Laryngocele

A disorder in which the laryngeal saccule is inflated and becomes abnormally enlarged. A common symptom of a laryngocele is hoarseness.

How it develops:

The laryngeal saccule, or laryngeal appendix, is a very small blind sac—a dead-end corridor, so to speak—which is located just above the vocal cords, one on each side, and is lined with glands that supply lubrication to the cords. When a person makes voice, it is possible for a little bit of the air being pushed up out of the trachea to slip into this saccule. If over time enough air enters the saccule with enough force, the saccule may begin to be inflated and stretched out, leading to a laryngocele.

In some cases, the air that slips into and inflates the laryngocele will slip back out again as soon as the person stops making voice, so that the laryngocele abruptly inflates and deflates with each start and stop of speech or voice-making. (The photos and video below are an example of this.) In other cases, the air cannot exit as easily, but it may be reabsorbed slowly during quiet times or during sleep—only to be inflated again at the next instance of more active speaking.

Laryngocele vs. saccular cyst:

A much more common disorder of the laryngeal saccule (compared with a laryngocele) is a saccular cyst, which can occur if the entrance to the laryngeal saccule becomes blocked. In this scenario, air is absorbed, but secretions build up and gradually expand the saccule.

Symptoms and treatment for laryngocele:

A common symptom is hoarseness, because while the saccule is inflated, it may press press down on the vocal cords, not allowing them to vibrate freely, or it may block the laryngeal vestibule just above the cords and partially muffle the sound produced by the cords. Standard treatment is surgical removal, through one of two approaches: a small incision on the neck that leads into the larynx from the outside, or a laryngoscope that is inserted through the mouth and down into the larynx so that the laryngocele can be removed using a laser.


Photos:

Laryngocele

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Laryngocele (1 of 5)

Before phonation begins: the laryngocele is not visible.

Saccule (2 of 5)

Phonation begins: the saccule suddenly begins to inflate.

Saccule blocks airway (3 of 5)

The saccule is at peak inflation. Note how this obstructs the laryngeal airway.

Phonation ending (4 of 5)

The saccule is deflating. Note the motion blur; inflation and deflation each happens in a fraction of a second.

Phonation ended (5 of 5)

The laryngocele is again fully deflated and hidden from view.

Bilateral Laryngocele, Before and After Removal

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Bilateral laryngocele (1 of 8)

Vocal cords approaching point of best closure possible (due to left cord paresis). Faint dotted lines outline the approximate boundary of each laryngeal saccule, which not yet inflated.

Bilateral laryngocele (2 of 8)

As air just begins coming upward between the cords, one can see subtle inflation (dotted lines), particularly of the right saccule (left of image).

Bilateral laryngocele (3 of 8)

As phonation continues, inflation of the (now diagnosable) laryngocele becomes obvious, and the left laryngocele (right of image) is now more obviously inflated than before, again indicated by the dotted lines.

Bilateral laryngocele (4 of 8)

Near the end of a sustained period of voicing, maximum inflation of the laryngoceles is seen (dotted lines). On the right side (left of image), the stretching mucosa is so thinned as to appear translucent.

Bilateral laryngocele, after removal (5 of 8)

Same patient, breathing position, 12 weeks after complete removal of the bilateral laryngoceles via false cord incisions (lines of incision shown by dotted lines). This patient also has long-standing paralysis of the right vocal cord (left of image) and limited mobility of the left cord, so the cords don’t open fully for breathing.

Bilateral laryngocele, after removal (6 of 8)

Phonatory position. Note the lack of inflation of the now-absent laryngoceles, and compare that with photos 3 and 4 of this series.

Bilateral laryngocele, after removal (7 of 8)

Closer view of the posterior ends of the true vocal cords during maximal abduction for breathing. Space between the vocal cords is an estimated 50% of normal, because of the paralyzed right cord and the limited mobility of the left cord.

Bilateral laryngocele, after removal (8 of 8)

Same close-up view, but during phonation. The left vocal cord (right of image) has shifted slightly toward the midline, but the cords do not actually close and, thus, the patient cannot produce glottic (true vocal cord) voice. An implant could help to close this gap, but the patient will first try developing a “false cord voice.”

Laryngocele, Seen in a CT Image

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Laryngocele, seen in a CT image (1 of 1)

The patient’s left-sided saccule is dilated and filled by air, forming a laryngocele (the largest black spot in the image). The right-sided saccule is not seen because it is of normal size. The two smaller black spots show air in the pyriform sinuses (a normal finding).

Videos:

Laryngocele: A Cause of Hoarseness
A laryngocele is a disorder of the saccule, or laryngeal appendix, in which air abnormally expands it. Watch this video to see how a laryngocele behaves in real-time, and why that can affect the voice.

Vallecular Cyst

A vallecular cyst is a mucus-containing cyst in the vallecula. Such cysts are relatively common. Vallecular cysts are almost always asymptomatic and found during examination for another issue, such as a voice problem.


Photos of Vallecular Cyst:

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Vallecular cysts (1 of 2)

Panoramic view of the laryngopharynx, showing two vallecular cysts (arrows), between the base of the tongue and epiglottis.

Vallecular cysts (2 of 2)

Closer view. These cysts were an incidental finding during an examination for an unrelated complaint. They were not causing the patient any problems and could be left alone.

Vallecular Cysts don’t Disturb Swallowing—Except When They Do

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Vallecular cyst (1 of 4)

Enormous vallecular cyst in this young woman. Swallowing of solids is affected. Food seems to catch and then expectorate back up to the mouth. No problem with liquids.

Evaluation of function (2 of 4)

Palate, pharynx, and larynx function are all normal. There is no pooling of saliva in the hypopharynx.

Applesauce residue (3 of 4)

An organized ring of applesauce remains after trying to swallow blue-stained applesauce.

Water wash (4 of 4)

Water wash is very effective in clearing the applesauce away. Vallecular cysts are usually left alone; here, the plan is to remove it with the thulium laser and see if swallowing is restored.

Laser for A Type of Lesion Usually Left Alone

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Vallecular cyst (1 of 8)

A large vallecular cyst in an older man with awareness of a “foreign body” sensation when swallowing.

Beginning swallow (2 of 8)

As a swallow begins, note the posterior pressure on the epiglottis and lateral pressure on the pharyngeal wall. Normally we leave these alone, but with careful discussion he wanted to be rid of this to see if it would diminish his symptoms.

Laser coagulation (3 of 8)

With the patient sitting in a chair under only topical anesthesia, office laser coagulation begins with a wide area.

Cyst wall (4 of 8)

Coagulation now involves the full thickness of the cyst wall. When it sloughs off, the cyst will be widely unroofed.

Contents spilling out (5 of 8)

Cyst contents are spilling out.

Concluding coagulation (6 of 8)

At the conclusion of the procedure the cyst has evacuated its contents and collapsed in size. The coagulated surface will detach over the next week or two.

3 weeks later (7 of 8)

Three weeks later, the vallecula is normal and the patient says symptoms are reduced “50%.”

Collapsed cyst (8 of 8)

The collapsed cyst with nearby unrelated and typical vallecular cyst requiring no treatment.

Anterior Commissure Microweb

Anterior commissure microweb is a tiny webbing between the vocal cords at the anterior commissure, where the two cords meet. Some think that this can help to cause vocal nodules, but we do not see any such relationship.


Microweb

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Vocal cord swelling (1 of 2)

Subtle vocal cord swellings, mid-membranous cord. This patient also has a microweb, not visible in this view.

Microweb (2 of 2)

Same patient, at closer range, showing the microweb at 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.

Nuances “Gleaned” from Daily Examinations

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Vocal "overdoer" (1 of 4)

A vocal “overdoer” with hoarseness. Note broad-based swelling of both vocal cord margins. A microweb, thought to be congenital, is also seen at the arrow. Tiny dots indicate a subtle wrinkle or shallow sulcus.

Inspiratory phonation (2 of 4)

The patient has been asked to produce inspiratory phonation to reveal the translucent polyp and “sulcus,” again at tiny dots.

Translucent polyp (3 of 4)

Under strobe light, the translucence of the polypoid elevation is seen more clearly.

Open phase (4 of 4)

At open phase of vibration again under strobe light, the broad based left vocal cord elevation is also seen.

Pachyderma

Pachyderma literally means “elephant skin.” Used in laryngology to refer to rough or thick mucosa. Most often seen in the interarytenoid area and is thought to be indicative of acid reflux or, sometimes, chronic bacterial infection. It does not typically affect the voice, though the underlying cause of the pachyderma can (e.g., chronic inflammation from acid reflux or chronic bacterial laryngitis). In such a case, the true vocal cords themselves appear intensely red.


Pachyderma, caused by laryngitis sicca

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Heaped up Mucosa (1 of 3)

Pachyderma, here referring to the heaped up mucosa in the interarytenoid area, in a patient with laryngitis sicca.

Pachyderma (2 of 3)

Adducted (voicing) position. Note that the pachyderma does not interfere with closure of the cords. In this case, it does not directly affect the patient’s voice, which is typical, but the more generalized inflammatory condition (see the redness of the cords) does.

Stippled Vascular Markings (3 of 3)

Narrow-band lighting. This shows some stippled vascular markings, often seen with chronic inflammation or HPV infection.

Acid Reflux Laryngitis

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Acid reflux laryngitis (1 of 2)

Panoramic view, shows interarytenoid pachyderma (“elephant skin”) at upper blue arrow; arytenoid redness at green arrows; and mucus retention cyst at lower blue arrow.

Acid reflux laryngitis (2 of 2)

During phonation, interarytenoid pachyderma and mucus retention cyst are typically obscured.

Elephant Skin

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Elephant skin (1 of 1)

The namesake of this phenomenon of rough or thick mucosa: elephant skin!

Saccular Cyst

A closed sac originating from a formerly open and functioning laryngeal saccule. An analogy for a saccular cyst is a velvet bag used to hold coins which has its opening cinched shut by a drawstring. The mouth of the saccule becomes blocked, and mucus secreted within the saccule cannot escape through the normal opening in the anterior ventricle. This closed sac gradually expands, causing the false cord and aryepiglottic cord to bulge; the sac can further expand over the top of the thyroid cartilage and into the neck.


Photos:

Anterior Saccular Cyst, before and after Removal

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Anterior saccular cyst (1 of 4)

Phonation, open phase of vibration, under strobe light. Left-sided cyst (right of image) causes mildly rough voice quality.

Anterior saccular cyst (2 of 4)

Four years later. Phonation, open phase of vibration, under strobe light. The cyst has enlarged, and voice quality has deteriorated. The patient wants this removed.

Anterior saccular cyst, removed (3 of 4)

Ten days after laser dissection of the complete cyst (not simple unroofing). At close range, looking into the left ventricle. The raw area (at arrows) is the bed of excision.

Anterior saccular cyst, removed (4 of 4)

Phonation, standard light. Some residual bruising of the left vocal cord (right of image), but voice quality and capabilities are normal.

20 Years after Saccular Cyst Removal!

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Saccular cyst (1 of 3)

Saccular cyst on the left was removed ~ 20 years ago. In this panoramic view, notice that the left false cord is surgically absent.

Phonation (2 of 3)

Voice is normal during this view of phonation. Dotted line indicates the outline of the original cyst, as much was delivered from within the aryepiglottic cord.

Respiration (3 of 3)

A closer view during respiration.

Anterior Saccular Cyst

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Anterior saccular cyst (1 of 4)

Breathing position, with a saccular cyst protruding from the right anterior ventricle (left of image). The cyst’s location, color, and superficial vessels indicate that it is neither a polyp nor granuloma.

Closer view (2 of 4)

Still closer view (under strobe light), breathing position, showing that the cyst does not arise from the cord, but appears to be depressing the anterior end of the right cord (left of image) slightly. On the left cord is an incidental finding of margin swelling, which is unsurprising in this very talkative individual.

Cyst vibrates when speaking (3 of 4)

Phonation, strobe light, open phase of vibration. The laryngeal vestibule between the false cords is partially blocked. The cyst occasionally participates in vibration, making an extra sound.

Anterior saccular cyst (4 of 4)

Phonation, strobe light, closed phase of vibration.

Bilateral Anterior Saccular Cysts

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Bilateral anterior saccular cysts (1 of 6)

Bilateral anterior saccular cysts (faint dotted lines), with vocal cords in open, breathing position. The right cyst (left of image) is larger than the left. These present only into the ventricle, and not significantly upwards into the false cords, nor downwards to press down on the true cords.

Phonation (2 of 6)

Phonation, at a high pitch, so that the laryngeal vestibule (the “airspace” above the vocal cords) is mostly open. Voice sounds normal.

Bilateral anterior saccular cysts (3 of 6)

Phonation at a high pitch again, but under strobe lighting, and at the closed phase of vibration. Note that there is good vibratory closure and that neither cord is pushed down by the cysts; again, the voice sounds normal at this pitch.

Bilateral anterior saccular cysts (4 of 6)

Phonation at a high pitch again, under strobe lighting, but at the open phase of vibration. Note that the cords aren’t impaired from oscillating laterally; again, the voice sounds normal.

Bilateral anterior saccular cysts (5 of 6)

Phonation at a mid-range pitch. The vocal cords shorten at this pitch, which constricts the laryngeal vestibule (up-down pairs of arrows) and brings the saccular cysts further over the cord (left-right arrows). Voice is still fairly normal.

Bilateral anterior saccular cysts (6 of 6)

Phonation at a low pitch. The laryngeal vestibule constricts even further (up-down pairs of arrows), bringing the cysts, especially the larger one, further yet over the cords ( left-right arrows), so that they interfere more with vibration. Voice at this pitch sounds congested or bottled up.

Removal of Lateral Saccular Cyst, Endoscopic Approach

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Lateral saccular cyst removal, endoscopic approach (1 of 4)

Note margin of false cord, at line of arrows.

Lateral saccular cyst removal, endoscopic approach (2 of 4)

Removal begins by excising the false cord margin in order to dissect downward to the lining of the saccule.

Lateral saccular cyst removal, endoscopic approach (3 of 4)

After removal, see upper border of inner surface of thyroid cartilage, at dotted line (distal end of laryngoscope aimed laterally towards neck contents).

Lateral saccular cyst removal, endoscopic approach (4 of 4)

In-line view of vocal cords at conclusion of surgery.

Removal of Lateral Saccular Cyst, External Approach

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Lateral saccular cyst removal, external approach (1 of 3)

Right of photo is superior, at chin. Note dome of cyst at arrow.

Lateral saccular cyst removal, external approach (2 of 3)

Near completion of dissection, cyst has ruptured and spilled its contents.

Lateral saccular cyst, external approach: Series of 1 photo

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Lateral saccular cyst, external approach (1 of 1)

The hemostat in the lower photo points to the upper part of the thyroid cartilage. The neck of the sack is being followed over the top of the cartilage and between the thyroid cartilage and soft tissue, to its origin at the ventricle.

Saccular Cyst with Extensive Oncocytic Metaplasia

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Spherical submucosal mass (1 of 7)

Spherical submucosal mass fills the left supraglottis (right of photo) and bulges into the medial left pyriform sinus, best seen using a “trumpet maneuver”.

Closer view (2 of 7)

Close range endoscopy shows that although the mass obscures the left true vocal cord (right of photo), it is clearly separate.

Preoperative CT (3 of 7)

On preoperative CT, the homogeneous, smoothly-marginated mass pushes superiorly into the preepiglottic space.3

Post laser resection (4 of 7)

Two months after endoscopic transoral laser resection. The normal contours of the supraglottis and medial pyriform have been restored, and the left vocal cord (right of photo) is now fully visible. Her voice has returned to normal.

Postoperative CT (5 of 7)

3 month postoperative CT shows complete excision of mass.

Pathology diagnosis (6 of 7)

Saccular cyst with extensive oncocytic metaplasia. Note the presence of both respiratory ciliated mucosa and granular oncocytic cells in the cyst lining.

Portion of cyst (7 of 7)

Portion of the cyst, lined by oncocytes.

Polyp or Cyst?

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Hoarseness (1 of 4)

During an upper respiratory infection, this older woman developed hoarseness that has not gone away during the past year. Is this the end stage perhaps of a hemorrhagic polyp?

Position of lesion (2 of 4)

In this slightly closer view, with the patient breathing out, the lesion appears too “high” within the laryngeal vestibule, and not truly at the level of the vocal cords.

Close view (3 of 4)

This close view is on the way to determining if there is any attachment to the vocal cords themselves. Not quite yet able to tell…

Anterior saccular cyst (4 of 4)

The tip of the scope has just passed the lesion and the vocal cords are unaffected. As it appears to be arising from the ventricle, it could be classified as an anterior saccular cyst. Likely the saccule or a mucus gland became plugged due to inflammation during the upper respiratory infection a year earlier, and it filled with mucus.

Anterior Saccular Cysts, Swellings, and Mucus: What’s the Main Issue?

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Are cysts the main issue? (1 of 4)

An experienced R & B singer has begun to experience loss of clarity and a “paper rattling” sound especially upper range. Are the bilateral saccular cysts (arrows) the explanation? Let’s look closer.

Closer range (2 of 4)

At closer range and higher pitch of G4 (392 Hz) produced with light falsetto, now we can also see bilateral margin swellings and a tiny capillary “dot.” Is this the explanation? Let's look further.

Pressed chest voice (3 of 4)

Now using pressed chest voice more typical of the patient’s singing style at E4 (330 Hz), the saccular cysts come into greater contact and considerable mucus begins to form.

Vibrating cysts and mucus (4 of 4)

Detailed review at the same pitch reveals that the rattling sound comes from a combination of vibratory participation of the saccular cysts, and a “boiling” sympathetic vibration of the mucus. If hydration, and a brief reflux trial do not help, the cysts will be removed.

Anterior Saccular Cysts as Incidental Finding

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Polyps? (1 of 3)

This man was examined elsewhere for another reason and sent for evaluation of “polyps” in his larynx. Notice the anterior saccular cysts protruding from the anterior ventricle and false cord margin bilaterally (see arrows). He considers his voice to be normal.

Cysts, not polyps (2 of 3)

At closer range, asterisks mark each cyst.

No voice disturbance (3 of 3)

During voice making, notice that neither cyst presses downwards on the vocal cords. That is why voice is normal. Cysts of this sort, diagnosed by intense visual criteria, can be followed once or twice at long intervals, and only occasionally need to be removed due to voice disturbance.

Supraglottic Cyst

A retention-type cyst of the supraglottic structures not manifesting as either an anterior or lateral saccular cyst. With a supraglottic cyst, the duct of a single gland is thought to become obstructed and to thereby retain secretions. By contrast, with a saccular cyst, the mouth of the laryngeal saccule becomes obstructed.

Photos:

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Supraglottic cyst? (1 of 2)

On panoramic view, one can see that this is not an anterior saccular cyst, as it does not protrude from the ventricle.

It's a dual cyst (2 of 2)

Closer view, with obvious translucence, verifying that this is a ductal cyst and not a saccular cyst, which is deeper within the false cord and aryepiglottic cord.

Post-Radiation Telangiectasia

Post-radiation telangiectasia is atypical dilation or formation of capillaries (typically seen in the laryngopharynx) as a mid- or long-term response to radiation. These are a benign but sometimes impressive-looking tissue change. Often, post-radiation telangiectasia does not appear until a year or more following the end of the course of radiation.


Photos:

Telangiectasia, Gradually Developing Post-radiation

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Soon after end of radiotherapy (1 of 4)

Early after conclusion of radiotherapy for a left anterior vocal cord cancer. There is a small amount of resolving radiation mucositis (white patches) in the interarytenoid area.

1 year later: slight post-radiation telangiectasia (2 of 4)

Nearly a year later, with mild vascular prominence, especially left vocal cord (right of image).

2 years later: post-radiation telangiectasia (3 of 4)

Now nearly two years after end of radiotherapy, much more prominent vascularity, called post-radiation telangiectasia. This side effect of radiation often begins to happen between one and two years after the end of radiotherapy. Notice that the post-radiation telangiectasias involve all areas that received radiation (including false vocal cords, etc.), and not just the area of original tumor. Voice remains very good.

3 years later: post-radiation telangiectasia (4 of 4)

Just over three years after the radiotherapy, telangiectasia now exuberant, but fairly stable. Voice remains very good.

Radiation: Telangiectasia Increases Slowly but is Maximal by 3 Years after End of Radiation

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Inflammation with moderate dysplasia (1 of 8)

Hoarseness began 2 years prior to this initial examination photo. This middle aged man has never smoked; has no reflux symptoms, nor has he had any response to empiric reflux therapy. Biopsy shows inflammation with moderate dysplasia. HPV testing was negative. No explanation for this chronic inflammation is ever found. A series of KTP laser treatments of stippled vascular areas and leukoplakia ensues.

Squamous cell carcinoma-in situ (2 of 8)

A year later, similar findings except appearance of a slight anterior commissure inflammatory web. Eventually, after an additional 2 years (5 years after onset of hoarseness) a second biopsy is triggered by aberrant, “corkscrew” capillaries. The diagnosis: squamous cell carcinoma-in situ. Laser excision is typically preferred for well-demarcated early vocal cord cancer, but the diffuse, superficial and bilateral abnormalities suggested radiotherapy instead.

Post radiation (3 of 8)

Six weeks after the end of his 30 radiation treatments, healing of the superficial ulceration (within dotted lines) is underway.

Narrow band light (4 of 8)

Closer view, now under narrow band light: A fine vascular pattern has returned except in the areas bounded by dotted lines.

Regenerated vascular pattern (5 of 8)

Six weeks later (3 months after end of radiotherapy), the superficial ulceration has healed, and voice is very functional. Note the regenerated vascular pattern, and compare with photo 4.

Post-radiation telangiectasias (6 of 8)

“On schedule” a year after the end of successful radiation therapy, post-radiation telangiectasias are becoming evident. Compare progression of these telangiectasias in photos 4, 5, 6, 7, and 8.

Standard light (7 of 8)

Now 3 years from the end of radiotherapy, radiation telangiectasia are “maximal” and stable. Voice remains very good.

Narrow band light (8 of 8)

Same view, under narrow band light.

Office Laser of Post-radiation Telangiectatic Polyp

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Post-radiation telangiectasias (1 of 4)

Years after radiotherapy for vocal cord cancer, the exaggerated capillaries are not typical capillary ectasia, but instead post-radiation telangiectasias. The "polyp" may be also radiation-related because there is no history of voice over-use.

Pulsed-KTP coagulation (2 of 4)

At the conclusion of pulsed-KTP coagulation of the "polyp."

"Polyp" pulled off (3 of 4)

The "polyp" has pulled off with the fiber.

Three weeks later (4 of 4)

Three weeks later, the vocal cords now match, voice is improved, and the site of surgery (arrow) is healed.

Telangiectasias and more after Radiotherapy

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Post radiotherapy (1 of 2)

More than five years after radiotherapy for early vocal cord cancer, the post-radiation telangiectasias seen here are maximal and not expected to increase further. What can occasionally increase, are small polyp-like elevations (arrow to the left).

Narrow band lighting (2 of 2)

Narrow band light at closer range dramatically accentuates vascularity. Intense red becomes almost black; pink becomes blue-green.

Mucus Retention Cyst

Mucus Retention Cyst is a cyst that forms when one of the mucus glands just below the vocal cord’s free margin becomes plugged. Mucus glands in this location secrete mucus in order to bathe and lubricate the vocal cords, but if a gland becomes obstructed, then the mucus it produces gets trapped and accumulates, leading to a mucus retention cyst. They typically occurs without any correlation to vocal overuse, in contrast to epidermoid cysts as well as nodules and polyps.

Signs:

It can cause hoarseness, because it interferes with the normal vibrations of the vocal cords and the accuracy of their match with each other (see the videos below). The cyst is most often unilateral—that is, occurring on one cord but not the other. It appears as a bulge or deformation of the vocal cord’s free margin, and sometimes undersurface, and it may be yellowish in color.

Treatment:

The cyst may be surgically removed, by creating a small incision on the vocal cord and then dissecting the cyst from the cord. Photos of the surgical process can be found below. Also, the two videos below show how removing this kind of cyst can improve the voice.


Photos:

Removal of Mucus Retention Cyst

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Mucus retention cyst (1 of 3)

Mucus retention cyst of right vocal cord. Yellowish spherical mass shines through overlying mucosa. This was causing the patient severe hoarseness. Incision to enter the cord at dotted line.

Removal of Mucus retention cyst (2 of 3)

Near completion of dissection of cyst from its final attachments, using curved scissors.

Mucus retention cyst (3 of 3)

After cyst’s removal. The patient’s voice sounded virtually normal in the recovery room, though upper voice still abnormal.

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Injecting Xylocaine (1 of 5)

The physician injects xylocaine with epinephrine into the tissue before surgery, so as to inhibit bleeding and to cause some of the layers of tissue to expand and spread apart (hydrodissection).

Hydrodissection effect (2 of 5)

The hydrodissection effect of the injection is now visible

Removal of cyst (3 of 5)

The incision has been made. Now, curved scissors (pointing downward) release the cyst’s anterior attachment.

Removal of cyst (4 of 5)

The cyst is now almost fully released from the vocal cord.

Cyst is gone! (5 of 5)

Removal completed. The line of incision is visible.

Mucus Retention Cyst

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Mucus retention cyst (1 of 1)

After laser excision of early vocal cord cancer, left vocal cord (right of image), a small mucus gland became plugged. This could instead be mistaken as a polyp, but a polyp does not fit this man's quiet nature and minimal vocal commitments. Note that the lesion is below the point of maximum vibratory contact that would produce a polyp. This man's voice is excellent.

Mucus-Retention Cyst—not Polyp—Before and After Removal

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Mucus-retention cyst (1 of 5)

This person has chronic hoarseness, without prior illness or voice overuse. The explanation is this left-sided mucus-retention cyst (right of photo). The next photo shows more clearly how we know this is a cyst and not a polyp.

Below the margin (2 of 5)

This photo is under a strobe light during the open phase of vibration and dotted line shows the free margin of the cord. It shows that the swelling originates from below this free margin, common for mucus-retention cysts. The two solid lines show the incision line options for planned dissection and removal of this cyst. Here the medial one (on the cyst) was chosen, as seen in the next photo.

One week post-op (3 of 5)

A week after incision and dissection and removal of the cyst. You can see the incision line at the dotted line.

Better medializtion (4 of 5)

Closed phase of vibration at E5 shows perfect match of the margins.

Better flexibility (5 of 5)

Open phase of vibration at same pitch shows that both cords make lateral excursions, confirming lack of stiffness and scarring due to the incision and dissection being below most of the vibrating part of the mucosa.

Videos:

Mucus Retention Cyst: Before and After
Watch this video to see images and hear audio of a mucus retention cyst’s effect on the vocal cords, followed by the surgical removal and the post-surgical results.
Mucus Retention Cyst II: Before and After
Another example of a mucus retention cyst, with images and audio before, during, and after the cyst’s surgical removal. This video highlights a bit more of the vocal capability battery.

Leukoplakia

A white patch found on the mucosa anywhere in the body. In the larynx, leukoplakia is most often seen on the vocal cords, either in long-time smokers or in individuals with some other cause of chronic inflammation. It is the descriptive term for what, on biopsy, may prove to be keratosis, carcinoma in situ, or carcinoma.

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Cake-icing Leukoplakia (1 of 4)

The leukoplakia here is heaped up in three main areas, as what some might call "cake-icing" leukoplakia. With this view only, a person could easily overlook the second component of "hazy" or " spilled milk" leukoplakia shown in the next three photos. All of this leukoplakia would be considered "bland" and non-threatening because there is no component of vascular prominence or erythema (erythroplasia). Erythroplasia would much more strongly indicate the need for biopsy.

Hazy Leukoplakia (2 of 4)

Pre-phonatory phase, showing mild bowing of the vocal cords. There is also the hazy leukoplakia component indicated by the dotted line.

Leukoplakia (3 of 4)

Vocal cords are in the nearly closed phase of vibration. The bluish light from the strobe light makes the hazy leukoplakia even more evident (indicated by the dotted line).

Closer look (4 of 4)

Open phase of vibration, shown under strobe lighting.

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Leukoplakia (1 of 2)

Leukoplakia, left vocal cord (right of image), standard light.

Leukoplakia (2 of 2)

Same lesion, under narrow band illumination.

Leukoplakia, Before and After Surgical Removal

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Diffuse Leukoplakia (1 of 4)

Diffuse leukoplakia (seen under standard light) in a man who had undergone removal elsewhere at least twice, with rapid return of diffuse disease on both vocal cords.

HPV effect (2 of 4)

Closer view, using narrow-band illumination. Leukoplakia is accentuated, but punctate vascular markings are also accentuated. We sometimes call this “HPV effect,” though in fact this man’s HPV subtyping was negative.

Leukoplakia, after surgical removal (3 of 4)

Two years after one superficial yet intensely precise peeling of the leukoplakia, plus one follow-up thulium laser ablation of scattered residual disease. The patient, a tenor, considers his voice to be normal. Closed phase of vibration, as seen under strobe light.

Leukoplakia, after surgical removal (4 of 4)

Open phase of vibration, demonstrating that the mucosa on both vocal cords remains flexible. The shifting hazy patches seen here and in photo 3 are collections of mucus.

Leukoplakia Battled Over Time

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Leukoplakia (1 of 8)

Leukoplakia, recurrent, in a former smoker, several years after initial diagnosis. The patient has had this removed in the operating room several times elsewhere, and pathology has only shown hyperkeratosis. HPV testing is negative. Notice both the “cake icing” (green arrows) and “spilled milk” (white arrow) components of the leukoplakia. At this examination, the patient is severely hoarse.

Spilled Milk (2 of 8)

Closer view, under narrow-band illumination, which accentuates in particular the “spilled milk” component (arrows) of the leukoplakia on the left vocal cord (right of image).

Thulium laser (3 of 8)

In the midst of coagulation using the thulium laser, delivered via glass fiber (right of image).

Coagulated tissue (4 of 8)

The thulium laser session is done. On the left cord (right of image), mostly near-contact mode was used, and the coagulated tissue, which has gone from leukoplakia-white to coagulated-white, will slough off within days. On the right cord (left of image), contact mode was used, to coagulate more deeply and detach the bulkier lesion. An additional surface layer will also slough on this cord.

Leukoplakia (5 of 8)

A year and a half later, after a few interval laser treatments, there is a small persistent patch of leukoplakia.

Detachment (6 of 8)

At the conclusion of another thulium laser procedure, using brief contact mode for superficial detachment of the patch of leukoplakia.

Superficial vascular pattern (7 of 8)

Fourteen months after photos 5 and 6. After roughly a dozen treatments spanning more than a decade, the voice sounds effortless and has no syllable dropouts. It is mildly husky but entirely satisfactory to the patient. Note how well-preserved and “unscarred” the superficial vascular pattern of the mucosa is (arrows), after so many surgical procedures.

Coagulated tissue (8 of 8)

At the conclusion of thulium coagulation of this linear patch of leukoplakia. Arrows show the line of coagulated tissue.

Leukoplakia, Before, During, and After Laser Coagulation

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Leukoplakia, not yet seen (1 of 6)

A few years earlier, this patient underwent superficial laser cordectomy of the right vocal cord (left of photo) for cancer. The voice result is excellent, and the patient is being seen this day for a routine interval examination, and has no new complaints.

Leukoplakia (2 of 6)

At closer range, tiny points of leukoplakia (inside the green dotted oval) become evident. The bright white spot in the photo is just a light reflection.

Leukoplakia (3 of 6)

Still closer view, again confirming the tiny patches of leukoplakia. There is another light reflection in this view, right in the middle of the photo.

Leukoplakia, coagulated by laser (4 of 6)

Thulium laser coagulation of the leukoplakia lesions, through a glass fiber (blue-ish cylinder at top-right of photo), as seen under narrow-band illumination. The Thulium laser had been placed on stand-by prior to the routine examination, to save the patient a potential second visit. The coagulated tissue is also white, but will slough off within a few days, and along with it, the leukoplakia.

Leukoplakia, 3 months after laser treatment (5 of 6)

Three months after laser treatment, the patient has healed.

Leukoplakia, 3 months after laser treatment (6 of 6)

Three months after laser treatment, a close up view shows no signs of leukoplakia spots.

Vocal Nodules, Leukoplakia, and Capillary Ectasia

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Vocal nodules, leukoplakia, and capillary ectasia (1 of 4)

Abducted breathing position, standard light. Notice not only the margin swellings (nodules) but also the ectatic capillaries and the roughened leukoplakia. This person illustrates well the idea that vibratory injury can be manifested differently. Many express the injury more in the form of sub-epithelial edema and other changes; this person also has considerable epithelial change.

Vocal nodules, leukoplakia, and capillary ectasia (2 of 4)

Prephonatory instant, standard light.

Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (3 of 4)

Partial resolution of mucosal injury as a result of behavioral changes directed by a speech pathologist. Strobe light, open phase of vibration.

Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (4 of 4)

Strobe light, moving towards closed phase of vibration.

Glottic Furrow / Leukoplakia / Acid Reflux

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Glottic furrow / Leukoplakia / Acid reflux (1 of 4)

Panoramic view, standard light. Note general inflammatory appearance, left vocal cord leukoplakia, interarytenoid pachyderma. Some would call this a sulcus.

leukoplakia (2 of 4)

Furrow-like groove best seen on the left vocal cord (arrow). Beneath the arrow is the leukoplakia. Notice loss of fine surface vessels in this area.

Glottic furrows (3 of 4)

Furrows seen bilaterally.

Gap during closed phase (4 of 4)

Strobe light, closed phase. Note the slight gap; this is often seen as a kind of pseudo-bowing with furrow.

Thulium Laser Surgery, With Local Anesthetic Injection, to Treat Leukoplakia

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Leukoplakia, about to be treated with laser (1 of 4)

Leukoplakia of the vocal cords in a patient radiated years earlier for glottic cancer. This disease is mostly benign, but foci of carcinoma-in-situ have also been removed twice in the operating room, yet with rapid return of leukoplakia. The patient has had no glottic voice. In an effort to avoid total laryngectomy, we are managing these visual abnormalities with the thulium laser in an outpatient videoendoscopy room.

Injection of local anesthetic (2 of 4)

Since this patient cannot tolerate aggressive laser therapy with topical anesthesia alone, we are here adding injection of local anesthetic. Note the blanching of tissue surrounding the needle.

Injection of local anesthetic (3 of 4)

Further injection of the local anesthetic.

Right after thulium laser treatment (4 of 4)

At the completion of aggressive laser coagulation of abnormal tissue. Compare with photo 1. The patient will return in a month for additional laser treatment as indicated.

Laryngopharynx Acid Reflux Disease (LPRD)

Laryngopharynx acid reflux disease (LPRD) is a constellation of symptoms and findings caused by reflux (backwards flow) of stomach acid into the throat or larynx, typically during sleep. It may be seen with or without the heartburn, acid belching, etc., commonly associated with gastroesophageal reflux disease (GERD). The classic symptoms of LPRD may be exaggerated in the morning and include one or more of the following: dry throat, rawness or scratchy sensation, increased mucus production and attendant throat clearing, husky voice quality or low-pitched morning voice, irritative cough, and, if one is a singer, the need for prolonged warm-up. For appropriate treatment measures, see GERD.

Sometimes acid reflux is diagnosed when it isn’t the real problem. The do-it-yourself trials in this downloadable article can help a person and his or her personal physician verify if acid reflux is the appropriate diagnosis: When Acid Reflux Treatment Takes You Down a Rabbit Trail

1. Originally published in Classical Singer, April 2009. Posted with permission.


Photos:

Acid Reflux

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Phonation (1 of 2)

Open phase of vibration, strobe light, with white mucus sometimes but not always suggestive of acid reflux laryngitis.

Acid reflux (2 of 2)

Closed phase of vibration, strobe light, with same mucus findings.

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Acid reflux (1 of 2)

Phonation under strobe light. Mild capillary prominence.

Excessive mucus (2 of 2)

As phonation proceeds, appearance of large amounts of viscous white mucus.

Acid Reflux Laryngitis

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Acid reflux laryngitis (1 of 2)

Panoramic view, shows interarytenoid pachyderma (“elephant skin”) at upper blue arrow; arytenoid redness at green arrows; and mucus retention cyst at lower blue arrow.

Acid reflux laryngitis (2 of 2)

During phonation, interarytenoid pachyderma and mucus retention cyst are typically obscured.

Acid Reflux and Sicca Syndrome

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Acid reflux (1 of 4)

This man has obvious clinical symptoms of acid reflux such as heartburn, excessive morning mucus, husky morning voice. Note classic interarytenoid pachyderma, diffuse pinkness.

Prominent capillaries & mucus (2 of 4)

Here we see loss of color differential between true and false cords. Capillaries are prominent (like bloodshot eyes) on the true cords. There is also adherent mucus.

Closer view (3 of 4)

Closer view of the prominent capillaries.

Redness and inflammation (4 of 4)

Even the upper trachea shows evidence of redness and inflammation. This is not seen that often except with truly severe nocturnal acid reflux/ LPR.