Infection by a fungal organism, Histoplasma capsulatum. This organism is found in soil, especially in areas contaminated by bird or bat droppings. Sometimes it is called “spelunker’s disease,” and it seems to be commoner in the Mississippi River valley than in other areas of the United States. Persons who contract this organism may not even know it, as they may have a self-limited, mild, flu-like syndrome. As with many infections, histoplasmosis can of course be more severe and even disseminated in persons who are immunocompromised. Transmission is primarily respiratory, and the primary target is the lungs, where it can cause non-progressive granulomas. It is quite rare in the larynx.
Photos:
Histoplasmosis of the Larynx
Unexplained hoarseness (1 of 4)
Unexplained severe hoarseness of several months’ duration. The marked inflammatory change does not look neoplastic, yet a biopsy seemed mandatory. The pathologist’s answer? Histoplasmosis.
Unexplained severe hoarseness of several months’ duration. The marked inflammatory change does not look neoplastic, yet a biopsy seemed mandatory. The pathologist’s answer? Histoplasmosis.
Subglottis (2 of 4)
Note as well the involvement in the subglottis. The patient began a long course of the antifungal, itraconazole.
Note as well the involvement in the subglottis. The patient began a long course of the antifungal, itraconazole.
3 months later (3 of 4)
Still on itraconazole 3 months later, the vocal cords have healed to a great extent, and voice, while continuing to be hoarse, is at least functional. In this narrow band view, healing is indicated partly by neovascularization.
Still on itraconazole 3 months later, the vocal cords have healed to a great extent, and voice, while continuing to be hoarse, is at least functional. In this narrow band view, healing is indicated partly by neovascularization.
Signs of healing (4 of 4)
The subglottic lesion is also showing signs of healing as compared with photo 2.
Closeup, magnified examination finds barbecue brush bristle base of tongue: Series of 4 photos
Pain in throat (1 of 4)
While eating barbecued steak, this person felt a sharp pain deep in her throat. At this visit the next day, she continued to feel a sharp sensation, especially when swallowing. Note the faint dark line at the arrow.
While eating barbecued steak, this person felt a sharp pain deep in her throat. At this visit the next day, she continued to feel a sharp sensation, especially when swallowing. Note the faint dark line at the arrow.
Closer view (2 of 4)
From a slightly closer vantage, the abnormality is seen better.
At this final view, the metallic nature of the foreign body and stuck-on carbonaceous debris can be appreciated. This bristle was removed with cup forceps through a channel scope in an office setting.
At this final view, the metallic nature of the foreign body and stuck-on carbonaceous debris can be appreciated. This bristle was removed with cup forceps through a channel scope in an office setting.
Idiopathic (unknown cause) inflammatory subglottic stenosis is a frustrating breathing problem seen mostly in women. It appears to be an autoimmune disorder that we have thought for many years to be an incomplete expression (forme fruste) of Wegener’s Granulomatosis, aka granulomatosis with polyangiitis (GPA). In a caseload of perhaps 125 patients, it appears that standard of care remains occasional outpatient dilation, steroid injection, and mitomycin C application. Most patients go a year or more between dilations. The rub: occasionally, dilations need to be done more frequently in an “active” case, or there may be reasons to avoid the brief general anesthesia required for dilation such as: morbid obesity, difficult jaw/tooth/neck anatomy, or even a phobia of general anesthesia.
“Office” Treatment Option for Inflammatory Subglottic Stenosis
In such situations, one naturally casts about for alternatives. Low dose methotrexate has not been very effective in our experience. And we work with a motivated rheumatologist open to considering rituximab, even with a negative ANCA study. Or the laryngologist might consider an office-based airway procedure as illustrated in the photos below. This particular person only requires dilation every 18 months or so, but it represents a major stressor for her given her fears, her size, and somewhat challenging anatomy. She is one of several offered the treatment shown below: steroid injection in the voice laboratory, followed by laser treatment.
Our thought is that in some, it may be the ridges and air turbulence that creates the feeling of airway restriction, or that these rings of stenosis “catch” mucus. In the case below, the clinician was almost dubious that what was accomplished would make that much difference to the person’s breathing. But upon calling her a week after the procedure below, and asking if the improvement was nil, subtle, small, medium, or large, she replied “large…a huge improvement.”
60% Stenosis (1 of 5)
Estimated at a 60% stenosis, using the vocal cords as a reference.
At closer range, the examiner sees concentric ridges of narrowing and erythema characteristic of this disorder.
Triamcinolone is injected (3 of 5)
With patient sitting in the chair with topical anesthesia, a needle is passed from anteriorly just below the cricoid. Here, triamcinolone is being injected into the posterior component of the stenosis.
With patient sitting in the chair with topical anesthesia, a needle is passed from anteriorly just below the cricoid. Here, triamcinolone is being injected into the posterior component of the stenosis.
Laser ablation (4 of 5)
The blue laser fiber (thulium laser) is seen just prior to beginning laser ablation. Note in particular the circular shape of the area of greatest stenosis, to compare with the next photo.
The blue laser fiber (thulium laser) is seen just prior to beginning laser ablation. Note in particular the circular shape of the area of greatest stenosis, to compare with the next photo.
Stenosis is coagulated (5 of 5)
The anterior half of the ring of greater stenosis has been coagulated. Note that the shape of the opening is changed to more of an anterior-posteriorly oriented oval. Distal trachea is also more easily seen. Again, the patient reported that this improved her breathing to a large degree.
The anterior half of the ring of greater stenosis has been coagulated. Note that the shape of the opening is changed to more of an anterior-posteriorly oriented oval. Distal trachea is also more easily seen. Again, the patient reported that this improved her breathing to a large degree.
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Photos:
Idiopathic Subglottic Stenosis Has Different Levels
Post dilation (1 of 4)
Six months after dilation of idiopathic (inflammatory) subglottic stenosis, the patient has noted only slight deterioration, and breathing ability remains acceptable to her.
Six months after dilation of idiopathic (inflammatory) subglottic stenosis, the patient has noted only slight deterioration, and breathing ability remains acceptable to her.
Closer view (2 of 4)
At closer range, the inflammatory component appears more evident.
The rich vascular pattern accompanying the lesion is seen better and is a visual finding of inflammation.
"Sharing" the airway (4 of 4)
Here, the scope has been passed through the area of maximal narrowing and the patient becomes acutely aware of greater difficulty breathing. "Sharing the airway" is a way of 'measuring' it functionally. Note again the congested capillaries.
Here, the scope has been passed through the area of maximal narrowing and the patient becomes acutely aware of greater difficulty breathing. "Sharing the airway" is a way of 'measuring' it functionally. Note again the congested capillaries.
Another way to Inject Idiopathic Subglottic Stenosis
Idiopathic inflammatory subglottic stenosis (1 of 3)
This patient is about to receive a triamcinolone (steroid) injection into her idiopathic inflammatory subglottic stenosis, while sitting in a chair under topical anesthesia. Dotted circle is for reference with Photo 2.
This patient is about to receive a triamcinolone (steroid) injection into her idiopathic inflammatory subglottic stenosis, while sitting in a chair under topical anesthesia. Dotted circle is for reference with Photo 2.
Priot to injection (2 of 3)
A needle has been passed through anterior neck skin and its tip rests out of sight, submucosally just inferior to the anterior cricoid ring. Note that the milky white medication has been infused submucosally within the dotted ring.
A needle has been passed through anterior neck skin and its tip rests out of sight, submucosally just inferior to the anterior cricoid ring. Note that the milky white medication has been infused submucosally within the dotted ring.
Injection (3 of 3)
Here, the 27-gauge needle traverses the trachea in order to inject the posterior tracheal wall. The submucosal white medication appears at the *.
Subglottic stenosis is narrowing just below the vocal cords, in the lowest part of the larynx and immediately above the first tracheal ring. Examples of causes include scarring from a breathing tube used during a long ICU stay, Wegener’s Granulomatosis (aka Granulomatosis with polyangiitis), and idiopathic subglottic stenosis (aka limited Wegener’s Granulomatosis).
Subglottic Stenosis, after Treatment
Subglottic stenosis, before treatment (1 of 2)
Subglottic and high tracheal stenosis, inflammatory, idiopathic (Lab).
Same patient, a few days after dilation and steroid injection (Lab).
Subglottic Stenosis, before and after Dilation
Subglottic stenosis, before dilation (1 of 2)
This individual has undergone at least a dozen prior dilations, each of which provides dramatic relief from noisy breathing and exercise intolerance. Here the patient is halfway to needing re-dilation, due to the typical inflammatory stenosis that is seen. Compare with photo 2.
This individual has undergone at least a dozen prior dilations, each of which provides dramatic relief from noisy breathing and exercise intolerance. Here the patient is halfway to needing re-dilation, due to the typical inflammatory stenosis that is seen. Compare with photo 2.
Subglottic stenosis, after dilation (2 of 2)
One week after one of this patient's dilations (with Kenalog injection and topical Mitomycin C), showing a dramatic widening of her airway; compare with photo 1. After a number of years, inflammatory lesions such as this sometimes "burn out," and the interval between dilations increases.
One week after one of this patient's dilations (with Kenalog injection and topical Mitomycin C), showing a dramatic widening of her airway; compare with photo 1. After a number of years, inflammatory lesions such as this sometimes "burn out," and the interval between dilations increases.
Subglottic stenosis (1 of 5)
Middle-aged woman with unexplained shortness of breath and noisy breathing, due to this idiopathic inflammatory and very high subglottic stenosis. The patient initially declined dilation due to her anxiety. She also had granularity of the nasal septum and a positive ANCA profile for Wegener’s granulomatosis.
Middle-aged woman with unexplained shortness of breath and noisy breathing, due to this idiopathic inflammatory and very high subglottic stenosis. The patient initially declined dilation due to her anxiety. She also had granularity of the nasal septum and a positive ANCA profile for Wegener’s granulomatosis.
Subglottic stenosis, worsened (2 of 5)
Five months later, the symptoms became intolerable, and the stenosis was noted to be slightly narrower and with a greater posterior component. The patient agreed to dilation.
Five months later, the symptoms became intolerable, and the stenosis was noted to be slightly narrower and with a greater posterior component. The patient agreed to dilation.
Subglottic stenosis, worsened (3 of 5)
Same exam as photo 2; this close-up view shows more clearly the inflammatory nature of this stenosis.
Same exam as photo 2; this close-up view shows more clearly the inflammatory nature of this stenosis.
Subglottic stenosis, after dilation (4 of 5)
Five days after outpatient dilation, triamcinolone injection, and topical mitomycin C application. The patient’s symptoms have vanished, the harsh inspiratory noise is no longer heard, and the size of the airway, though still not normal, is more than doubled. Compare with photo 2 of this series.
Five days after outpatient dilation, triamcinolone injection, and topical mitomycin C application. The patient’s symptoms have vanished, the harsh inspiratory noise is no longer heard, and the size of the airway, though still not normal, is more than doubled. Compare with photo 2 of this series.
Subglottic stenosis, after dilation (5 of 5)
Same exam as photo 4, close-up view. Intensification of the inflammatory changes of this stenosis are expected so early after dilation. Compare size of the stenosis with photo 3 of this series.
Same exam as photo 4, close-up view. Intensification of the inflammatory changes of this stenosis are expected so early after dilation. Compare size of the stenosis with photo 3 of this series.
Stenosis Before and After Dilation for Forme Fruste Wegener’s
Subglottic stenosis (1 of 5)
High-grade subglottic stenosis in a woman diagnosed syndromically with forme fruste Wegener's granulomatosis-related subglottic stenosis. With a narrowing less than 50%, she is very symptomatic. Her breathing is noisy, and her forced inspiration time is about 3 seconds. Compare with photo 4.
High-grade subglottic stenosis in a woman diagnosed syndromically with forme fruste Wegener's granulomatosis-related subglottic stenosis. With a narrowing less than 50%, she is very symptomatic. Her breathing is noisy, and her forced inspiration time is about 3 seconds. Compare with photo 4.
Inflammation (2 of 5)
Closer visualization reveals the inflammatory nature of the stenosis.
Closer visualization reveals the inflammatory nature of the stenosis.
Flexible scope (3 of 5)
Here the distal chip flexible scope has passed through the narrowing not only to see into distal trachea, but also as a breathing test. The patient becomes very aware of reduced space and this indicates a marginal airway.
Here the distal chip flexible scope has passed through the narrowing not only to see into distal trachea, but also as a breathing test. The patient becomes very aware of reduced space and this indicates a marginal airway.
Post-dilation (4 of 5)
A week after dilation, triamcinolone injection and mitomycin C application, the patient says breathing is now normal, and forced inspiration time is only a second in duration--normal. Compare with photo 1.
A week after dilation, triamcinolone injection and mitomycin C application, the patient says breathing is now normal, and forced inspiration time is only a second in duration--normal. Compare with photo 1.
Post-operative bruising (5 of 5)
Closer visualization with early postoperative bruising. The trachea is now easily visible through the larger opening. Compare with photo 2.
Close view, showing the inflammatory nature of the stenosis.
Subglottic Stenosis, Due to Wegener’s Granulomatosis
Subglottic stenosis, due to Wegener's (1 of 2)
This person has Wegener’s granulomatosis, confirmed by anti-neutrophil cytoplasmic antibodies (ANCA) testing. Here, looking from above the vocal cords, one can see an estimated 50% narrowing of the subglottic and high tracheal passageway.
This person has Wegener’s granulomatosis, confirmed by anti-neutrophil cytoplasmic antibodies (ANCA) testing. Here, looking from above the vocal cords, one can see an estimated 50% narrowing of the subglottic and high tracheal passageway.
Subglottic stenosis, due to Wegener's (2 of 2)
Viewed from within the subglottis, one can see more clearly the inflammatory nature of this stenosis. A dotted oval estimates what the normal caliber or width of this airway would be. This patient has been managed with systemic medication, but also occasional dilation, steroid injection, and Mitomycin C application.
Viewed from within the subglottis, one can see more clearly the inflammatory nature of this stenosis. A dotted oval estimates what the normal caliber or width of this airway would be. This patient has been managed with systemic medication, but also occasional dilation, steroid injection, and Mitomycin C application.
Supraglottic, Glottic, and Subglottic Endotracheal Tube Injury
Breathing tube injury (1 of 4)
This 20-something individual was premature at birth and intubated for several weeks. Decades later, the evidence of breathing tube injury can be seen. Here, parallel lines outline likely trajectory of tube, taped at right corner of mouth. This fits as well with the left medial arytenoid divot at arrow. Dotted lines indicate aryepiglottic cord margins. Note deficit on right (left of photo) suggesting pressure necrosis from the endotracheal tube.
This 20-something individual was premature at birth and intubated for several weeks. Decades later, the evidence of breathing tube injury can be seen. Here, parallel lines outline likely trajectory of tube, taped at right corner of mouth. This fits as well with the left medial arytenoid divot at arrow. Dotted lines indicate aryepiglottic cord margins. Note deficit on right (left of photo) suggesting pressure necrosis from the endotracheal tube.
Aryepiglottic cord defect (2 of 4)
Aryepiglottic cord defect is better seen during phonation. The details of posterior commissure injury are obscured at this distance.
Aryepiglottic cord defect is better seen during phonation. The details of posterior commissure injury are obscured at this distance.
Phonation (3 of 4)
During phonation, low voice, note that the posterior vocal cords cannot come together, (even with cough or breath-holding) due to joint capsule injury from the endotracheal tube. Voice is intractably breathy.
During phonation, low voice, note that the posterior vocal cords cannot come together, (even with cough or breath-holding) due to joint capsule injury from the endotracheal tube. Voice is intractably breathy.
Posterior subglottic thickening (4 of 4)
Posterior subglottic thickening surrounded by dotted lines, indicating a third level of old injury, here with no functional consequence.
Posterior subglottic thickening surrounded by dotted lines, indicating a third level of old injury, here with no functional consequence.
Pinhole Opening in Near-Complete Subglottic Stenosis
Narrowed space for breathing (1 of 4)
This man was gravely ill and intubated for several weeks. He is now well, but tracheotomy-dependent. The vocal cords do not abduct fully due to scarring of the cricoarytenoid joints. However, the narrowed space for breathing between the posterior vocal cords is not the main reason he is tracheotomy-dependent, as seen in the next photos.
This man was gravely ill and intubated for several weeks. He is now well, but tracheotomy-dependent. The vocal cords do not abduct fully due to scarring of the cricoarytenoid joints. However, the narrowed space for breathing between the posterior vocal cords is not the main reason he is tracheotomy-dependent, as seen in the next photos.
Looking between the vocal cords (2 of 4)
At closer range, a deep erosion “divot” of the right posterior vocal cord (left of photo at dotted line) is the result of pressure necrosis of the endotracheal tube. Looking between the vocal cords into the subglottic airway, a small white oval is seen (arrow). This is the upper surface of the white plastic tracheotomy tube.
At closer range, a deep erosion “divot” of the right posterior vocal cord (left of photo at dotted line) is the result of pressure necrosis of the endotracheal tube. Looking between the vocal cords into the subglottic airway, a small white oval is seen (arrow). This is the upper surface of the white plastic tracheotomy tube.
At yet closer range. The size of this pinhole between subglottis and trachea below cannot measure more than 3 mm. Crico-tracheal resection and re-anastomosis (planned for soon after this examination) is the best option to work towards decannulation.
At yet closer range. The size of this pinhole between subglottis and trachea below cannot measure more than 3 mm. Crico-tracheal resection and re-anastomosis (planned for soon after this examination) is the best option to work towards decannulation.
Difficulty Breathing after a 3-day Intubation
Noisy, restricted breathing following intubation (1 of 5)
This teenager was intubated for 3 days due to tongue swelling. Breathing became noisy and restricted approximately 6 weeks later. Note that the vocal cords do not abduct fully and there is what appears to be granulation tissue at the posterior commissure (anterior asterisk).
This teenager was intubated for 3 days due to tongue swelling. Breathing became noisy and restricted approximately 6 weeks later. Note that the vocal cords do not abduct fully and there is what appears to be granulation tissue at the posterior commissure (anterior asterisk).
Normal voice (2 of 5)
The vocal cords can come into contact as shown here, consistent with her normal-sounding voice.
The vocal cords can come into contact as shown here, consistent with her normal-sounding voice.
At close range (3 of 5)
At very close range within the posterior commissure, a small tract is seen posterior to the "granulation" which is now seen more clearly to be a broad-based synechiae with asterisks marking anterior and posterior limits.
At very close range within the posterior commissure, a small tract is seen posterior to the "granulation" which is now seen more clearly to be a broad-based synechiae with asterisks marking anterior and posterior limits.
At even closer range (4 of 5)
An even closer view verifies a posterior tract, and this makes it less likely that the cricoarytenoid joints are also injured.
An even closer view verifies a posterior tract, and this makes it less likely that the cricoarytenoid joints are also injured.
Mucosa-only scar (5 of 5)
This view is taken with the scope passed just between the vocal cords and just anterior to the synechiae and angled directly posteriorly. A small superficial-looking "mucosa-only" scar is seen bilaterally, surrounded by dotted line. It can be confidently predicted that when the synechiae is released, the arytenoid cartilages will likely be able to abduct fully.
This view is taken with the scope passed just between the vocal cords and just anterior to the synechiae and angled directly posteriorly. A small superficial-looking "mucosa-only" scar is seen bilaterally, surrounded by dotted line. It can be confidently predicted that when the synechiae is released, the arytenoid cartilages will likely be able to abduct fully.
An open epidermoid cyst occurs when it spontaneously ruptures, but yet not empty all of its contents (keratin). The outline of the partially-emptied cyst may still be very evident, but it usually assumes an oval shape with the long axis oriented anteriorly and posteriorly. If the cyst empties nearly completely, the white oval is no longer seen, but the vocal cord may have a mottled appearance. If the cyst empties completely, a sulcus lined by epithelium remains.
Photos:
A Case That Clearly Shows the Relationship Between Cyst & Sulcus
White Lesion on Right Vocal Cord (1 of 6)
This young man is known as vocally exuberant. For some years, he has used his voice socially to the point of hoarseness countless times, including at heavy metal rock concerts. In the past year or so, his hoarseness never went away. In this distant view, a white lesion is seen on his right vocal cord (left of photo).
This young man is known as vocally exuberant. For some years, he has used his voice socially to the point of hoarseness countless times, including at heavy metal rock concerts. In the past year or so, his hoarseness never went away. In this distant view, a white lesion is seen on his right vocal cord (left of photo).
White Lesion Under Strobe Light (2 of 6)
Under strobe light and with higher magnification, the open phase of vibration shows this lesion as a white nubbin protruding from a fossa.
The closed phase of vibration shows more clearly the depression from which the lesion is protruding.
White Lesion Removed (4 of 6)
After surgical removal and healing, voice is improved though not fully restored. The lesion was granulation and keratosis. It was plucked from the depression without deepening the pre-existing “divot.”
After surgical removal and healing, voice is improved though not fully restored. The lesion was granulation and keratosis. It was plucked from the depression without deepening the pre-existing “divot.”
Vocal Cords (5 of 6)
At the open phase of vibration, showing the trough from which the lesion was removed. There is a smaller depression on the left also consistent with vibratory trauma.
At the open phase of vibration, showing the trough from which the lesion was removed. There is a smaller depression on the left also consistent with vibratory trauma.
Vocal Cords without Lesion (6 of 6)
The closed phase of vibration. Compare with photo 3.
Prephonatory instant shows some muscular tension dysphonia as well.
Open cyst (3 of 3)
Closer view. While an intact epidermoid cyst has a distinct outline, an open cyst develops a more mottled appearance. It may leak intermittently from a tiny dimple or sulcus which is sometimes seen at very close range.
Closer view. While an intact epidermoid cyst has a distinct outline, an open cyst develops a more mottled appearance. It may leak intermittently from a tiny dimple or sulcus which is sometimes seen at very close range.
Open Cyst and Sulcus in Same Patient
Hoarse voice (1 of 4)
A young woman with a history of repeated loud cheering during athletic activities, to the point of hoarseness. She has a sulcus of the right cord (left of photo), and an open cyst of the left ( right of photo). Openings from sulcus and cyst are indicated by dotted lines.
A young woman with a history of repeated loud cheering during athletic activities, to the point of hoarseness. She has a sulcus of the right cord (left of photo), and an open cyst of the left ( right of photo). Openings from sulcus and cyst are indicated by dotted lines.
Cyst + sulcus (2 of 4)
Narrow band light. The lateral lip of a sulcus is often bordered by a prominent capillary as seen here. An open cyst assumes an elliptical shape in the anteroposterior direction. It fails to empty completely because the opening draining it is smaller than the diameter of the cyst.
Narrow band light. The lateral lip of a sulcus is often bordered by a prominent capillary as seen here. An open cyst assumes an elliptical shape in the anteroposterior direction. It fails to empty completely because the opening draining it is smaller than the diameter of the cyst.
Open Cyst and Sulcus; Normal and Segmental Vibration
Margin swelling (1 of 6)
Breathing position of the vocal cords of a very hoarse actor. Note the margin swelling of both sides. The white material on the left vocal cord (right of photo) is keratin debris emerging from an open cyst. Find the sulcus of the right vocal cord (left of photo) which is more easily seen in the next photo.
Breathing position of the vocal cords of a very hoarse actor. Note the margin swelling of both sides. The white material on the left vocal cord (right of photo) is keratin debris emerging from an open cyst. Find the sulcus of the right vocal cord (left of photo) which is more easily seen in the next photo.
Narrow band light (2 of 6)
Further magnified and under narrow band light. The right sulcus is within the dotted outline. Compare now with photo 1.
At the same pitch, the closed phase again includes the full length of the cords.
Segmental vibration (5 of 6)
At the much higher pitch of C5 (523 Hz) a “tin whistle” quality is heard and only the anterior segment (at arrows) is opening for vibration. The posterior opening is static and not oscillating, as seen in the next photo.
At the much higher pitch of C5 (523 Hz) a “tin whistle” quality is heard and only the anterior segment (at arrows) is opening for vibration. The posterior opening is static and not oscillating, as seen in the next photo.
Closed phase (6 of 6)
The closed phase of vibration involves only the tiny anterior segment of the vocal cords, at the arrows. The posterior segment is not vibrating and is unchanged.
The closed phase of vibration involves only the tiny anterior segment of the vocal cords, at the arrows. The posterior segment is not vibrating and is unchanged.
Open Epidermoid Cyst-Sulcus
Chronic hoarseness (1 of 4)
This woman suffers from chronic hoarseness. Note the relatively normal left vocal cord (right of photo) but that the right side has a whitish lesion at the margin. Equally important is the faint white submucosal collection of keratin indicated by dotted line.
This woman suffers from chronic hoarseness. Note the relatively normal left vocal cord (right of photo) but that the right side has a whitish lesion at the margin. Equally important is the faint white submucosal collection of keratin indicated by dotted line.
Cyst under narrow band light (2 of 4)
Under narrow band light, the arrow indicates the sulcus opening that allows what was likely an epidermoid cyst to partially empty.
An Actress’ Polyp Before and Hours After Surgical Removal
Vocal cord polyp (1 of 8)
Musical theater actress with chronic hoarseness due to this right vocal cord polyp (left of photo), first identified a year earlier and unresponsive to speech therapy.
Musical theater actress with chronic hoarseness due to this right vocal cord polyp (left of photo), first identified a year earlier and unresponsive to speech therapy.
Closer view (2 of 8)
Magnified view shows small elevation of the left cord (right of photo) as well.
The next day, only a few hours after surgical removal. Note slight bruising from the endotracheal tube (long arrows), and small dots where a laser impact was used to interrupt flow in a prominent capillary (short arrows).
The next day, only a few hours after surgical removal. Note slight bruising from the endotracheal tube (long arrows), and small dots where a laser impact was used to interrupt flow in a prominent capillary (short arrows).
Primary “wound” (6 of 8)
Magnified view. Primary “wound” from polyp removal is at the arrows. Edema of the opposite side is from minimal trimming on that side.
Closed phase of vibration, strobe light, at D5 (587 Hz). Increased mucus is from endotracheal tube and surgical manipulation just hours earlier.
Open phase (8 of 8)
Open phase, at same pitch. Subtle irregularities will “iron out” within over time. Voice is already much better (tested briefly because the patient is within the four days of voice rest, and then will gradually increase amounts of voice use for the subsequent month).
Open phase, at same pitch. Subtle irregularities will “iron out” within over time. Voice is already much better (tested briefly because the patient is within the four days of voice rest, and then will gradually increase amounts of voice use for the subsequent month).
Hemorrhagic Polyp, before and after Surgery
Hemorrhagic polyp (1 of 8)
Standard light, close-up view of a hemorrhagic polyp of the vocal cord.
Same patient, one week after surgical removal of the polyp, standard light.
Hemorrhagic polyp: 1 week after surgery (5 of 8)
Strobe light, open phase of vibration. Compare with photo 2. Note here that the vibratory amplitude of both cords is the same, showing that the operated cord remains flexible.
Strobe light, open phase of vibration. Compare with photo 2. Note here that the vibratory amplitude of both cords is the same, showing that the operated cord remains flexible.
Hemorrhagic polyp: 1 week after surgery (6 of 8)
Strobe light, closed phase of vibration. Compare with photo 3; the vocal cords now match much better during voicing, and the voice is completely normalized.
Strobe light, closed phase of vibration. Compare with photo 3; the vocal cords now match much better during voicing, and the voice is completely normalized.
Hemorrhagic polyp: 7 months after surgery (7 of 8)
Seven months later. Strobe light, closed phase of vibration. The patient feels his voice is normal, and swelling checks don't indicate any impairment.
Chronic polyp on the right vocal cord (left of image), with ectatic capillaries, unresponsive to voice rest and therapy.
Vocal polyp, surgically removed (2 of 2)
Seven weeks after surgical removal and spot coagulation of ectatic capillaries. The margins of the vocal cords now match, and capillaries are normalized. Mucosal vibration is preserved to the highest reaches of the singing range. At this pre-phonatory instant, one can see that muscle memory is keeping the vocal cords slightly apart, suggesting the need for additional speech therapy.
Seven weeks after surgical removal and spot coagulation of ectatic capillaries. The margins of the vocal cords now match, and capillaries are normalized. Mucosal vibration is preserved to the highest reaches of the singing range. At this pre-phonatory instant, one can see that muscle memory is keeping the vocal cords slightly apart, suggesting the need for additional speech therapy.
Vocal polyp (1 of 6)
Prephonatory instant, standard light. The space between the vocal cords is larger than necessary to accommodate the polyp (right of image) and low-profile elevation (left of image).
Prephonatory instant, standard light. The space between the vocal cords is larger than necessary to accommodate the polyp (right of image) and low-profile elevation (left of image).
Six days after surgical removal. Prephonatory instant, standard light. Compare with photo 1. The patient continues to position vocal cords in a surprisingly separated position, as though the ghosts of the swellings remain. We call this “gap memory” or “posture memory,” though it is a manifestation as well of muscular tension dysphonia.
Six days after surgical removal. Prephonatory instant, standard light. Compare with photo 1. The patient continues to position vocal cords in a surprisingly separated position, as though the ghosts of the swellings remain. We call this “gap memory” or “posture memory,” though it is a manifestation as well of muscular tension dysphonia.
Vocal polyp, surgically removed (4 of 6)
Phonation with blurring, standard light. Compare with photo 2.
Phonation with blurring, standard light. Compare with photo 2.
Vocal polyp, surgically removed (5 of 6)
Phonation, strobe light, open phase of vibration, at high G# (~831 Hz), just below A5. Even at this high pitch, both cords oscillate out to a full lateral excursion.
Phonation, strobe light, open phase of vibration, at high G# (~831 Hz), just below A5. Even at this high pitch, both cords oscillate out to a full lateral excursion.
Vocal polyp, surgically removed (6 of 6)
Phonation, strobe light, closed phase of vibration, also at high G#. Since the patient is only six days postop, mild residual swelling is still present. More importantly, note that this “closed” vibration phase is not in fact fully closed, as further evidence of the patient’s “gap memory” and muscular tension dysphonia. Singing voice-qualified speech therapy and work with a singing teacher will address this.
Phonation, strobe light, closed phase of vibration, also at high G#. Since the patient is only six days postop, mild residual swelling is still present. More importantly, note that this “closed” vibration phase is not in fact fully closed, as further evidence of the patient’s “gap memory” and muscular tension dysphonia. Singing voice-qualified speech therapy and work with a singing teacher will address this.
Vocal polyp (1 of 6)
An operatic baritone has a chronic left vocal cord polyp (right of image), and small contact reaction, right cord.
Closed phase of vibration, high falsetto, shows equal vibratory amplitude on both sides (no stiffness) and excellent match of the cords.
Pre-op and very early Post-op Mucosal Match and Flexibility in Male Singer
Bilateral chronic injuries (1 of 8)
Young music teacher and choral director with chronic hoarseness for more than a year. Note bilateral chronic injuries, and also recent bruise of the right cord (left of photo).
Young music teacher and choral director with chronic hoarseness for more than a year. Note bilateral chronic injuries, and also recent bruise of the right cord (left of photo).
Closeup of injuries (2 of 8)
Closeup of injuries and their "refusal" to let the cords approximate, when attempting (unsuccessfully) to sing a high pitch.
7 days after vocal cord microsurgery, the voice can already pass for normal quality and capability. Compare with photo 1.
Prephonatory instant (4 of 8)
Prephonatory instant at high pitch, showing that the match of the cords is already markedly restored. The tiny elevation will disappear with further healing.
Prephonatory instant at high pitch, showing that the match of the cords is already markedly restored. The tiny elevation will disappear with further healing.
Closed phase, A-flat 3 (5 of 8)
Closed phase of vibration at A-flat 3 (208 Hz), seen under strobe light.
Phonation under standard light shows that vocal cord margins now match, and both margins blur; suggesting vibratory flexibility.
Margin fibrosis (7 of 8)
Closed phase of vibration, at ~ A4 (440 Hz), as seen under strobe light. Margin fibrosis seen best here, indicated by the black dotted line. Compare with photo 3.
Closed phase of vibration, at ~ A4 (440 Hz), as seen under strobe light. Margin fibrosis seen best here, indicated by the black dotted line. Compare with photo 3.
Open phase (8 of 8)
Open phase of vibration. The same pitch (A4) reveals excellent vibratory flexibility and equal amplitude (lateral excursion) of vibration. Compare with photo 4.
Open phase of vibration. The same pitch (A4) reveals excellent vibratory flexibility and equal amplitude (lateral excursion) of vibration. Compare with photo 4.
Vocal Nodules, Before and After Surgery
Vocal nodules (1 of 6)
Strobe light, phonation, open phase of vibration, at the pitch D5 (~587 Hz). There are vocal nodules on both vocal cords, of very long duration, even after voice rest and speech therapy. Compare with photos 3 and 5.
Strobe light, phonation, open phase of vibration, at the pitch D5 (~587 Hz). There are vocal nodules on both vocal cords, of very long duration, even after voice rest and speech therapy. Compare with photos 3 and 5.
Breathy voice (2 of 6)
Same as photo 1, but during the closed phase of vibration. The nodules keep the vocal cords from coming together completely (as seen here), making the patient’s voice breathy. Compare with photos 4 and 6.
Same as photo 1, but during the closed phase of vibration. The nodules keep the vocal cords from coming together completely (as seen here), making the patient’s voice breathy. Compare with photos 4 and 6.
1 week after surgery (3 of 6)
One week after surgical removal of the vocal nodules. Strobe light, phonation, open phase of vibration, at the pitch B5 (~988 Hz). (The small “blob” seen at the midpoint of the cords is just incidental mucus.)
One week after surgical removal of the vocal nodules. Strobe light, phonation, open phase of vibration, at the pitch B5 (~988 Hz). (The small “blob” seen at the midpoint of the cords is just incidental mucus.)
Closed phase (4 of 6)
Same as photo 3, but during the closed phase of vibration.
Same as photo 3, but during the closed phase of vibration.
7 weeks after surgery (5 of 6)
Seven weeks after surgical removal of the nodules. Strobe light, phonation, open phase of vibration, at the pitch C#6 (~1109 Hz). (Incidental mucus is obscuring the posterior end of the vocal cords.)
Seven weeks after surgical removal of the nodules. Strobe light, phonation, open phase of vibration, at the pitch C#6 (~1109 Hz). (Incidental mucus is obscuring the posterior end of the vocal cords.)
7 weeks after surgery (6 of 6)
Same as photo 5, but during the closed phase of vibration. Voice is no longer breathy, and the upper range has been restored.
Closed phase of vibration, with notable translucency of the right vocal cord (left of image), which is often a predictor of chronicity and only partial response to speech (voice) therapy.
Closed phase of vibration, with notable translucency of the right vocal cord (left of image), which is often a predictor of chronicity and only partial response to speech (voice) therapy.
Prephonatory instant shows recurrent swelling due to persistent vocal overuse, despite careful preoperative preparation for surgery by a voice-qualified speech pathologist. Patients must know “we are only operating on your vocal cords, not your personality, occupation, friend group, social life, etc.”
Prephonatory instant shows recurrent swelling due to persistent vocal overuse, despite careful preoperative preparation for surgery by a voice-qualified speech pathologist. Patients must know “we are only operating on your vocal cords, not your personality, occupation, friend group, social life, etc.”
Closed phase of vibration, strobe light. The “original equipment” capabilities of the voice early after successful vocal cord microsurgery (above) have been diminished, but capabilities remain markedly better than they were with the original lesions.
Closed phase of vibration, strobe light. The “original equipment” capabilities of the voice early after successful vocal cord microsurgery (above) have been diminished, but capabilities remain markedly better than they were with the original lesions.
Vocal nodules (1 of 4)
Vocal nodules, moderately large, seen with cords in abducted (breathing) position.
Open phase of vibration (strobe light), at D5 (587 Hz). Irregular margins will iron out across time.
Closed phase (8 of 8)
At closed phase of vibration, also at D5. Note excellent match, bilaterally equal vibratory excursions, and partial correction of the MTD posterior commissure gap.
At closed phase of vibration, also at D5. Note excellent match, bilaterally equal vibratory excursions, and partial correction of the MTD posterior commissure gap.
Vocal Nodule Postop Irregularity yet Match and Flexibility
Large vocal nodules (1 of 8)
Bilateral large vocal nodules in band singer that does close harmony musical styles.
Approximately one month after excision, healing progressing.
Vocal cord cancer, after complete healing (4 of 4)
After complete healing, patient has a voice that passes for normal. Under strobe light, right cord oscillates well except at very high vocal pitch. Note, however, the mild pseudo-bowing of the right cord due to tissue loss, and that there is a mucosal wave on the left, but not on the right.
After complete healing, patient has a voice that passes for normal. Under strobe light, right cord oscillates well except at very high vocal pitch. Note, however, the mild pseudo-bowing of the right cord due to tissue loss, and that there is a mucosal wave on the left, but not on the right.
Vocal cord cancer (1 of 8)
Patient from elsewhere, first seen 9 months after radiotherapy, with obvious persistent right vocal cord cancer.
Nearly complete healing after complete cordectomy right vocal cord. Only residual granulation.
Vocal cord cancer, 7 weeks after surgery (6 of 8)
Closer view of defect. Thin mucosa covers inner surface of thyroid cartilage, and residual exposed cartilage, not yet healed over with mucosa, at arrow.
Closer view of defect. Thin mucosa covers inner surface of thyroid cartilage, and residual exposed cartilage, not yet healed over with mucosa, at arrow.
Vocal cord cancer, 7 weeks after surgery (7 of 8)
At maximum phonatory adduction. Note that the left vocal process is turned medially (arrow), signifying maximum adductory “effort” of that side. There is no right vocal cord, and hence there is no possibility of glottic voice.
At maximum phonatory adduction. Note that the left vocal process is turned medially (arrow), signifying maximum adductory “effort” of that side. There is no right vocal cord, and hence there is no possibility of glottic voice.
Vocal cord cancer, 7 weeks after surgery (8 of 8)
Vibration of the arytenoid apices (arrows) against the petiole of the epiglottis (line), providing a rough, voice serviceable for quiet conversation, but highly limited in noisy surroundings.
Vibration of the arytenoid apices (arrows) against the petiole of the epiglottis (line), providing a rough, voice serviceable for quiet conversation, but highly limited in noisy surroundings.
Scarring after Cancer Treatment but with very Good Voice
Post laser excision (1 of 4)
Ten years after laser excision of a left vocal cord (right of photo) cancer, viewed from a distance. Voice has been extremely serviceable, if slightly husky.
Ten years after laser excision of a left vocal cord (right of photo) cancer, viewed from a distance. Voice has been extremely serviceable, if slightly husky.
Prephonatory instant (2 of 4)
Closer visualization at the prephonatory instant. Now the pseudobowing of the left cord (from tissue loss is easily seen.
Closer visualization at the prephonatory instant. Now the pseudobowing of the left cord (from tissue loss is easily seen.
Phonation (3 of 4)
Making voice, the faint blurring of the right cord margin (left of photo), but non-vibrating left cord (right of photo) can be more easily appreciated.
Making voice, the faint blurring of the right cord margin (left of photo), but non-vibrating left cord (right of photo) can be more easily appreciated.
Close-up view (4 of 4)
At very close range, medial-to-lateral capillary reorientation—typical of superficial cordectomy after healing.
At very close range, medial-to-lateral capillary reorientation—typical of superficial cordectomy after healing.
Vocal Cord Cancer, before, during, and after Radiation
Vocal cord cancer (1 of 8)
Superficial cancer involving both vocal cords. This is stage 1 disease (T1B). The greatest bulk is on the right posterior cord (left of image), but the majority of both cords is involved with at least superficial disease. A faint dotted rectangle indicates the zoomed-in area seen in photo 2.
Superficial cancer involving both vocal cords. This is stage 1 disease (T1B). The greatest bulk is on the right posterior cord (left of image), but the majority of both cords is involved with at least superficial disease. A faint dotted rectangle indicates the zoomed-in area seen in photo 2.
Vocal cord cancer (2 of 8)
Close-up view of only the anterior half of the cords. Notice the irregular surface, and areas of leukoplakia within this squamous cell carcinoma.
Just over midway through radiation treatment. One can see that the tumor is melting away.
Vocal cord cancer, during radiation (4 of 8)
Postcricoid / hypopharyngeal mucositis. In this view, the patient is performing a so-called trumpet maneuver to splay open the lower throat. The radiation delivered to the vocal cords (which inhabit the airway but are hidden here due to the momentary constriction of the laryngeal vestibule, at arrows) also causes superficial ulceration of the swallowing passage (upper half of the photo), directly behind the vocal cords. On occasion, if tissue reaction and mucositis are much more severe than seen here, a stricture can form, requiring dilation.
Postcricoid / hypopharyngeal mucositis. In this view, the patient is performing a so-called trumpet maneuver to splay open the lower throat. The radiation delivered to the vocal cords (which inhabit the airway but are hidden here due to the momentary constriction of the laryngeal vestibule, at arrows) also causes superficial ulceration of the swallowing passage (upper half of the photo), directly behind the vocal cords. On occasion, if tissue reaction and mucositis are much more severe than seen here, a stricture can form, requiring dilation.
Vocal cord cancer, 2 months after radiation (5 of 8)
Two months after radiation is complete, showing that the tumor is gone, and the mucositis has resolved. There is a small anterior commissure web (at arrow) just below the free margin of the cords. The patient’s voice can nevertheless pass for normal.
Two months after radiation is complete, showing that the tumor is gone, and the mucositis has resolved. There is a small anterior commissure web (at arrow) just below the free margin of the cords. The patient’s voice can nevertheless pass for normal.
Vocal cord cancer, 4 months after radiation (6 of 8)
Now four months after the end of radiation. Close-up view of the postcricoid / hypopharynx regions (compare with photo 4 in this series). Mucositis here is resolved as well, and there is no stricture.
Now four months after the end of radiation. Close-up view of the postcricoid / hypopharynx regions (compare with photo 4 in this series). Mucositis here is resolved as well, and there is no stricture.
Vocal cord cancer, 6 months after radiation (7 of 8)
Now six months after the end of radiation. Strobe illumination, open phase of vibration. Note that the contours of the vocal cords are not perfectly normal, even though voice is very good.
Now six months after the end of radiation. Strobe illumination, open phase of vibration. Note that the contours of the vocal cords are not perfectly normal, even though voice is very good.
Vocal cord cancer, 6 months after radiation (8 of 8)
Strobe illumination, nearly closed phase of vibration. Oscillatory flexibility is preserved, but the vocal cord margins are not perfectly straight.
Strobe illumination, nearly closed phase of vibration. Oscillatory flexibility is preserved, but the vocal cord margins are not perfectly straight.
Vocal Cord Cancer, before and after Radiotherapy
Vocal cord cancer (1 of 7)
A 66-year-old man who complains of hoarseness. He smoked a pack a day for 50 years but quit five years ago. Note here the fullness and irregular contour especially of the left vocal cord ( right of photo). A biopsy confirmed this was cancer.
A 66-year-old man who complains of hoarseness. He smoked a pack a day for 50 years but quit five years ago. Note here the fullness and irregular contour especially of the left vocal cord ( right of photo). A biopsy confirmed this was cancer.
Vocal cord cancer (2 of 7)
At closer range, scattered leukoplakia and stippled vascular markings (suggestive of HPV effect, but HPV tested negative).
Vocal cord cancer, 3 weeks after radiotherapy (4 of 7)
Same patient, three weeks after the end of full-course radiotherapy. Distant view shows radiation-induced mucositis on the false and true cords, seen as areas of white, superficial ulceration. General redness is also a radiation effect.
Same patient, three weeks after the end of full-course radiotherapy. Distant view shows radiation-induced mucositis on the false and true cords, seen as areas of white, superficial ulceration. General redness is also a radiation effect.
Vocal cord cancer, 3 weeks after radiotherapy (5 of 7)
Closer view, showing that the main tumor of the left vocal cord (again, right of photo) has melted away. Note that the mucositis is generalized, and not necessarily focal to the area of tumor sloughing.
Closer view, showing that the main tumor of the left vocal cord (again, right of photo) has melted away. Note that the mucositis is generalized, and not necessarily focal to the area of tumor sloughing.
Vocal cord cancer, 2 months after radiotherapy (6 of 7)
Same patient, now two months after the end of radiotherapy. All of the visible tumor is gone, and voice is very good. Small anterior web. Compare with photo 1 of this series.
Same patient, now two months after the end of radiotherapy. All of the visible tumor is gone, and voice is very good. Small anterior web. Compare with photo 1 of this series.
Vocal cord cancer, 2 months after radiotherapy (7 of 7)
Cancer, HPV Subtype 16, Before and After Radiation
Cancer: HPV Subtype 16 (1 of 5)
Cancer, in a patient with HPV subtype 16. The divot and blood seen on the left vocal cord (right of image) are the result of a biopsy performed elsewhere (not by BVI physician) earlier the same day as this examination.
Cancer, in a patient with HPV subtype 16. The divot and blood seen on the left vocal cord (right of image) are the result of a biopsy performed elsewhere (not by BVI physician) earlier the same day as this examination.
Cancer: HPV Subtype 16, after radiation therapy (3 of 5)
Six weeks after the end of radiation therapy, the tumor is no longer seen. However, part of the left cord (right of image) is missing, due to sloughing of the tumor that had eaten away part of the cord’s normal tissue.
Six weeks after the end of radiation therapy, the tumor is no longer seen. However, part of the left cord (right of image) is missing, due to sloughing of the tumor that had eaten away part of the cord’s normal tissue.
Cancer: HPV Subtype 16, after radiation therapy (4 of 5)
Phonation. Strobe light, open phase of vibration, shows that the margin of the left cord (right of image) is at a lower level than the right’s, due to loss of some of the bulk of the cord where the tumor died and sloughed away.
Phonation. Strobe light, open phase of vibration, shows that the margin of the left cord (right of image) is at a lower level than the right’s, due to loss of some of the bulk of the cord where the tumor died and sloughed away.
Cancer: HPV Subtype 16, after radiation therapy (5 of 5)
Strobe light, closed phase of vibration. The more normal right cord (left of image) unsuccessfully attempts to reach the left cord’s residual upper surface mucosa. Voice is functional but hoarse.
Strobe light, closed phase of vibration. The more normal right cord (left of image) unsuccessfully attempts to reach the left cord’s residual upper surface mucosa. Voice is functional but hoarse.
Pre-and 1 Week Post-removal Vocal Nodules
Verrucous carcinoma (1 of 5)
Verrucous carcinoma, left vocal cord, persistent after radiotherapy elsewhere, in a patient unable to undergo general anesthesia due to severe lung disease.
Verrucous carcinoma, left vocal cord, persistent after radiotherapy elsewhere, in a patient unable to undergo general anesthesia due to severe lung disease.
Verrucous carcinoma, after laser treatment (3 of 5)
After several Thulium Laser ablations, using topical and injected local anesthesia, with patient sitting in examination chair, thereby avoiding general anesthesia.
After several Thulium Laser ablations, using topical and injected local anesthesia, with patient sitting in examination chair, thereby avoiding general anesthesia.
Verrucous carcinoma, several weeks after laser treatment (4 of 5)
Approximately six weeks later, durable resolution of tumor. Yellow material is mucus.
Partially closed phase of vibration, strobe light.
Capillary ectasia and hemorrhagic polyp, after treatment (3 of 4)
Abducted breathing position after vocal cord microsurgery, standard light. Note that the right cord is normalized, the capillary ectasia on the left is smaller, but persists in spite of spot-coagulation. A simple pulsed-KTP laser procedure in the videoendoscopy procedure room abolished this residual lesion.
Abducted breathing position after vocal cord microsurgery, standard light. Note that the right cord is normalized, the capillary ectasia on the left is smaller, but persists in spite of spot-coagulation. A simple pulsed-KTP laser procedure in the videoendoscopy procedure room abolished this residual lesion.
Capillary ectasia and hemorrhagic polyp, after treatment (4 of 4)
Pre-phonatory instant, standard light, showing excellent match. Oscillatory ability entirely normal into extreme upper range in this professional singer.
Pre-phonatory instant, standard light, showing excellent match. Oscillatory ability entirely normal into extreme upper range in this professional singer.
Two weeks after microsurgical removal, cidofovir injection, and return of normal voice.
Papillomas, removed: HPV Subtype 11 (4 of 4)
Closer view of left posterior vocal cord, narrow band illumination. Notice that there are a few dot-like vascular marks. These are typical of HPV effect, and may presage recurrence.
Closer view of left posterior vocal cord, narrow band illumination. Notice that there are a few dot-like vascular marks. These are typical of HPV effect, and may presage recurrence.
Lesions and Papillomas of HPV, Before and After Removal and Adjuvant Injection
Lesions and papillomas of HPV subtype? (1 of 8)
At initial diagnosis, as yet untyped for HPV. Multi-focal lesions on both vocal cords.
Strobe illumination, closed phase. Even in falsetto, oscillatory ability is preserved due to the precise and superficial removal of the papillomas.
Injecting adjuvant (6 of 8)
At three weeks after removal, the patient regards his voice as normal. The patient has neither lesion nor vascular change to suggest any residual or recurrent lesion. Needle in photo (arrow) positioned to inject adjuvant medication in attempt to prevent recurrence. This procedure is done in a voice lab under topical anesthesia, not the operating room.
At three weeks after removal, the patient regards his voice as normal. The patient has neither lesion nor vascular change to suggest any residual or recurrent lesion. Needle in photo (arrow) positioned to inject adjuvant medication in attempt to prevent recurrence. This procedure is done in a voice lab under topical anesthesia, not the operating room.
After injecting adjuvant (7 of 8)
After both cords have been “inflated” with adjuvant medication. Note the convex, slightly blanched vocal cord margins, due to superficial infiltration of the medication.
After both cords have been “inflated” with adjuvant medication. Note the convex, slightly blanched vocal cord margins, due to superficial infiltration of the medication.
After final adjuvant injection (8 of 8)
Nearly a month later, immediately after the third and final adjuvant injection (hence the blood below the vocal cords). The patient again regarded his voice as completely normal. No sign at this early point of recurrence of papillomas or other HPV lesions. Patients with focal disease as seen in photo 1 of this series not infrequently go into long-term remission or “cure,” though it may be impossible to discern the relative roles of surgery, adjuvants, and the patient’s immune system.
Nearly a month later, immediately after the third and final adjuvant injection (hence the blood below the vocal cords). The patient again regarded his voice as completely normal. No sign at this early point of recurrence of papillomas or other HPV lesions. Patients with focal disease as seen in photo 1 of this series not infrequently go into long-term remission or “cure,” though it may be impossible to discern the relative roles of surgery, adjuvants, and the patient’s immune system.
Papillomas, HPV Subtype 6, before and after Removal
Papillomas: HPV Subtype 6 (1 of 4)
Papilloma, left vocal cord (right of image), standard light. Voice is grossly hoarse. This patient has HPV subtype 6.
TA-only Paresis before and after Voice Gel Injection
TA weakness, intact LCA + PCA (1 of 5)
TA weakness indicated by bowed margin and “spaghetti-linguini” difference between the cords. Medial turning of vocal process (arrow) suggests intact LCA; abducted position suggests intact PCA function. Blood is from cricothyroid membrane puncture to instill topical anesthesia.
TA weakness indicated by bowed margin and “spaghetti-linguini” difference between the cords. Medial turning of vocal process (arrow) suggests intact LCA; abducted position suggests intact PCA function. Blood is from cricothyroid membrane puncture to instill topical anesthesia.
Prephonatory instant (2 of 5)
Before voice gel injection at prephonatory instant. Wasting of left cord (right of photo), and capacious ventricle on the left (right of photo) clearly evident.
Before voice gel injection at prephonatory instant. Wasting of left cord (right of photo), and capacious ventricle on the left (right of photo) clearly evident.
Gel injection (3 of 5)
At beginning of voice gel injection (needle at white arrow).
Phonation after injection complete. Voice dramatically strengthened. Compare with photo 2.
Paresis, TA-only: before and after an Implant
Paresis, TA-only (1 of 5)
During abducted breathing position, note the atrophy of the left cord (right of image), mild margin convexity, and the capacious ventricle (at bottom-right), all of which indicate TA paresis. The cord abducts fully, demonstrating intact PCA fuction. LCA function cannot be determined in this view.
During abducted breathing position, note the atrophy of the left cord (right of image), mild margin convexity, and the capacious ventricle (at bottom-right), all of which indicate TA paresis. The cord abducts fully, demonstrating intact PCA fuction. LCA function cannot be determined in this view.
Paresis, TA-only (2 of 5)
Adducted position for phonation, with phonatory blurring as seen under standard light. LCA appears to be functioning, as indicated by the strict anterior-posterior direction of the left vocal process (right of image), just the same as for the right. This accounts for quite good approximation of the cords. The ventricle again appears capacious (dotted oval). Based upon these first two photos, we can surmise that this is a TA-only paresis.
Adducted position for phonation, with phonatory blurring as seen under standard light. LCA appears to be functioning, as indicated by the strict anterior-posterior direction of the left vocal process (right of image), just the same as for the right. This accounts for quite good approximation of the cords. The ventricle again appears capacious (dotted oval). Based upon these first two photos, we can surmise that this is a TA-only paresis.
Paresis, TA-only (3 of 5)
Under strobe light, showing increased amplitude of vibration of the left cord (right of image). This finding suggests in yet another way that the TA muscle is paralyzed.
Under strobe light, showing increased amplitude of vibration of the left cord (right of image). This finding suggests in yet another way that the TA muscle is paralyzed.
Paresis, TA-only: after implant is placed (4 of 5)
After placement of an implant into the left cord (right of image). Note the bulging of that cord and straightening of the cord's margin, and also that the ventricle on that side no longer appears capacious. Compare with photo 1.
After placement of an implant into the left cord (right of image). Note the bulging of that cord and straightening of the cord's margin, and also that the ventricle on that side no longer appears capacious. Compare with photo 1.
Paresis, TA-only: after implant is placed (5 of 5)
Under strobe illumination. Note that the lateral excursion of both cords is the same, since the left cord (right of image) is now less flaccid. Compare with photo 3
Under strobe illumination. Note that the lateral excursion of both cords is the same, since the left cord (right of image) is now less flaccid. Compare with photo 3
Vocal Cord Paralysis, Before and After Medialization
Vocal cord paralysis: before medialization (1 of 12)
A classic example of “spaghetti-linguine” vocal cords, here in breathing position. The “linguine” cord (left of image) is normal; the “spaghetti” cord (right of image) is paralyzed, likely since birth. On the paralyzed side, notice the deep and broad ventricle, mild bowing of the margin of the cord, and reduced width of the upper surface of the cord (“spaghetti”-like), as compared with the non-paralyzed side.
A classic example of “spaghetti-linguine” vocal cords, here in breathing position. The “linguine” cord (left of image) is normal; the “spaghetti” cord (right of image) is paralyzed, likely since birth. On the paralyzed side, notice the deep and broad ventricle, mild bowing of the margin of the cord, and reduced width of the upper surface of the cord (“spaghetti”-like), as compared with the non-paralyzed side.
Vocal cord paralysis: before medialization (2 of 12)
Phonation, more distant view, under standard light. Notice the considerable gap between the vocal cords. This gap correlates with the patient’s weak and air-wasting voice quality.
Phonation, more distant view, under standard light. Notice the considerable gap between the vocal cords. This gap correlates with the patient’s weak and air-wasting voice quality.
Vocal cord paralysis: before medialization (3 of 12)
Open phase of vibration, under strobe light. The paralyzed cord (right of image) has a much increased amplitude (lateral or outward excursion) and exaggerated bowing, due to its flaccidity.
Open phase of vibration, under strobe light. The paralyzed cord (right of image) has a much increased amplitude (lateral or outward excursion) and exaggerated bowing, due to its flaccidity.
Vocal cord paralysis: before medialization (4 of 12)
“Closed” phase of vibration, which is of course not closed at all, because the paralyzed cord (right of image) cannot come fully to the midline.
“Closed” phase of vibration, which is of course not closed at all, because the paralyzed cord (right of image) cannot come fully to the midline.
Vocal cord paralysis: 1 week after medialization (5 of 12)
One week after surgical medialization of the paralyzed cord (right of image), using a silastic implant buried deeply within the cord. Notice that the ventricle is no longer capacious, and the free margin is no longer bowed. Furthermore, in contrast with photo 1 of this series, the “spaghetti-linguine” description of these vocal cords is no longer apt.
One week after surgical medialization of the paralyzed cord (right of image), using a silastic implant buried deeply within the cord. Notice that the ventricle is no longer capacious, and the free margin is no longer bowed. Furthermore, in contrast with photo 1 of this series, the “spaghetti-linguine” description of these vocal cords is no longer apt.
Vocal cord paralysis: 1 week after medialization (6 of 12)
Phonation, under standard light. The gap between the cords is no longer seen (compare with photo 2), and the patient's spontaneous speaking voice sounds normal. She can recruit loudness effectively without any luffing or observable weakness.
Phonation, under standard light. The gap between the cords is no longer seen (compare with photo 2), and the patient's spontaneous speaking voice sounds normal. She can recruit loudness effectively without any luffing or observable weakness.
Vocal cord paralysis: 1 week after medialization (7 of 12)
Open phase of vibration, under strobe light. The lateral or outward excursion of the paralyzed cord (right of image) is now similar to that of the non-paralyzed cord. Compare with photo 3.
Open phase of vibration, under strobe light. The lateral or outward excursion of the paralyzed cord (right of image) is now similar to that of the non-paralyzed cord. Compare with photo 3.
Vocal cord paralysis: 1 week after medialization (8 of 12)
The closed phase of vibration is much more closed than preoperatively. Compare with photo 4.
Phonation, under standard light, showing vibratory blur. Compare with photos 2 and 6 of this series.
Vocal cord paralysis: 5 months after medialization (11 of 12)
Open phase of vibration, under strobe light. As in photo 7 of this series, and in contrast to photo 3, the implant does not permit the paralyzed cord (right of image) to “buckle” laterally, or outward. If anything, the vibratory excursion of the non-paralyzed (and un-implanted) cord is greater than that of the paralyzed, implanted cord.
Open phase of vibration, under strobe light. As in photo 7 of this series, and in contrast to photo 3, the implant does not permit the paralyzed cord (right of image) to “buckle” laterally, or outward. If anything, the vibratory excursion of the non-paralyzed (and un-implanted) cord is greater than that of the paralyzed, implanted cord.
Vocal cord paralysis: 5 months after medialization (12 of 12
The closed phase of vibration is now virtually normal, similar to photo 8 and in contrast with photo 4.
The closed phase of vibration is now virtually normal, similar to photo 8 and in contrast with photo 4.
Paresis, TA + LCA, before and after Placement of an Implant
Paresis, TA + LCA (1 of 6)
Distant view shows lesser normal-appearing abduction left cord (right of image) during breathing, suggesting that the left posterior cricoarytenoid muscle is working. Note the lesser bulk of the left vocal cord as compared with the right, although this is subtle at this viewing distance.
Distant view shows lesser normal-appearing abduction left cord (right of image) during breathing, suggesting that the left posterior cricoarytenoid muscle is working. Note the lesser bulk of the left vocal cord as compared with the right, although this is subtle at this viewing distance.
Paresis, TA + LCA (2 of 6)
At closer range, still in breathing position, one can see more easily the “linguine” of the right vocal cord (left of image) compared with the “spaghetti” and slight bowing of the left. These findings correlate with left thyroarytenoid (TA) muscle weakness and atrophy.
At closer range, still in breathing position, one can see more easily the “linguine” of the right vocal cord (left of image) compared with the “spaghetti” and slight bowing of the left. These findings correlate with left thyroarytenoid (TA) muscle weakness and atrophy.
Paresis, TA + LCA (3 of 6)
In phonatory position under strobe light, the bowing of the left cord (right of image) is more evident, as is the lateral turning of the left vocal process, consistent with weakness of the left lateral cricoarytenoid (LCA) muscle. Lines denote the direction each vocal process is pointing.
In phonatory position under strobe light, the bowing of the left cord (right of image) is more evident, as is the lateral turning of the left vocal process, consistent with weakness of the left lateral cricoarytenoid (LCA) muscle. Lines denote the direction each vocal process is pointing.
Paresis, TA + LCA: 1 week after implant is placed (4 of 6)
One week after placement of a large silastic implant into the left vocal cord (right of image). Notice the temporary eversion of the left ventricle, almost simulating a large polyp.
One week after placement of a large silastic implant into the left vocal cord (right of image). Notice the temporary eversion of the left ventricle, almost simulating a large polyp.
Paresis, TA + LCA: 3 months after implant is placed (5 of 6)
A few months later, fullness of left vocal cord (right of image) remains, but eversion / edema of ventricular mucosa has resolved. Compare with image 1.
A few months later, fullness of left vocal cord (right of image) remains, but eversion / edema of ventricular mucosa has resolved. Compare with image 1.
Paresis, TA + LCA: 3 months after implant is placed (6 of 6)
During phonation, much better closure (with markedly improved voice) but still slightly lateral turning of the left vocal process (right of image). Compare with image 3.
During phonation, much better closure (with markedly improved voice) but still slightly lateral turning of the left vocal process (right of image). Compare with image 3.
Paresis, TA + LCA, before and after Injection of Voice Gel
Paresis, TA + LCA (1 of 5)
Right vocal cord paresis (left of image). Note marked atrophy as compared with the left cord. Highly lateralized position denotes some persistent action of the right posterior cricoarytenoid muscle.
Right vocal cord paresis (left of image). Note marked atrophy as compared with the left cord. Highly lateralized position denotes some persistent action of the right posterior cricoarytenoid muscle.
Paresis, TA + LCA (2 of 5)
Initiation of phonation. Note medical turning off left vocal process of arytenoid (right of image), and absent movement of the right vocal cord. Neither thyroarytenoid nor lateral cricoarytenoid muscles are innervated.
Initiation of phonation. Note medical turning off left vocal process of arytenoid (right of image), and absent movement of the right vocal cord. Neither thyroarytenoid nor lateral cricoarytenoid muscles are innervated.
Paresis, TA + LCA: voice gel injection (3 of 5)
Immediately following injection of right vocal cord (left of image) with voice gel, with patient in videoendoscopy room chair, under topical anesthesia. Note bulging of right vocal cord.
Immediately following injection of right vocal cord (left of image) with voice gel, with patient in videoendoscopy room chair, under topical anesthesia. Note bulging of right vocal cord.
Paresis, TA + LCA: 1 month after voice gel injection (4 of 5)
A month later, showing plumping up of the right vocal cord (left of image) with voice gel. Vocal cord continues to abduct fully, due to functioning posterior branch of recurrent nerve, which innervates the posterior cricoarytenoid muscle.
A month later, showing plumping up of the right vocal cord (left of image) with voice gel. Vocal cord continues to abduct fully, due to functioning posterior branch of recurrent nerve, which innervates the posterior cricoarytenoid muscle.
Paresis, TA + LCA: 1 month after voice gel injection (5 of 5)
Phonation. There is some movement to the midline due to the bilaterally innervated interarytenoid muscle. The lateral cricoarytenoid muscle is paralyzed, as seen in lateral turning of the vocal process. Voice is dramatically improved as compared with pre-injection. The voice gel will be expected to gradually absorb over three to nine months, during which time the anterior branch of the recurrent nerve may recover its function.
Phonation. There is some movement to the midline due to the bilaterally innervated interarytenoid muscle. The lateral cricoarytenoid muscle is paralyzed, as seen in lateral turning of the vocal process. Voice is dramatically improved as compared with pre-injection. The voice gel will be expected to gradually absorb over three to nine months, during which time the anterior branch of the recurrent nerve may recover its function.
Voice Gel Injection for Vocal Cord Paralysis
Left vocal cord paralysis (1 of 4)
This photo shows left vocal cord paralysis in the breathing position. Note the margin bowing, “spaghetti-linguini” difference in bulk, and capacious ventricle. Note: the * is for comparison with photo 3.
This photo shows left vocal cord paralysis in the breathing position. Note the margin bowing, “spaghetti-linguini” difference in bulk, and capacious ventricle. Note: the * is for comparison with photo 3.
Voice-making position (2 of 4)
Here the paralysis is shown in the voice-making position. Note the lateral buckling of the left vocal cord (right of photo). This flaccidity and the gap between the vocal cords explain the patient’s breathy (air-wasting) voice quality.
Here the paralysis is shown in the voice-making position. Note the lateral buckling of the left vocal cord (right of photo). This flaccidity and the gap between the vocal cords explain the patient’s breathy (air-wasting) voice quality.
Voice gel injection (3 of 4)
This is the same patient at the beginning of voice gel injection. Needle at arrow coming from subglottis upwards and laterally. At * one can see the beginning of bulging in the posterior ventricle. The vocal cord also looks slightly shifted towards the midline. Compare with photo 1.
This is the same patient at the beginning of voice gel injection. Needle at arrow coming from subglottis upwards and laterally. At * one can see the beginning of bulging in the posterior ventricle. The vocal cord also looks slightly shifted towards the midline. Compare with photo 1.
After voice gel injection (4 of 4)
Voice-making position after voice gel injection is complete and bulge in ventricle at * is more evident. Closure is much better; the voice is dramatically stronger and the air-wasting quality much less. Compare with photo 2.
Voice-making position after voice gel injection is complete and bulge in ventricle at * is more evident. Closure is much better; the voice is dramatically stronger and the air-wasting quality much less. Compare with photo 2.
Middle-aged woman with unexplained shortness of breath and noisy breathing, due to this idiopathic inflammatory and very high subglottic stenosis. The patient initially declined dilation due to her anxiety. She also had granularity of the nasal septum and a positive ANCA profile for Wegener’s granulomatosis.
Middle-aged woman with unexplained shortness of breath and noisy breathing, due to this idiopathic inflammatory and very high subglottic stenosis. The patient initially declined dilation due to her anxiety. She also had granularity of the nasal septum and a positive ANCA profile for Wegener’s granulomatosis.
Subglottic stenosis, worsened (2 of 5)
Five months later, the symptoms became intolerable, and the stenosis was noted to be slightly narrower and with a greater posterior component. The patient agreed to dilation.
Five months later, the symptoms became intolerable, and the stenosis was noted to be slightly narrower and with a greater posterior component. The patient agreed to dilation.
Subglottic stenosis, worsened (3 of 5)
Same exam as photo 2; this close-up view shows more clearly the inflammatory nature of this stenosis.
Same exam as photo 2; this close-up view shows more clearly the inflammatory nature of this stenosis.
Subglottic stenosis, after dilation (4 of 5)
Five days after outpatient dilation, triamcinolone injection, and topical mitomycin C application. The patient’s symptoms have vanished, the harsh inspiratory noise is no longer heard, and the size of the airway, though still not normal, is more than doubled. Compare with photo 2 of this series.
Five days after outpatient dilation, triamcinolone injection, and topical mitomycin C application. The patient’s symptoms have vanished, the harsh inspiratory noise is no longer heard, and the size of the airway, though still not normal, is more than doubled. Compare with photo 2 of this series.
Subglottic stenosis, after dilation (5 of 5)
Same exam as photo 4, close-up view. Intensification of the inflammatory changes of this stenosis are expected so early after dilation. Compare size of the stenosis with photo 3 of this series.
Same exam as photo 4, close-up view. Intensification of the inflammatory changes of this stenosis are expected so early after dilation. Compare size of the stenosis with photo 3 of this series.
Subglottic stenosis, before dilation (1 of 2)
This individual has undergone at least a dozen prior dilations, each of which provides dramatic relief from noisy breathing and exercise intolerance. Here the patient is halfway to needing re-dilation, due to the typical inflammatory stenosis that is seen. Compare with photo 2.
This individual has undergone at least a dozen prior dilations, each of which provides dramatic relief from noisy breathing and exercise intolerance. Here the patient is halfway to needing re-dilation, due to the typical inflammatory stenosis that is seen. Compare with photo 2.
Subglottic stenosis, after dilation (2 of 2)
One week after one of this patient's dilations (with Kenalog injection and topical Mitomycin C), showing a dramatic widening of her airway; compare with photo 1. After a number of years, inflammatory lesions such as this sometimes "burn out," and the interval between dilations increases.
One week after one of this patient's dilations (with Kenalog injection and topical Mitomycin C), showing a dramatic widening of her airway; compare with photo 1. After a number of years, inflammatory lesions such as this sometimes "burn out," and the interval between dilations increases.
Tracheal Stenosis, before and after Tracheal Resection and Primary Reanastomosis
Tracheal stenosis (1 of 8)
This view from the level of the vocal cords shows high-grade tracheal stenosis, involving rings two, three, and four; the airway here is an estimated 30% of its normal diameter. For reference, a dotted line marks the level of the cricoid cartilage.
This view from the level of the vocal cords shows high-grade tracheal stenosis, involving rings two, three, and four; the airway here is an estimated 30% of its normal diameter. For reference, a dotted line marks the level of the cricoid cartilage.
Tracheal stenosis (2 of 8)
Slightly closer view. This patient is very short of breath with minimal activity and, even at rest, has audible stridor. Elsewhere, across a span of several prior weeks, she had undergone three dilation procedures with only minimal, transient benefit.
Slightly closer view. This patient is very short of breath with minimal activity and, even at rest, has audible stridor. Elsewhere, across a span of several prior weeks, she had undergone three dilation procedures with only minimal, transient benefit.
Close up view (3 of 8)
Close-up view shows scarring, collapse of tracheal walls, and some granulation tissue.
Five days after tracheal resection and primary reanastomosis. Compare with photo 1. Note that the airway’s diameter has at least tripled (part of the opening is obscured by tenacious mucus). The patient’s shortness of breath is now gone, as is the stridor.
Five days after tracheal resection and primary reanastomosis. Compare with photo 1. Note that the airway’s diameter has at least tripled (part of the opening is obscured by tenacious mucus). The patient’s shortness of breath is now gone, as is the stridor.
Tracheal stenosis, 5 days after surgery (6 of 8)
Close-up of the line of anastomosis, with a couple of sutures visible. Compare with photo 3. Again, tenacious mucus in the upper part of the photo is obscuring part of the view.
Close-up of the line of anastomosis, with a couple of sutures visible. Compare with photo 3. Again, tenacious mucus in the upper part of the photo is obscuring part of the view.
Tracheal stenosis, 2 months after surgery (7 of 8)
Another eight weeks later. The airway is wide-open and has also now healed since the surgery. Compare this view with photo 1 (pre-surgery) and photo 5 (early follow-up).
Another eight weeks later. The airway is wide-open and has also now healed since the surgery. Compare this view with photo 1 (pre-surgery) and photo 5 (early follow-up).
Tracheal stenosis, 2 months after surgery (8 of 8)
Tracheal Deformity and Stenosis, before and after Repair
Upper tracheal stenosis, before repair (1 of 6)
View from above the level of the vocal cords, showing severe narrowing and deformity of the upper trachea, caused by a “difficult” tracheotomy many years earlier. This man is frustrated by activity limitations, and difficulty coughing up accumulated mucus.
View from above the level of the vocal cords, showing severe narrowing and deformity of the upper trachea, caused by a “difficult” tracheotomy many years earlier. This man is frustrated by activity limitations, and difficulty coughing up accumulated mucus.
Upper tracheal stenosis, before repair (2 of 6)
View from just below the level of the vocal cords, showing the deformity and stenosis more clearly.
View from just above the level of the vocal cords, six weeks after tracheal resection and primary anastomosis, showing final result. Patient feels he breathes completely normally. Compare with photo 1.
View from just above the level of the vocal cords, six weeks after tracheal resection and primary anastomosis, showing final result. Patient feels he breathes completely normally. Compare with photo 1.
After tracheal repair (5 of 6)
View from just below the level of the vocal cords. The tracheal caliber is now virtually normal. A broken, absorbable suture is seen at 2 o’clock, and a tiny remaining unhealed area is at 11 o'clock. Compare with photo 2.
View from just below the level of the vocal cords. The tracheal caliber is now virtually normal. A broken, absorbable suture is seen at 2 o’clock, and a tiny remaining unhealed area is at 11 o'clock. Compare with photo 2.
After tracheal repair (6 of 6)
A close-up view shows the circular line of the anastomosis more clearly.
After 15 days of oral fluconazole. Obvious improvement, but incomplete resolution of tissue changes.
Candida laryngitis, several months later (4 of 4)
After longer-term fluconazole, along with reduction of inhaled steroid dose, complete resolution. Strobe light, closed phase of vibration at high vocal pitch.
After longer-term fluconazole, along with reduction of inhaled steroid dose, complete resolution. Strobe light, closed phase of vibration at high vocal pitch.
Epidermoid Cyst, before and after Removal
Epidermoid cyst (1 of 3)
Epidermoid cyst, right vocal cord. Note white submucosal mass predominately on upper surface of the cord, but with bilateral free margin elevation as well.
Epidermoid cyst, right vocal cord. Note white submucosal mass predominately on upper surface of the cord, but with bilateral free margin elevation as well.
Epidermoid cyst (2 of 3)
Close view, initiation of phonation under strobe light.
Close view, initiation of phonation under strobe light.
Epidermoid cyst, removed (3 of 3)
After submucosal dissection and removal of cyst. Free margin swelling remains, as one cannot straighten the free margin (remove redundant mucosa stretched over the cyst) at the same time as cyst removal.
After submucosal dissection and removal of cyst. Free margin swelling remains, as one cannot straighten the free margin (remove redundant mucosa stretched over the cyst) at the same time as cyst removal.
Choral Singer’s Voice Fully Restored
Hoarse choral singer (1 of 4)
Older amateur but experienced and committed choral singer is grossly hoarse due to this chronic vascular lesion, left vocal cord (right of photo).
Less than a week after surgical removal, residual bruising is seen.
2 months post-surgery (3 of 4)
Nearly 2 months after surgery, only a bit of ectasia (non-threatening as it is upper surface e of the cord) is seen. The patient says voice is fully restored.
Nearly 2 months after surgery, only a bit of ectasia (non-threatening as it is upper surface e of the cord) is seen. The patient says voice is fully restored.
Margins match (4 of 4)
Under strobe light, the margins match perfectly at D5 (587 Hz) and vibratory flexibility is equal to the unoperated side.
Under strobe light, the margins match perfectly at D5 (587 Hz) and vibratory flexibility is equal to the unoperated side.
Medialization, before and after
Before medialization (1 of 4)
Right vocal cord (left of photo) paralysis. During breathing as shown here, the right cord (left of photo) is paramedian, while the left cord (right of photo) is widely abducted. Note also the bowing (curvature) of the right cord (left of photo), and the prominent ventricle, both of which are indications of atrophy/ reduced bulk of the muscle within that cord.
Right vocal cord (left of photo) paralysis. During breathing as shown here, the right cord (left of photo) is paramedian, while the left cord (right of photo) is widely abducted. Note also the bowing (curvature) of the right cord (left of photo), and the prominent ventricle, both of which are indications of atrophy/ reduced bulk of the muscle within that cord.
Before medialization (2 of 4)
Phonation, with vibratory blurring under standard light. Right cord (left of photo) remains paramedian, and the left cord (right of photo) has swung to the midline. Even so, large gap between the cords shows that closure is incomplete, and this explains the weak, air-wasting voice; the patient can only say a few words before running out of air and having to take another breath.
Phonation, with vibratory blurring under standard light. Right cord (left of photo) remains paramedian, and the left cord (right of photo) has swung to the midline. Even so, large gap between the cords shows that closure is incomplete, and this explains the weak, air-wasting voice; the patient can only say a few words before running out of air and having to take another breath.
After medialization (3 of 4)
After medialization and placement of a silastic implant, the right cord (left of photo) is less atrophied and the bowing much diminished. The cord has also been shifted slightly to the midline.
After medialization and placement of a silastic implant, the right cord (left of photo) is less atrophied and the bowing much diminished. The cord has also been shifted slightly to the midline.
After medialization (4 of 4)
Phonation, again with vibratory blurring, but notice the much better approximation of the cords. The voice is stronger, and less air-wasting.
Phonation, again with vibratory blurring, but notice the much better approximation of the cords. The voice is stronger, and less air-wasting.
Airway Stenosis Caused By Wegener’s Granulomatosis, Before and After Dilations
Airway stenosis (1 of 5)
Marked inflammatory narrowing in the immediate subglottis. Within the ring of arrows is the inflamed, reddened tissue, which is narrowing the airway into the shape of a slit. This man needs to be active for his work, but notices shortness of breath and noisy breathing with exertion.
Marked inflammatory narrowing in the immediate subglottis. Within the ring of arrows is the inflamed, reddened tissue, which is narrowing the airway into the shape of a slit. This man needs to be active for his work, but notices shortness of breath and noisy breathing with exertion.
Airway stenosis, after dilation (2 of 5)
Nine days after a dilation procedure, with local steroid injection and painting with Mitomycin C. The airway has widened, so that it is more oval-shaped and less slit-like. Compare with photo 1. Although a degree of stenosis remains, symptoms have subsided dramatically. For reference, asterisks mark the same points in the subglottis in this photo and the next photo.
Nine days after a dilation procedure, with local steroid injection and painting with Mitomycin C. The airway has widened, so that it is more oval-shaped and less slit-like. Compare with photo 1. Although a degree of stenosis remains, symptoms have subsided dramatically. For reference, asterisks mark the same points in the subglottis in this photo and the next photo.
Airway stenosis, after dilation (3 of 5)
Same exam, looking beyond the immediate subglottis. There is an inflammatory response that involves several centimeters of the upper trachea. Inflammatory areas often “trap” mucus, as seen here.
Same exam, looking beyond the immediate subglottis. There is an inflammatory response that involves several centimeters of the upper trachea. Inflammatory areas often “trap” mucus, as seen here.
Airway stenosis, before another dilation (4 of 5)
Now five months after the dilation procedure mentioned in photos 2 and 3. The patient has been receiving systemic treatment with methotrexate and prednisone. General appearance of the inflammation has decreased. In spite of this, as expected, the stenosis has persisted (dotted oval shows the estimated caliber or width of a normal airway) and symptoms have gradually increased. Thus, another dilation was scheduled for the next day.
Now five months after the dilation procedure mentioned in photos 2 and 3. The patient has been receiving systemic treatment with methotrexate and prednisone. General appearance of the inflammation has decreased. In spite of this, as expected, the stenosis has persisted (dotted oval shows the estimated caliber or width of a normal airway) and symptoms have gradually increased. Thus, another dilation was scheduled for the next day.
Airway stenosis, after another dilation (5 of 5)
A week after photo 4, following the most recent dilation. There is expected immediate postoperative inflammation and an increase in the airway’s caliber or width by an estimated 30% (dotted oval again shows the estimated caliber or width of a normal airway; compare with photo 4). Symptoms are again abolished.
A week after photo 4, following the most recent dilation. There is expected immediate postoperative inflammation and an increase in the airway’s caliber or width by an estimated 30% (dotted oval again shows the estimated caliber or width of a normal airway; compare with photo 4). Symptoms are again abolished.
Smoker’s Polyps, before and after Surgery
Smoker's polyps, BEFORE surgery (1 of 4)
Even during quiet breathing, the convexity of the vocal cord margins (dotted lines show where normal margins would be) reveal the presence of smoker's polyps.
Even during quiet breathing, the convexity of the vocal cord margins (dotted lines show where normal margins would be) reveal the presence of smoker's polyps.
Smoker's polyps, BEFORE surgery (2 of 4)
During inspiratory phonation: the polyps are drawn inward and are easier to see.
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