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 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.

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.

Microweb (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.

Pachyderma (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, the pachyderma does not directly affect the patient’s voice, which is typical, but the more generalized inflammatory condition (see the redness of the cords) does.

Pachyderma (3 of 3)
Narrow-band lighting. This shows some stippled vascular markings, often seen with chronic inflammation or HPV infection.

Elephant skin (1 of 1)
The namesake of this phenomenon of rough or thick mucosa: elephant skin!

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.

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 (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.

Anterior saccular cyst (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.

Anterior saccular cyst (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 (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.

Bilateral anterior saccular cysts (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.

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.

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 removal, external approach (3 of 3)
Complete, if collapsed, cyst.

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.

Spherical submucosal mass (1 of 6)
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 6)
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 6)
On preoperative CT, the homogeneous, smoothly-marginated mass pushes superiorly into the preepiglottic space.

Post laser resection (4 of 6)
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 6)
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.

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.

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.

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 (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.

Supraglottic 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.

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.

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.

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.

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.

Leukoplakia (1 of 2)
Leukoplakia, left vocal cord (right of image), standard light.

Leukoplakia (2 of 2)
Same lesion, under narrow band illumination.

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.

Leukoplakia (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 (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.

Leukoplakia (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).

Leukoplakia (3 of 8)
In the midst of coagulation using the thulium laser, delivered via glass fiber (right of image).

Leukoplakia (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.

Leukoplakia (6 of 8)
At the conclusion of another thulium laser procedure, using brief contact mode for superficial detachment of the patch of leukoplakia.

Leukoplakia (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.

Leukoplakia (8 of 8)
At the conclusion of thulium coagulation of this linear patch of leukoplakia. Arrows show the line of coagulated tissue.

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.

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.

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 (1 of 4)
Panoramic view, standard light. Note general inflammatory appearance, left vocal cord leukoplakia, interarytenoid pachyderma. Some would call this a sulcus.

Glottic furrow / Leukoplakia / Acid reflux (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 furrow / Leukoplakia / Acid reflux (3 of 4)
Furrows seen bilaterally.

Glottic furrow / Leukoplakia / Acid reflux (4 of 4)
Strobe light, closed phase. Note the slight gap; this is often seen as a kind of pseudo-bowing with furrow.

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.

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).

Leukoplakia (4 of 4)
Open phase of vibration, shown under strobe lighting.

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.

Food and liquid blocked from trachea (1 of 3)
This view is just inside the upper esophagus in a man who has undergone laryngectomy. The white-edged “disc” at the bottom of the photo is the inner flange of the TEP device. The arrow points towards the valve just inside the flange. This valve says “no” to any food or liquid that wants to pass in the direction of the arrow and into the trachea (not seen here).

Closer look at closed valve (2 of 3)
Here, we see the flapper valve more clearly. Again in its “closed” position, it will not let food or liquid enter.

Opened valve (3 of 3)
Now we see the flapper valve lifted out of its housing. The patient is placing his thumb over the tracheostome (not seen here) and diverting air through the TEP device and into the esophagus. The esophageal walls are brought into vibration to produce continuous, pulmonary air-powered esophageal voice.