Laughing

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

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

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False cord phonation due to flaccid true cords (1 of 5): before false cords begin to vibrate

An elderly man, quiet by nature who uses the voice little, complains of weak, gravelly voice quality. This view of phonation, standard light, shows a slightly wider dark line of phonatory blurring. Also, the false vocal cords are overly approximated, but not yet participating in vibration (for that, see images 4 and 5).

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 (3 of 5): before false cords begin to vibrate

Maximum closed phase shows the telltale residual opening at the anterior commissure (from this perspective, the lowermost end of the true cords), also a potent indicator of flaccidity.

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.

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

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Supraglottic phonation (1 of 6)

After right hemilaryngectomy for cancer, performed elsewhere, breathing position. Notice the left vocal cord (right of image) is partially intact (arrow), though with scarring at its anterior end (at “S”).

True vocal cords are blocked (2 of 6)

During supraglottic phonation using conventional view, true vocal cords cannot be seen.

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.

Breathy voice (4 of 6)

Same view as photo 3, still under strobe illumination, now with left vocal cord slightly lateralized for the “open phase” of vibration. Note that the black glottal gap is slightly wider. This “glottic” or true vocal cord voice is extremely breathy and high-pitched, and will not serve the patient’s vocal needs.

Residual aryepiglottic (5 of 6)

Strobe view during supraglottic phonation, using a much lower pitch and with a rough vocal quality. This is the “closed” phase of vibration with residual aryepiglottic and false cord tissue at "X" partially closing at the level of the intact left false vocal cord.

Open phase (6 of 6)

Same view as Photo 5, but at open phase of vibration, with the marked "X" tissue at the “lateral swing” point of vibration.

False Cord Phonation

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:

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False cord phonation due to flaccid true cords (1 of 5): before false cords begin to vibrate

An elderly man, quiet by nature who uses the voice little, complains of weak, gravelly voice quality. This view of phonation, standard light, shows a slightly wider dark line of phonatory blurring. Also, the false vocal cords are overly approximated, but not yet participating in vibration (for that, see images 4 and 5).

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 (3 of 5): before false cords begin to vibrate

Maximum closed phase shows the telltale residual opening at the anterior commissure (from this perspective, the lowermost end of the true cords), also a potent indicator of flaccidity.

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.

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.

True and False Cord Voice

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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

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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)

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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

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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

Tracheoesophageal Party Wall

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

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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.

Tracheobronchial cough vibration (2 of 2)

Patient is at the moment of a deep, productive-sounding cough, but in fact it is not productive. Her many courses of antibiotics are probably unnecessary. The narrowing of the lumen is due to inward bulging of the membranous tracheal wall. The blur is caused by vibration during this cough.

Tracheoesophageal Party Wall with Wheezing

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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

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).

See also: anterior commissure.

Anterior Commissure

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.

See also: Anterior Commissure Microweb


Photos of the Anterior Commissure:

 

Capillary Ectasia with Vocal Nodules

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Capillary ectasia with vocal nodules (1 of 2)

Breathing position, note insignificant microweb at anterior commissure.

Capillary ectasia with vocal nodules (2 of 2)

Phonatory position, with poor match of vocal margins.

Subtle Papillomas and the Importance of A Motivated Examination

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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

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

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Reflux into hypopharynx (1 of 3)

The patient has swallowing problems typical of cricopharyngeal dysfunction. This swallow study reinforces that impression as well as the likely presence of a Zenker's diverticulum. In this photo, blue-stained water has just been swallowed, and the vocal cords are beginning to open. At this point, the hypopharynx contains no residue.

Water flows into the swallowing crescent (2 of 3)

One second later, the blue-stained water begins to emerge from just above the cricopharyngeus muscle into the "swallowing crescent".

Larynx opens up (3 of 3)

Another two seconds later, the larynx has fully opened post-swallow. The post-swallow hypopharyngeal re-emergence of the blue-stained water is apparent.

Hypopharynx Pooling After Swallow

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Hypopharynx pooling after swallow (1 of 1)

Shows trace of blue-stained applesauce remaining behind after the patient has swallowed.

Cervical Osteophyte

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Cervical osteophyte (1 of 1)

Panorama of the hypopharynx and larynx. The posterior pharyngeal wall protrudes forward and seems to contact the posterior surface of the arytenoid cartilages.

Pyriform Sinus

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.


Pharynx Contraction

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Pharynx contraction (1 of 2)

Laryngopharyngeal view of a young woman, phonating at F4 (~349 Hz). Here the pharynx is relaxed: notice the broad arc of the pharyngeal wall (green dotted line) and the widely open pyriform sinuses (blue dotted lines).

Pharynx contraction (2 of 2)

Same patient, now phonating at C5 (~523 Hz). The pharynx has contracted: notice the narrower, more pointed arc of the pharyngeal wall (green dotted line) and that the pyriform sinuses (blue dotted lines) are nearly closed. In this relatively young soprano, this degree of pharyngeal contraction should not occur until she sings as high as G5 (~784 Hz) or higher. This singer is experiencing loss of expected upper range—a lowered “muscular” ceiling of the voice.

Palate Deviation Showing Hemi-palate Paralysis

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Palate paralysis (1 of 2)

View of the upper surface of the palate from within the nasopharynx. Due to this patient's hemi-palate paralysis, the palate deviates to one side, such that its midline (darker dotted line) no longer matches the nasopharynx's midline (lighter dotted line).

Palate and pharyngeal paralysis (2 of 2)

Panorama of the laryngopharynx. Note the capacious left pyriform sinus (right of photo), one strong indicator of paralysis of the pharynx on that side.

Pharyngocele

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Pharyngocele: view at vocal cord level (1 of 6)

A 20-year-old man complains that his neck expands and that he has pain while playing the trumpet. This radiographic image is at the level of the vocal cords, during quiet breathing; at this point, the pharyngeal dilation and pharyngocele are not yet seen. Compare with image 2.

Pharyngocele: view at vocal cord level (2 of 6)

Same view as in image 1, except that the patient is performing a Valsalva maneuver, to simulate trumpet playing. Whereas in image 1 the pharynx is completely collapsed, here it is inflated with air. A true pharyngocele, seen on the right side of the image, is beginning to develop. Also, compare the neck’s surface contour between this image and image 1.

Pharyngocele: view at supraglottic level (3 of 6)

This view is at the supraglottic level, during quiet breathing, and already shows mildly dilated pyriform sinuses. Compare with image 4.

Pharyngocele: view at supraglottic level (4 of 6)

The patient again performs a Valsalva maneuver, during which the pharynx dilates dramatically. Compare with image 3.

Pharyngocele: view at base of tongue level (5 of 6)

Higher view yet, at the base of the tongue opposite the tip of the epiglottis, during quiet breathing. Compare with image 6.

Pharyngocele: view at base of tongue level (6 of 6)

The patient again performs a Valsalva maneuver, during which the hypopharynx expands dramatically; the beginning of a true pharyngocele can be seen again, this time on the left of image. If this young man were to continue playing trumpet, one would expect the pharynx to expand more and more over time.

Inappropriate Pharynx Contraction Is A Component of (MTD)

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Rest Position of Pharynx (1 of 6)

This talented teenaged classical singer is bothered by a sense of effort, fatigue, and discomfort when attempting her high soprano notes. Quiet breathing (seen here) establishes the rest position of pharynx (dotted lines), with wide open pyriform sinuses (P). A thin sheet of muscle is just beneath the mucosa.

Inactive Pharynx Musculature (2 of 6)

Pharynx muscle should be inactive (not contracted) until a singer reaches the top few notes of his or her range. This singer is producing voice at B3 (247 Hz), a low note for this singer. The pharynx musculature remains inactive, like in photo 1.

Contracted Pharynx (3 of 6)

At B4 (495 Hz), which is only middle voice, the pharynx begins to contract, inappropriately. Note the smaller diameter of pyriform sinuses (see lines), and the more curved pharyngeal wall contour (dotted lines).

Contracted Pharynx (4 of 6)

At E-flat 5, still far from upper range, the pharynx is contracting a lot, and again inappropriately. This degree of contraction should not be seen until much higher in her range. If she sings continually at this pitch and higher, she will experience paralaryngeal discomfort and effort, and sometimes a “reaching up” vocal quality.

Greater Contraction of Pharynx (5 of 6)

Now at “only” f#5 (_____ Hz), the contraction of the pharynx is maximal and pyriform sinuses closed. For a soprano, this degree of contraction is ideally not seen before reaching C6 (_____ Hz) or higher! As the pharynx is not designed for sustained contraction, upper voice singing will be impossibly uncomfortable for her.

Phonating Larynx (6 of 6)

Close-range visualization of the phonating larynx (note the vibratory blur) shows a characteristic posterior commissure gap (arrows). This finding is also characteristic of MTD.

Secretional Pooling Predicts Swallowing Function

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Pooling (1 of 4)

This man coughs frequently especially when drinking. While his palate elevation, pharynx squeeze, and vocal cord functions are intact (as determined during VESS part 1A), note the pooling of saliva especially in the right pyriform sinus (left of photo) and on the pharyngeal wall (arrows) as well as within the laryngeal vestibule (bottom, left arrow). This predicts that his swallowing of blue-stained applesauce, water, and cracker will also be abnormal.

Residue (2 of 4)

As predicted by the information in photo 1, after administration of blue-stained applesauce, we see here an amount and location of residue that mirrors that of the saliva in photo 1. Greater residue in the right pyriform sinus (left of photo) is often seen with right-sided pharynx weakness, but that is not the case here.

Cracker (3 of 4)

After administration of cheese cracker, some of it remains in the vallecula, where it has displaced some of the applesauce.

Blue-stained water (4 of 4)

After administration of blue-stained water, most of cracker and applesauce are washed through. Some minimal blue-staining of the laryngeal vestibule explains why coughing tends to occur when drinking (especially thin liquids).

Vocal Process

A projection of the anterior arytenoid cartilage, to which is attached the membranous vocal cord.


Photos:

Arytenoid’s Vocal Process

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Vocal process of the arytenoid, artificially highlighted

Strobe light, as the vocal cords are just coming into contact for phonation. The vocal process of each arytenoid is brightly highlighted; the extension of each vocal process back into the arytenoid is moderately highlighted.

Vocal Processes of the Arytenoid Cartilages, Accentuated by Vocal Cord Atrophy

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Vocal processes, accentuated by vocal cord atrophy (1 of 3)

Panoramic view of the vocal cords just before voicing. Notice the obvious outline of both vocal processes. (For orienting, the processes are bounded at one end by small arrows.) The processes shine through particularly clearly due to the marked atrophy of the vocal cords as a whole.

Vocal processes, accentuated by vocal cord atrophy (3 of 3)

Notice that the overlying mucosa is very thin and tightly adherent along the entire medial surface of the arytenoid cartilages. This shows very graphically why the posterior third of the cords do not participate in vibration.

Vocal Processes of the Arytenoid Cartilages, Accentuated by Vocal Cord Atrophy

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Vocal processes, accentuated by vocal cord atrophy (1 of 4)

The vocal processes in this patient are extremely visible because the rest of the vocal cord on each side is atrophic and bowed.

Vocal processes, accentuated by vocal cord atrophy (2 of 4)

The vocal cords approach each other for voicing. Note the evident asymmetry between the vocal processes. The left vocal process (right of image) projects further anteriorly than does the opposite process. It is also at a higher (more cephalad) level.

Vocal processes, accentuated by vocal cord atrophy (3 of 4)

Phonation, closed phase of vibration, under strobe lighting. Note the overlap (scissoring) of the left vocal process (right of image) on top of the other process.

Vocal processes, accentuated by vocal cord atrophy (4 of 4)

Phonation, at a higher pitch, at which the scissoring of the left vocal process (right of image) on top of the other becomes even more evident.