. After the patient underwent several injections of cidofovir, the lesions persisted but seemed to become more indolent. On compassionate grounds, this fairly young person was then prescribed celecoxib for six months.

Papillomas, in remission: HPV Subtype 31 (3 of 4)
Three years after photos 1 and 2, standard light view. Within two months of the start of celecoxib, voice improved very noticeably, and the "HPV effect" vascularity resolved. Still, it is unknown what roles in this recovery were played by the patient's immune system, the cidofovir, and the celecoxib, respectively.

Papillomas, in remission: HPV Subtype 31 (4 of 4)
Closer view than photo 3, under narrow-band light.

Papillomas, HPV: Series of 2 photos

Papillomas: HPV Subtype ? (1 of 2)
Papillomas involving both the true and false vocal cords.

Papillomas: HPV Subtype ? (2 of 2)
At higher magnification, the stippled vascular markings become more evident.

Pushing past red herrings to find the real issue: Series of 3 photos

Obvious lesion not important (1 of 3)
Several months after removal of exuberant papillomas, voice remains quite good, but is becoming a little deeper. The obvious lesion here is not important; the subtle one is the key.

Granuloma (2 of 3)
Narrow band light reveals the spherical lesion to be a granuloma, not papilloma (which would have stippled vascular markings).

Carpet-varient papilloma (3 of 3)
At closer range, still under narrow band light, carpet-variant papilloma can be seen on the posterior right vocal cord (left of photo). This is the important finding.

Papillomas, HPV subtype 18 or 45: Series of 2 photos

Papillomas: HPV Subtype 18 or 45 (1 of 2)
Papilloma growths on the right vocal cord (left of image), standard light. This patient's papillomatosis is caused by HPV, narrowed down to either subtype 18 or 45.

Papillomas: HPV Subtype 18 or 45 (2 of 2)
Slightly magnified view of the same papilloma growths under narrow-band illumination, which accentuates the vascular pattern.

Lesions of HPV subtype 16: Series of 3 photos

Lesions of HPV Subtype 16 (1 of 3)
Recurring inflammatory and leukoplakic lesions caused by HPV subtype 16. A left vocal cord cancer (right of image) was removed several years earlier, and the patient developed a right vocal cord cancer almost a year later.

Lesions of HPV Subtype 16 (2 of 3)
Slightly magnified view, focusing on the anterior (frontward) ends of the vocal cords. The cords' stippled vascularity, which often accompanies HPV infection, is more apparent here.

Lesions of HPV Subtype 16 (3 of 3)
A similar view to image two, but with narrow-band illumination, which accentuates the vascular pattern. Biopsy/removal of these lesions revealed high-grade dysplasia; re-biopsy almost a year after this examination returned a diagnosis of cancer.

Cancer, HPV Subtype 16, before and after radiation: Series of 5 photos

Cancer: HPV Subtype 16 (1 of 5)
Cancer, in a patient with HPV subtype 16. The divot and blood seen on the left vocal cord (right of image) are the result of a biopsy performed elsewhere (not by BVI physician) earlier the same day as this examination.

Cancer: HPV Subtype 16 (2 of 5)
Closer view.

Cancer: HPV Subtype 16, after radiation therapy (3 of 5)
Six weeks after the end of radiation therapy, the tumor is no longer seen. However, part of the left cord (right of image) is missing, due to sloughing of the tumor that had eaten away part of the cord’s normal tissue.

Cancer: HPV Subtype 16, after radiation therapy (4 of 5)
Phonation. Strobe light, open phase of vibration, shows that the margin of the left cord (right of image) is at a lower level than the right’s, due to loss of some of the bulk of the cord where the tumor died and sloughed away.

Cancer: HPV Subtype 16, after radiation therapy (5 of 5)
Strobe light, closed phase of vibration. The more normal right cord (left of image) unsuccessfully attempts to reach the left cord’s residual upper surface mucosa. Voice is functional but hoarse.

Papillomas, HPV subtype 45: Series of 2 photos

Papillomas: HPV Subtype 45 (1 of 2)
Papillomas in the supraglottis, left of image. The pink, velvety area of papillomas is outlined by small arrows.

Papillomas: HPV Subtype 45 (2 of 2)
Closer view of the vocal cords, showing leukoplakia. This is presumably a second expression of the HPV infection, though the typical dotted or pointed vascular marks of HPV are not seen in the area of the leukoplakia.

Mid-tracheal papilloma, treated by thulium laser: Series of 5 photos

Mid-tracheal papilloma, being treated by thulium laser (1 of 5)
The papilloma is seen attached to the posterior tracheal wall, at the midpoint of the trachea. Note the areas of scarring from prior laser procedures. The dots seen indicate reference points for photo 5.

Mid-tracheal papilloma, being treated by thulium laser (2 of 5)
Using the channel scope, a blue glass fiber is extended from the tip of the scope.

Mid-tracheal papilloma, being treated by thulium laser (3 of 5)
In a closer view, the papilloma has been mostly cauterized using near-contact (not touching) mode.

Mid-tracheal papilloma, being treated by thulium laser (4 of 5)
The papilloma is then penetrated multiple times to deliver laser energy to its base. Some of the papilloma is pulled off by attachment to the fiber, and the remainder will slough off and be swept upwards by the mucociliary blanket (thin layer of mucus being swept upward) within the trachea.

Months after treatment: no papilloma (5 of 5)
Durable resolution of papilloma, many months afterwards. Compare with photo 1.

Subtle papillomas, HPV subtype 6: Series of 3 photos

Subtle papillomas, HPV subtype 6 (1 of 3)
After achieving a normal voice through several procedures, the patient came in for reexamination due to the return of mild huskiness. This distant panoramic view with standard illumination does not reveal any obvious papillomas.

Subtle papillomas, HPV subtype 6 (2 of 3)
At close range, using narrow band illumination, a subtle but definite HPV effect is seen. Notice the stippled vascular markings and the faintly increased pinkness at the margins of the cords, indicated by dotted lines.

Subtle papillomas, HPV subtype 6 (3 of 3)
With the vocal cords now at the pre-phonatory instant, these low-profile HPV-related papillomas are again seen, indicated by dotted lines.

HPV vascular effect: Series of 3 photos

Two papillomas (1 of 3)
Approximately one month after removal of papillomas and Avastin injection in a man who has battled aggressively-recurring disease caused by HPV, type 6. In this view using narrow band light, only two small papillomas are visible.

Stippled vascularity (2 of 3)
At closer range, careful inspection shows no papilloma (yet), but only the stippled vascularity typical of HPV infection.

HPV vascular effect (3 of 3)
HPV vascular effect is seen even more clearly.

Laryngeal papillomas rarely can be found by ... accident: Series of 4 photos

Papilloma finding (1 of 4)
This young man had a tonsil problem and normal voice but during the initial head and neck examination was found to have a papilloma in his larynx. Rapid recurrence and spread triggered referral. Note stippled vascularity on masses along the edges of the false vocal cords.

Narrow band light (2 of 4)
Narrow band light makes the papillomas much more evident.

Closed phase (3 of 4)
Under strobe light, closed phase of vibration, the true cords are seen to be uninvolved, and this explains his normal voice.

Open phase (4 of 4)
Open phase of vibration, strobe light. The plan is definitive removal and HPV subtyping.

Winning papilloma battles, but not winning the war....yet: Series of 8 photos

Left vocal cord lesion (1 of 8)
Middle aged woman with a 6-month history of hoarseness. Note the left vocal cord lesion (right of photo at arrow).

Narrow band light (2 of 8)
At closer range under narrow band light, the stippled vascular pattern suggests that this is HPV-related papilloma. Very tiny secondary lesions may be present at the arrow and ?

One week after removal (3 of 8)
A week after removal (and proof of HPV subtype 6), the left cord (right of photo) shows expected pinkness. The tiny lesion under the right cord (left of photo) “escaped” and appears larger but is still not a verifiable papilloma, nor is the tiny lesion on the upper surface of the right cord (left of photo) at the ?

2 months after removal (4 of 8)
Now 2 months after surgical removal of the original left cord lesion, that cord is healed and without evidence of papilloma. Voice is excellent—can pass for normal—but the tiny lesions previously seen are now verifiably flat papillomas (see stippled vascularity at arrows).

7 months after removal (5 of 8)
Now 7 months after original surgery, voice remains “almost” normal to the patient. Cord margins match well with voicing. Irregular margins are primarily due to overlying mucus.

Papilloma and mucus (6 of 8)
With abduction of the cords for breathing, a papilloma is seen below the margin of the right cord (left of photo at large arrow); the small arrows outline a peculiar “elevated” area that looks to be more than mucus the mucus seen at 'X'.

Stippled vascularity (7 of 8)
At closer range, under narrow band light, the stippled vascular marks further define the papilloma. Note normalized vasculature on the left cord (right of view) where the original papilloma was found. The “battle” of the left cord (right of photo) may have been won…

HPV disease (8 of 8)
Still under narrow band light, stippled vascularity in the area of the arrows suggests that this elevated area also represents HPV disease.

What "cured" this case of RRP? Surgery? Cidofovir? The patient's immune system? All three?: Series of 8 photos

Papilloma (1 of 8)
Papilloma on right vocal cord (left of photo), proven by biopsy elsewhere. The disease has both a projecting component along with 'carpet-variant' component seen only via stippled vascular marks (within dashed line).

Stippling (2 of 8)
Closer view under strobe light; stippling is seen more clearly. Compare the stippling with the linear capillaries of the opposite cord.

One week after surgical removal (3 of 8)
One week after removal and sub typing (HPV 6) and cidofovir injection. Under narrow band light there is residual bruising but no significant stippling.

Cidofovir injection (4 of 8)
At final office-based cidofovir injection. Blood from the injection is seen, but still no stippling.

Six months after surgical removal (5 of 8)
Six months after removal, papillomas have recurred at the margin of the vocal cord, but not on its upper surface where linear capillaries have replaced stippling.

One week after second removal (6 of 8)
A week after second removal of papillomas and cidofovir injection, with expected inflammation, but no visible remaining stippled vascularity.

4 months later, healed (7 of 8)
4 months later, the vocal cord has long since healed and narrow band light is used to accentuate capillaries. No HPV effect (stippling) is seen.

3 years later, no sign of papilloma (8 of 8)
3 years later, there is still no sign of papilloma or stippled vascularity (HPV effect).

RRP Cure? Or just long term remission?: Series of 4 photos

Chronic hoarseness (1 of 4)
Chronic hoarseness, due to these papillomas, subsequently proven to be caused by subtype 6. Note HPV-effect vascularity.

4 months later (2 of 4)
A second surgery, 5 cidofovir injections (3 in office), and 4 months later, neither papilloma nor HPV vascular effect are seen here, under narrow band light.

8 months from start of treatment (3 of 4)
Now 8 months from the start of treatment, and 5 months since the final (office) cidofovir injection, there remains no evidence of abnormality. This view is under standard light.

Narrow band lighting (4 of 4)
An even closer view under narrow band light still shows no sign of HPV effect or papilloma. Voice is normal and vibratory flexibility is maintained when examined under strobe light.

Polyps need a close look: here's one reason why: Series of 4 photos

"Polyps" diagnosis (1 of 4)
This patient is representative of persons initially diagnosed with "polyps," based upon a view like this one.

Papillomas (2 of 4)
Now we can see that these lesions are papillomas by the powerful visual criterion of vascular stippling aka "HPV vascular effect." Another clue of incorrect diagnosis, even with a distant view, would be the patient's non-match with the vocal overdoer syndrome.

Vascular stippling (3 of 4)
Narrow band light at the same magnification accentuates the vascular stippling. Typical papillomas indicated by arrows, and faint lines online areas of "carpet variant" papillomas.

Prephonatory instant (4 of 4)
Prephonatory instant shows additionally that the right vocal cord lesion (left of photo) is in the wrong location for vibratory injury.

Long-term remission or even "cure" of RRP/ laryngeal papilloma: Series of 6 photos

Chronic hoarseness (1 of 6)
In this distant view, the nature of the abnormality of the right vocal cord (left of photo) is not well seen, and the lesion of the left posterior cord (right of photo) is subtle.

Narrow band light (2 of 6)
Under narrow band light, the two discrete lesions are better identified as being papillomas due to the punctate (dotted) vascular markings.

Higher magnification (3 of 6)
Again under standard light but at higher magnification.

Higher magnification, narrow band lighting (4 of 6)
Back to narrow band light, to more carefully scrutinize the anterior right vocal cord lesion (left of photo).

Post-operation (5 of 6)
18 months after surgical removal and cidofovir injection, voice is excellent and there is no sign of recurrent papilloma.

Post-operation, narrow band lighting (6 of 6)
Under narrow band light, no stippled vascularity is seen. The question is: is remission due to surgery, cidofovir, or the patient's immune system?

Injected local anesthetic causes blanching: Series of 3 photos

Infiltrating anesthetic (1 of 3)
A 27-gauge needle tip is poised to infiltrate local anesthetic lidocaine with epinephrine into the papillomas (within dotted line) located just below the anterior commissure. In a moment, the needle will enter the papillomas at the "X".

Blanching (2 of 3)
The needle is buried and the tissue is blanching due to hydrostatic pressure of the injected fluid. The green dot is for reference with photo 3.

Subglottis being injected (3 of 3)
Farther below the vocal cords, the anterior subglottis is seen here being injected. The green dot is for reference with photo 2. The shank of the needle guide looks like a "Doctor Octopus" arm!

Local rather than topical anesthesia can permit fairly major tracheal surgery: Series of 4 photos

Obstructive papillomas (1 of 4)
This middle aged man has had lifelong RRP due to HPV 11. Primary focus of his recurrences for many years has been the trachea. Prior operative removals under general anesthesia have been challenging and recent work has used the thulium laser in an office setting. The papillomas seen here explain his mild pre-procedure stridor. His tracheal lumen should be approximately the size of the dotted circle.

Local injections (2 of 4)
A needle catheter passed through the channel of the scope is embedded at arrow, and is injecting 1% lidocaine with epinephrine (see blanched area). Numerous areas are similarly injected.

Removal of papilloma (3 of 4)
Here a large chunk of papilloma (stuck to the laser fiber at arrow) is being pulled away.

Improved breathing with papilloma removal (4 of 4)
An additional chunk is being detached. The patient’s breathing at the conclusion of this procedure is much improved. The tracheal lumen will be even larger when a lot of remaining coagulated papillomas slough away.

Videos:

https://youtu.be/1zQ9jy6JVxo

Papillomas of the Larynx and Trachea (https://youtu.be/1zQ9jy6JVxo)

Papillomas of the Larynx and Trachea
This video shows wart-like growths in the voicebox and windpipe (larynx and trachea) caused by chronic infection with the human papillomavirus (HPV).

https://vimeo.com/77169624

Pulsed-KTP Laser Coagulation of Vocal Cord Papillomas (RRP) (https://vimeo.com/77169624)

Pulsed-KTP Laser Coagulation of Vocal Cord Papillomas
See a video demonstration of laser coagulation of vocal cord papillomas.

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

Approaches for treating the inability to burp:

Check out our list of resources containing peer-reviewed articles, patient stories and more!

Photos of the cricopharyngeus muscle:

Cricopharyngeus Muscle (1 of 3)

Cricopharyngeus Muscle (1 of 3)

Cricopharyngeus Muscle (2 of 3)

Cricopharyngeus Muscle (2 of 3)

Contracted Cricopharyngeus Muscle (3 of 3)

Contracted Cricopharyngeus Muscle (3 of 3)

Esophageal Findings: Series of 3 photos

Esophageal Findings (1 of 3)

Esophageal Findings (1 of 3)

Esophageal Findings (2 of 3)

Esophageal Findings (2 of 3)

Esophageal Findings (3 of 3)

Esophageal Findings (3 of 3)

Abdominal Distention of R-CPD: Series of 3 photos

Gastric Air Bubble (1 of 3)

Gastric Air Bubble (1 of 3)

Bloated Abdomen (2 of 3)

Bloated Abdomen (2 of 3)

Non-bloated Abdomen (3 of 3)

Non-bloated Abdomen (3 of 3)

Dramatic Lateral Dilation of the Upper Esophagus: Series of 3 photos

(1 of 3)

(1 of 3)

(2 of 3)

(2 of 3)

(3 of 3)

(3 of 3)

What the Esophagus Can Look Like “Below A Burp”: Series of 3 photos

Baseline (1 of 3)

Baseline (1 of 3)

Pre-burp (2 of 3)

Pre-burp (2 of 3)

Post-burp (3 of 3)

Post-burp (3 of 3)

Where have no-burpers traveled from?

TEST I: “HAPPY BIRTHDAY”

TEST II: STACCATO

COMMON QUESTIONS

* Vocal overdoer: Defined as an individual with both of the following:

Photos:

Closeup, magnified examination finds barbecue brush bristle base of tongue: Series of 4 photos

Pain in throat (1 of 4)

Pain in throat (1 of 4)

Closer view (2 of 4)

Closer view (2 of 4)

Bristle identified (3 of 4)

Bristle identified (3 of 4)

Bristle to be removed (4 of 4)

Bristle to be removed (4 of 4)

Podcast:

Photos:

Idiopathic subglottic stenosis has different levels: Series of 4 photos

Post dilation (1 of 4)

Post dilation (1 of 4)

Closer view (2 of 4)

Closer view (2 of 4)

Rich vascular pattern (3 of 4)

Rich vascular pattern (3 of 4)

"Sharing" the airway (4 of 4)

"Sharing" the airway (4 of 4)

Another way to inject idiopathic subglottic stenosis: Series of 3 photos

Idiopathic inflammatory subglottic stenosis (1 of 3)

Idiopathic inflammatory subglottic stenosis (1 of 3)

Priot to injection (2 of 3)

Priot to injection (2 of 3)

Injection (3 of 3)

Injection (3 of 3)

Photos of subglottic stenosis:

Subglottic stenosis, after treatment

Subglottic stenosis, before treatment (1 of 2)

Subglottic stenosis, before treatment (1 of 2)

Subglottic stenosis, after treatment (2 of 2)

Subglottic stenosis, after treatment (2 of 2)

Photos of open epidermoid cyst:

Background:

Photos of Indicator Lesions: